Embedding and sustaining quality improvement in hospitals: the CARE model – an expert-informed qualitative study

Purpose Sustaining quality improvement (QI) in hospitals remains challenging, as many initiatives fail to become embedded in everyday clinical practice. This study explores how QI experts understand the contextual, cultural, organisational and relational conditions shaping the implementation, embedding and sustainability of QI, and translates these insights into practice-oriented guidance. Design/methodology/approach We employed a qualitative design informed by scientific pragmatism. Data were collected in two Danish hospitals through 14 semi-structured interviews with QI experts, followed by a structured focus group. We analysed data using the Gioia approach and abductive reasoning. Analytically derived domains were subsequently refined and translated into the CARE model and practice-oriented recommendations through structured expert involvement. Findings The analysis identified four interdependent domains in experts' accounts of embedding QI in hospital work: Co-creation and Engagement, Adaptive Contextualisation, Relational Leadership, and Enhanced Learning and Progress. These domains were synthesised into the CARE model, an analytical and practice-oriented model for examining how organisational, relational, contextual and learning conditions may be aligned. Healthcare professionals, managers and QI teams may use CARE to structure reflection on where an improvement initiative is aligned with everyday clinical practice and where further attention may be needed. Research limitations/implications The study was conducted in two Danish hospitals, which may limit transferability. The CARE model has not yet been tested as an intervention. Future research should examine its use and effects in different hospital settings. Practical implications The CARE model can help healthcare professionals, managers, and QI teams assess whether improvement work is locally relevant, supported by leadership, and reinforced through learning. It can also help identify areas where better alignment is needed. Social implications The CARE model highlights the value of staff involvement, trust, supportive leadership, and shared learning. It may support greater ownership of improvement work and reduce the risk that QI is experienced as an additional burden. Originality/value The study translates established QI knowledge into an evidence-informed practice-oriented model for supporting reflection on the embedding and sustainability of QI in hospitals. CARE integrates engagement contextual adaptation leadership and learning into structured guidance for everyday QI work and provides a foundation for future empirical evaluation.