Previous studies of health care quality improvement (QI) have listed factors associated with change but neglected how these factors interact and the contexts in which they occur. There are many different paths to sustained improvement, but successful efforts share two features: an ability to address multiple challenges simultaneously and skill in adapting solutions to the organization’s specific context. QI efforts should pay attention to the organizational and human dimensions of change and the processes by which these dimensions are set in motion and unfold over time. (Abstract)