Techniques and tools are pervasive in organizations: managers rely heavily in their daily practices on a variety of procedures, forms, graphs, tables, ledgers and key performance indicators. In management studies, interest in techniques and “materiality” in management practices, while relatively recent (Carlile *et al.*, 2013; Vaujany & Mitev, 2013), has become significant. Over the years, scholars from a variety of perspectives have emphasized the role of materiality in organizational and economical processes, drawing on competing conceptualizations of material and human agency (Latour, 1987; Star & Griesemer, 1989; Leonardi 2011) and launching debate on the ontology of material and social worlds (Orlikowski & Scott, 2008; Orlikowski, 2010; Leonardi, 2012; Kallinikos, 2011).

In one important stream of literature, practices have been conceptualized as the arrangement of human and non-human actors with a view to disentangling how and why specific socio-technical arrangements emerge, stabilize and spread (Akrich, 1993; Callon, 1992; Latour, 1987). From a socio-material perspective and at a more micro-level of analysis, scholars have studied the possibilities for actions or practices associated with material objects and artefacts and their affordances (Jarzabkowski & Kaplan, 2014, Leonardi, 2011, Orlikowski & Scott, 2008, Orlikowski, 2010). Other studies have concentrated on the performativity of artefacts, analyzing the processes by which theories incorporated into techniques and related artefacts induce actors to change their practices (Callon, 2007; MacKenzie & Millo, 2003; MacKenzie, 2006; Cabantous & Gond, 2011). More recently, material artefacts have been viewed as carriers of institutionalized practices that can facilitate or hamper institutional work and the institutionalization of new logics (Beunza & Ferraro, 2019; Vaujany *et al.*, 2019).

Research in management studies has therefore extended our understanding of why and how materiality “matters” (Carlile *et al.*, 2013). In short, material artifacts possess enabling and constraining properties, or exert performative, enrolling or legitimizing effects in organizations and society. These results are fundamental to help managers in their relations to these artifacts but they do not address the question of their practical efficacy, i.e. how these artefacts can successfully lead to the intended effects expected out of their implementation. Even if this preoccupation may appear rather normative, this is a fundamental managerial concern since material artefacts are used for such purposes in practice.

To explore this question in more depth, we turned to another area of literature: that of healthcare management. Indeed, healthcare management literature has a substantial field of inquiry focused on studying the practical efficacy of QI interventions, that is their ability to reach the expected outcomes on quality of care like reducing hygiene hazard or surgical complications. Quality of care is a key objective for health care organizations since it is central to patient health and well being. Since the Institute for Healthcare Improvement’s initiated the improvement movement in the United States in the 1990s ([1.97]), QI policies have spread to healthcare systems worldwide. The high practical relevance of QI in health care has produced sustained interest in research on QI initiatives, to the point that it has become a distinct research field: improvement science. However, while there may be growing support for investing in improvement capacities to achieve healthcare goals (Denis & Forest, 2012), studies and reviews conducted within the field of improvement science have failed to reach consensus on the conditions for their practical efficacy, i.e. the variables and processes that determine QI success in terms or quality of care improvement ([1.52]; [1.62]; [1.69]; [1.97]; [1.125]; [1.122]; [2.22]). Researchers suggest several explanations for difficulties in understanding the efficacy of QI at improving performance. First, the definitions and characteristics of QI interventions are diverse and unstable ([1.84]; [1.97]; [1.136]). Second, too little is known about “how” and “why” QI interventions work in practice ([1.62]; [1.69]; [1.145]; [2.6]; [2.7]; [4.17]), leading authors to call for more fine-grained studies of the contextual and contingent features of QI interventions (Bate *et al.*, 2008; Berwick, 2008; [1.103]; [1.144]). More recently, researchers have called for a new, complexity-informed approach to interventions in health care (Greenhalgh & Papoutsi, 2018), where complexity is seen as a trait of both the intervention, and of the context in which it is implemented.

Given the extent of this literature which is interested in the practical efficacy of a specific tools-based managerial initiative, QI intervention, we take it as a relevatory object of study to advance revalatory object of study to highlight what is known of the practical efficacy of management tools and how materiality is involved in it and identify avenues for future research. Quality improvement (QI) is used here as an umbrella term for a family of managerial techniques that includes Total Quality Management (TQM), Continuous Quality Improvement (CQI), Quality Improvement Collaboratives (QIC) and Lean management. These techniques share key features (Boerstler *et al.*, 1995; Brennan *et al.*, 2009): they view change as a continuous and incremental process; they involve a complex set of behavioural interventions that requires interdisciplinary collaboration within the organization; and their technical or theoretical foundations are associated with quality management (McLaughlin & McLaughlin, 2004). Taken up by private sector organizations in Western economies, QI has attracted limited yet sustained interest in management research since the 1990s (e.g. Academy of Management Review 1994; [2.5]; [2.20]; [2.25]).

In line with our research objective, we performed a structure literature review (Gatrell & Breslin, 2017; Post *et al.*, 2020). Healthcare literature is central to our research. Given the prominence of improvement science in that field and its difficulties in understanding how QI interventions can improve the quality of care, we also include in our review several papers from the broader field of management studies. This leads to the constitution of a heterogeneous and complex body of literature at the basis of our synthesis. To analyse such diverse body of work, we choose to perform a *Critical Interpretive Synthesis* (Noblit & Hare, 1988; Dixon-Woods *et al.*, 2006).

With this review, we make two main contributions to the literature: first, we propose a mapping of the different approaches to the study of QI interventions; secondly, we identify perspectives that stand to enrich the study of artifacts in organizations and their effects.

The paper is structured as follows: A first section explains our methods and subsequent sections explore the four approaches to QI research and present the key contributions and core dilemmas seen within this body of work.
# Methods

We adopt a method proposed by Dixon-Woods *et al.* (2006) for Critical Interpretive Synthesis (CIS). Presented by ([2.9]) as a form of meta-narrative review method, interpretive syntheses are needed when the aim is to develop a conceptual understanding of a heterogeneous and complex body of literature, including different types of evidence and theoretical perspectives (Noblit & Hare, 1988). This is consistent with the objective of our research and the body of works we have therefore assembled, with papers from the healthcare literature and papers from management studies, which have very different research approaches. It relies on an “author-based approach” ([2.9]) that draws on long research experience, scholarly sensitivity and skill to determine the relevance and quality of material.

In reviewing the literature, we first performed a broad keyword search with various search engines. As this proved insufficient, we adopted a more conservative and targeted strategy by first selecting a sample of 21 journals devoted to management and healthcare (see the list of journals in Appendix 1). Following the methodological approach used by Ferlie *et al.* (2012), journals were selected using the French Research Agency and Web of Science rankings, along with investigators’ experience, to ensure the quality of papers and include a variety of perspectives. We then carried out a search in each journal for papers published between 1990 and 2023 in two steps. The first step was carried out on papers published between 1990 and 2018. It led to identify an initial set of 7207 papers using the keywords *quality, quality management, quality process, total quality management, lean process, continuous quality improvement, business process reengineering, ISO, six sigma*.

We then excluded articles that did not focus mainly on QI tools and techniques (i.e. papers looking at public policies, measures of quality outcomes, methodological issues, training and educational interventions) or implementation processes (i.e. reports of QI implementation focused on impact with no specific account of process). At this first stage, 4027 papers were excluded as not relevant to our synthesis.

A second stage of selection consisted in setting more specific boundaries on what we considered to be “QI interventions”. Inclusion and exclusion criteria were discussed on several occasions by the research team. Papers devoted to presenting specific tools (e.g. clinical guidelines, electronic patient files and information systems) were excluded. Indeed, because of their narrower scope, their organizational and managerial impacts are less significant than seen with broader QI interventions which are organisational processes involving more than one tool. Papers devoted to presenting quality assessment tools (e.g. accreditation and clinical audit, quality assurance) were also excluded because they did not address the impact and process specifically. As a result of this selection process, a total of 253 articles published between 1990 and 2018 were retained for analysis and were then complemented by 8 papers published between 2019 and 2023 identified with the same approach (see references in Appendix 4).

In accordance with the CIS method, we developed our understanding of the literature through an iterative process during which we refined the aim and scope of the review.

The main analytical steps are summarized below:
# Analysis and discussion

In this research, we review approaches to the study of QI interventions. Among the four approaches, only implementation science (Approach 1) corresponds to a delineated research tradition and scientific community within QI scholarship. Papers in the other approaches come from various sources and authors who would not necessarily identify themselves as belonging to these approaches. A mapping of the body of resarch on QI interventions in health care management and more general management research is arguably the first contribution of our study. In particular, it higlights the differences in the way studies consider materiality and the efficacy of tools and in the importance they give to these dimensions.

In this section, we provide a comparative analysis of the four research approaches on these two dimensions - the materiality of QI interventions and their effects - in order to inform future research on the implementation and effects of artefacts from the standpoint of practical efficacy.

## Approaches to the materiality of QI interventions and their context

The constitutive elements of the intervention are conceptualized in two main ways in the four approaches to the study of QI interventions. Approaches 1 and 3 consider QI intervention to be constituted by a identifiable and stable set of tools and techniques. In contrast, studies in approaches 2 and 4 tend to overlook both the materiality and, to a lesser extent, the implementation frameworks associated with QI interventions.

In approach 3, the material artifacts that support the implementation of QI in organizations are described in a systematic way. In approach 1, the material artefacts of interventions are not a concern per se: under specific conditions, stable interventions are likely to be effective and produce the expected outcomes, but the material characteritics of these intervention is not considered as a subject of inquiry. Early work in this approach sought to neutralize contextual conditions. More recently, describing, analyzing and understanding the context of implementation has become central to the quest for a science of improvement (e.g. [1.69]).

In approaches 2 and 4, interventions are conceptualized, often implicitly, as “sets” of techniques and principles, without any descriptive analysis of the specific elements included in the intervention. The intervention is subject to multiple interpretations and representations and is therefore expected in itself to impact actors, processes, and practices. Impact is understood as not being related to the specific technical or material features of the intervention. [2.1] is a recent exception, as this study relies on a detailed analysis of both nurses’ practices and the material features of a QI tool (a board designed to consolidate information about patients and make it available to nursing staff). In both approaches, the evolution of the interventions over the implementation process is taken into account. In approach 4, our analysis indicates that the principles and logics encapsulated in QI interventions, often identified with predominant managerial logics, are more significant than, or can be decoupled from, their material aspects.

In summary, we find that in-depth description and analysis of the material characteristics of techniques and tools, with a view to better understanding their possible effects when they are implemented in specific organizational contexts, is arguably a blind spot in QI research. Also, in line with both socio-material and performativity studies, more attention could be paid to the processes by which specific features of QI interventions interact with features of the organization in which they are implemented. For instance, MacKenzie’s (2006) analysis of the performativity of the Black-Scholes-Merton model for option pricing outlines that the “Black sheets” – i.e. computer-generated sheets of prices for options traded on U.S. options exchanges that are photocopied and sent to the subscribers of Black’s pricing service – serve as “necessary material mediators” for the adoption of the pricing model by practitioners on trading floors. Or, drawing on ANT and performativity studies, respectively, researchers could integrate an analysis of the “inscriptions” (Callon, 1992) or theories (Cabantous & Gond, 2011) embedded in the design of quality improvement tools and techniques, and question the processes by which they are likely to be appropriated by users. Greater emphasis on the materiality of interventions would also be coherent with the managerial principles at the core of the quality movement, which promotes recurring processes in organizations that prompt actors to collectively analyze their practices with a view to improving them (e.g. Deming, 1986). In the original perspective, QI is less an intervention than a continuous collective learning process.

## The intricacies of effects and research approaches

In our review, we find that each research approach carries specific views on the effects of QI interventions. Here as well, we distinguish studies in approaches 1 and 3, which are more focused on QI impacts on quality, from studies in approaches 2 and 4, which adopt a broader view of what QI interventions may produce in organizations. We analyze these views in more detail before dicussing findings in relation to theoretical perspectives on materiality.

Studies in approaches 1 and 3 focus on the efficacy of QI interventions in terms of quality improvement and appear to share the same underlying assumptions and motivations. They postulate that the efficacy of QI interventions can be operationally defined, measured, monitored, reported and analyzed. The rationale for QI practices is interventionist or action-oriented: properly designed and implemented initiatives are the preferred mode of intervention to solve practical quality problems at the operational level in organizations and achieve desired outcomes. Research and practice therefore purposefully seek to identify the specific conditions under which QI interventions will work, i.e. will produce the expected positive effects ([2.17]). In these approaches, unexpected effects are a matter of concern and should be controlled or avoided. The main purpose is to explain why an intervention works or should work and not to account for the reasons an intervention fails to produce the desired effects. More recent papers question the impact of QI on the satisfaction and well-being of patients ([1.111]; [3.11]) and other stakeholders ([3.5]; [3.10]). These authors are extending the boundaries of the approach and adopting a more holistic view of the impacts of QI. In terms of expected effects, they consider that program leaders may rely on a theory of change ([2.7]<fnref n="2" />).

Studies in approaches 2 and 4 adopt a broader view when analyzing the impacts of QI interventions in organizational settings. For instance, interventions can be conducive to changes in professional and occupational norms, practices and identities ([2.31]; Joonsten *et al.*, 2009), changes in power relationships within and between professional or occupational groups ([2.16]; [2.18]), or to broader organizational change processes ([2.20]; [2.24]; [2.26]). Success is sometimes construed as the diffusion and perpetuation of a QI intervention [2.32], irrespective of the quality impacts associated with its adoption. With very few exceptions among studies in approach 2, the effect of the intervention in terms of actual QI is not a central concern.

Research in approaches 2 and 4 relies on the implicit postulate that interventions, as purposive social actions, are bound to produce unintended consequences (Baert, 1991; Franco-Santos & Otley, 2018). Studying the unintended consequences of QI interventions is actually the central concern and motivation for a number of papers in approaches 2 and 4 ([2.4]; [2.16]).

The four approaches can be seen as complementary in the way they consider and analyze the impact of QI interventions in organizations. Studies in approaches 1 and 3 focus primarily on the efficacy of QI interventions per se which is not the concern of approaches 2 and 4. They demonstrate a concern for the practical consequences of artefact-based interventions, a preoccupation that is also found in studies based on a performative and socio-material lens. However, studies in approaches 1 and 3 fail to consider the unexpected and unintended effects of interventions and the co-evolution of interventions with the organizational context in which they are implemented. Studies in approaches 2 and 4 focus instead on the *implementation* of QI interventions and/or their broader impacts in organizations, notably on cognitive and belief systems, identities, power relations and work practices. They may also consider how changes in the context of implementation recursively impacts the intervention itself. In that, they are similar to studies of materiality in organizations that rely on neo-institutionalist analyses or ANT. However, studies in approaches 2 and 4 tend to disregard the practical expected effects of interventions in terms of QI.

By highlighting four approaches which have different ways to approach the effects of QI intervention, our analysis reveals that, at least up to now, there is no comprehensive framework to better understand the relation between such intervention and their effects. Given the explanatory power of each approach and the potential interactions between various types of effects, we argue that paying more attention to the materiality of QI interventions, their context of implementation, their practical efficacy and their unexepected and unintended effects would advance our understanding of how QI interventions, and more broadly, tools-based managerial interventions, unfold in organizations, and how they may be designed and monitored when their efficacy is a central concern – for instance, to improve the quality of care in healtcare organizations.

<footnote n="2">In this paper they propose to develop an *ex post* theory of why a quality improvement program has worked based on research observation and to compare it to the ex ante theory as a fruitful way to update and advance theories of QI program effectiveness.</footnote>
# Conclusion

In this paper, we conduct a Critical Interpretive Synthesis of the literature on QI interventions as a means of providing insight on the practical efficacy of managerial tools and techniques as material artifacts. Our synthesis includes a variety of published papers in both management and healthcare research traditions, based on quantitative and qualitative, experimental and interpretive research designs.

Our research makes a first contribution in mapping the body of research into four research approaches used to study QI interventions: ‘Implementation science’, ‘Process and practice-based studies’, ‘Descriptive and normative’ and ‘Socio-cultural perspectives’ (approaches 1 to 4, respectively).

We then conduct a comparative analysis of these four approaches in order to inform future research on the implementation and effects of artefacts from the standpoint of practical efficacy. This is a second contribution of our work. Comparative analysis touches on two main themes. The first explores how frameworks and material artifacts that support the implementation of QI interventions are considered. Approaches 1 and 3 see the intervention as constituted by a set of identifiable and rather stable tools and techniques, and consider that the conditions of implementation will determine their impact on quality. However, approach 3 is mainly normative and in approach 1, the material artefacts of interventions are not a concern per se. In a second perspective (approaches 2 and 4), it is the intervention itself that is meaningful and not the specific techniques and tools embedded within the intervention. The lack of specific attention to the material characteristics of the intervention is therefore a blind spot in these approaches. The second theme relates to how the effects of QI interventions in organizations are accounted for in each of the four approaches. While research in approaches 1 and 3 is concerned with the practical efficacy of QI interventions, research in approaches 2 and 4 focuses on the implementation of QI interventions and/or the broader impacts of their implementation in the organization.

Our analysis suggests that, to advance research in this domain, studies of QI interventions as managerial approaches and tools should integrate in their research design more attention to the specific characteristics of these artifacts, their process of implementation, the quality impacts of the intervention, and its wider effects on organization.

Overall, our review of the literature on QI interventions indicates that when research is interested in the practical efficacy of a given intervention, studies should also pay attention to the specific features of tools and techniques (the practical form of the tool and associated implementation guidelines), the unfolding process of implementation (how the tools and techniques have been implemented and change through implementation), the socio-organisational context of implementation, and its influence on the trajectory and impact of tools in organizations (meaning both the organization itself and the actors within the organization) and the effects, both intended and unitended, of the QI implementation. Our analysis of a broad range of works within this area suggests that these different dimensions have not been systematically considered and integrated in the study of the practical efficacy of managerial tools.

In addition, the structuration of research on QI implementation from distinct perspectives, results in a lack of an integrative framework for the study of both the materiality of QI implementation and its practical effects. Given the results of the different approaches, such a framework seems necessary to advance the understanding of how QI interventions affect the quality of care. It should integrate the possibility of unintended effects of QI interventions and the interplay between the materiality of the interventions and their context of implementation. Proposals for developing these analytical frameworks would therefore be promising ways to advance the theoretical understanding of the effects of QI interventions in organizations and more, broadly for other managerial techniques and tools that are at the core of a wide range of policies.

This work has implications for managers regarding their use of QI tools: given the difficulty to identify what QI characteritics lead to quality improvements, managers should adopt a more experimental approach based on trial and errors to the implementation of such tools. They shall lead QI interventions cautiously, knowing that their implementation can lead to unexpected and broader outcomes. In these experiments, they also need to integrate dimensions or topics that are not always taken into account. For example, they shall put more emphasis on the implementation phase as a crucial determinant of tools efficacy and balance efforts at conception and design of managerial tools with efforts in supporting implementation and changes. Though these results are based on the study of QI intervention, one may hypothesise that these results can hold for other types of tools.

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