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The purpose of this paper is to identify five quality improvement initiatives for healthcare system leaders, produced by such leaders themselves, and to provide some guidance on how these could be implemented.

A multi-stage modified-Delphi process was used, blending the Delphi approach of iterative information collection, analysis and feedback, with the option for participants to revise their judgments.

The process reached consensus on five initiatives: change information privacy laws; overhaul professional training and work in the workplace; use co-design methods; contract for value and outcomes across health and social care; and use data from across the public and private sectors to improve equity for vulnerable populations and the sickest people.

Information could not be gathered from all participants at each stage of the modified-Delphi process, and the participants did not include patients and families, potentially limiting the scope and nature of input.

The practical implications are a set of findings based on what leaders would bring to a decision-making table in an ideal world if given broad scope and capacity to make policy and organisational changes to improve healthcare systems.

This study adds to the literature a suite of recommendations for healthcare quality improvement, produced by a group of experienced healthcare system leaders from a range of contexts.

The purpose of this paper is to investigate the contextual factors contributing to the sustainability of healthcare quality improvement (QI) initiatives.

Themes from semi-structured interviews with international healthcare leaders are compared with Kaplan and Provost et al.’s (2012) model for understanding success in quality (MUSIQ). Critical success factors within these themes are shown in detail.

The interviews provide a rich source of information on critical success factors. The themes largely correspond with MUSIQ, reinforcing its robustness. An important factor emerging from the interviews was the importance of engagement with patients and families in QI, and this needs consideration in seeking to understand context in QI.

Interview participants represent a limited set of western countries and health systems. Their experiences may not hold true in other settings.

The detail on critical success factors provides QI practitioners with guidance on designing and implementing sustainable initiatives.

Including consideration of contextual factors for engagement with patients and families in frameworks for context in QI appears to be an original idea that will add value to such frameworks. Researchers in patient engagement are starting to address contextual factors and connections should be made with this work.