Contextual determinants of implementation of stakeholder-selected quality indicators in Indian intensive care units: a mixed-methods evaluation within a national registry network.

Introduction: Critical care represents one of the highest stakes healthcare environments, which contribute significantly to the global burden of morbidity and mortality. Quality indicators (QIs) are important tools for monitoring and improving the quality of care in intensive care units (ICUs), yet their implementation and evaluation in low- and middle-income countries are insufficiently researched. The aim of this study was to examine the organisational readiness for the implementation of stakeholder-selected ICU QIs and identify the organisational, team, and behavioural factors that influenced the implementation of these QIs in ICUs in India. Methods: A mixed-methods study was conducted across seven sites (10 ICUs) within the Indian Registry for IntenSive care (IRIS) network between March and October 2023. Organisational readiness was assessed longitudinally using the validated Model for Understanding Success in Quality 2.0 (MUSIQ 2.0) tool at two time points (prior to implementation and 1 year following the first assessment). Barriers and facilitators to implementation were identified through observations of monthly ICU quality improvement meetings, guided by a semi-structured observation framework informed by the Consolidated Framework for Implementation Research (CFIR). A thematic analysis followed Braun and Clarke's six-phase framework, with inductive and deductive coding mapped to CFIR constructs. Results: Although scores varied across sites, readiness assessments indicated that sites considered themselves ready for quality improvement initiatives. The scores ranged from 118 to 160 in the first assessment and 114-147 during the second assessment, which meant all of the sites had a reasonable chance of success. Successful implementation meant that the sites collected the data for the indicators selected, received feedback of their sites' performance, and discussed how to use or intend to use the data for service improvement. Four overarching themes shaped implementation success: (1) cognitive bias, (2) leadership and team dynamics, (3) registry usability and implementation support, and (4) organisational resources and staffing. Audit and feedback meetings functioned as the central mechanism through which these factors interacted, enabling collective data interpretation and incremental engagement with quality improvement. Conclusions: A triad of interdependent conditions, namely, purposeful stakeholder engagement, appropriate resources, and implementation support, determined whether QI data translated into meaningful clinical engagement. These findings have direct implications for the design of registry-based quality improvement initiatives in resource-constrained health systems globally.