Developing programme theories as part of a realist evaluation of a healthcare quality improvement programme

The application of realist approaches to health services research and evaluation has continued to grow over the past two decades. However, difficulties in defining and operationalising key realist concepts of contexts, mechanisms and outcomes in healthcare settings continue to be recognised within the realist evaluation literature. Reflecting on an ongoing realist evaluation of a healthcare quality improvement programme across an inter-organisational context, this article explores some of the methodological challenges encountered by the author in the early stages of programme theory development. An individualised operationalisation and application of realist concepts are presented to demonstrate how initial programme theories can be developed despite the methodological difficulties presented.