Journal of Entrepreneurship, Management and Innovation (2026)

Volume 22 Issue 4: 67-92

DOI: https://doi.org/10.7341/20262244

JEL Codes: D23, M11, L25

André de Waal, Dr., HPO Center, Oude Enghweg 2, 1217JC, Hilversum, the Netherlands, e-mail: This email address is being protected from spambots. You need JavaScript enabled to view it.

Abstract

PURPOSE: This study examines which start conditions are recurrently reported as enabling the successful start of a high performance organization diagnosis and subsequent transformation. METHODOLOGY: This article combines two complementary secondary-source syntheses: (1) an integrative review of 34 peer-reviewed studies on quality improvement initiative (QII) readiness/feasibility and (2) a structured case survey of 69 published HPO diagnosis/transformation cases. The first synthesis develops literature-derived prerequisite categories and mechanisms; the second examines how start conditions, early failure modes, and sequencing statements are reported in published HPO cases. Cross-source pattern matching is then used to compare the literature-derived model with the HPO case evidence. FINDINGS: Within published HPO diagnosis/transformation cases, the combined evidence supports an HPO-specific stage-gated interpretive model of recurrently reported start conditions. To start an HPO diagnosis, the published cases recurrently report a structured entry method (diagnosis plus facilitated sensemaking), a credible ‘why now’ trigger, and leadership mandate/permission. To convert the diagnosis into an HPO transformation, the cases more often report additional conversion conditions such as clear ownership/governance home, adequate change-agent capacity and role clarity, protected capacity/resourcing, and embedding into routine cadences. The most common early derailments are communication/trust breakdowns, engagement deficits, and governance/follow-through gaps. IMPLICATIONS: Conceptually, the findings refine readiness thinking by distinguishing prerequisites for initiating the diagnosis from prerequisites for converting diagnosis into disciplined execution, and by identifying “translation into actionable focus” as a distinct start mechanism alongside the legitimacy, coordination, capability, and learning loops. Practically, the reporting-prevalence patterns identified here can inform a prelaunch stage-gate discussion and a postdiagnosis conversion checklist; they should not be read as a verified, universal checklist of necessary conditions. ORIGINALITY & VALUE: Provides an HPO-specific, stage-gated model of reported start conditions by applying a QII readiness lens to published HPO diagnosis and transformation cases.

Keywords: high-performance organization, organizational readiness, implementation readiness, quality improvement initiatives, continuous improvement, organizational transformation, stage-gate model, implementation feasibility, organizational diagnosis, change management.

INTRODUCTION

A successful start of a quality improvement initiative (QII) is achieved when the initiative moves from intention and planning to disciplined early execution: governance and roles are clear, the intervention is workable in the local context, and the first improvement cycles or pilots are actively running so that the organization can learn and adapt rather than stall (Naughton et al., 2024). Because early abandonment and failure are common when prerequisites are missing, understanding and managing prerequisites is critical to avoid wasting scarce resources and damaging change credibility (Ni et al., 2025). ‘Prerequisites’ are organizational readiness and feasibility conditions that matter for whether a QII can start and gain early traction (Akmal et al., 2022; Mamoojee-Khatib et al., 2025). In this article, the term ‘prerequisite’ is used in a descriptive and interpretive sense to refer to recurrently reported front-end enabling conditions. It does not imply that the present study formally tests causal necessity. ‘Readiness’ refers to the extent to which organizational members are collectively willing and able to implement change (i.e., shared commitment and shared efficacy) (Giroux et al., 2025). ‘Feasibility’ focuses on the barriers and enablers that determine whether a QII is workable at launch, can be integrated into daily roles, and can begin without immediate abandonment (Odhus et al., 2024). In this article, a prerequisite for a QII is defined as an enabling starting condition (at the level of people, the organization, the system context, and the intervention itself) that must already be present, or be deliberately put in place, before implementation begins, so the organization can start executing improvement without early derailment and can measure, learn, and integrate change into routine practice (Cherrafi et al., 2021; Naughton et al., 2024).

Reviews of process improvement failures and barriers/enablers consistently highlight that missing leadership support, motivation, basic capability-building and workable intervention design can prevent initiatives from starting or being sustained (Bader et al., 2024; Odhus et al., 2024). Accordingly, readiness models often treat prerequisites as a front-end stage gate: readiness should be assessed and weak areas strengthened before launch (Cherrafi et al., 2021; Giroux et al., 2025). Such a prerequisite has several characteristics:

• it is antecedent (front-end): it needs to exist before or at launch to make initiation feasible (not only as a later sustainment factor) (Cherrafi et al., 2021; Giroux et al., 2025);
• it enables start-through-action (intention → execution): it helps the organization move from “we plan to improve” to actually running early improvement cycles/pilots without stalling (Naughton et al., 2024; Ipinazar et al., 2021);
• its absence produces early failure modes (commonly: non-start, abandonment, resistance overload, low uptake, inability to measure/learn, or implementation chaos) (Bader et al., 2024; Odhus et al., 2024).

In this article, prerequisites are treated as recurrently reported front-end enabling conditions. Some are framed by source authors as practically indispensable because initiatives commonly stall or are abandoned when they are absent (Bader et al., 2024; Odhus et al., 2024); others are better understood as probability-raising enablers. A smaller subset is portrayed by source authors as stage-gating conditions that should be checked before launch (Cherrafi et al., 2021; Giroux et al., 2025). These formulations reflect how the source literature frames start conditions; they do not constitute a formal causal or necessity test.

Despite extensive work on readiness and enablers across QII contexts, the literature remains fragmented and often context-specific. Readiness tools have been developed for large-scale improvement programs (Cherrafi et al., 2021; Giroux et al., 2025), and systematic reviews identify broad sets of enablers for initiating QII across settings (Odhus et al., 2024). With respect to a culture transformation toward a high-performance organization (HPO), an effective start is associated with early communication and stakeholder engagement planning, a shared vision, and diagnostic capability to understand the starting point and adjust actions (Ipinazar et al., 2021). Currently, HPO-oriented transformation models describe what organizations should build to become high-performing and frequently include a diagnosis (e.g., culture measurement) and deliberate change-management planning as integral elements (Ipinazar et al., 2021). However, there is limited research that conceptualizes an HPO diagnosis and subsequent transformation explicitly as a QII with a definable start phase, and that synthesizes which prerequisites are most frequently reported as in place before initiating such an HPO initiative. But rather than claiming that the HPO literature has overlooked a problem that it should already have framed as a QII, this study deliberately adopts a QII readiness perspective to HPO diagnosis and transformation. The gap addressed is therefore analytical: although HPO research explains what high-performing organizations look like and how HPO diagnoses can guide change, it offers less explicit synthesis of the start-up conditions that source authors report as being in place before an HPO diagnosis and subsequent transformation can begin effectively.

This analytical reframing allows us to ask which front-end readiness and feasibility conditions matter most at the start of an HPO trajectory. This study, therefore, addresses the following research question (RQ):

RQ: What front-end conditions are recurrently reported as enabling the successful start of an HPO diagnosis and subsequent transformation?

This research topic is important and timely because organizations often launch improvement and transformation programs under resource constraints and performance pressure, and missing start conditions can lead to early non-starts, abandonment, or prolonged time-to-impact (Chirumalla et al., 2025). In such contexts, having a clearer evidence-informed view of the start conditions that are commonly reported before launch can support better go/no-go decisions and more targeted readiness-building (Kokkinou et al., 2025). The theoretical contribution of this article is therefore to propose an HPO-specific interpretive refinement of QII readiness thinking, rather than to verify a universally generalizable model of QII initiation. The practical contribution is an evidence-informed discussion aid for prelaunch and postdiagnosis decision-making, rather than a verified checklist of universally necessary conditions.

The remainder of this article is structured as follows. Section 2 presents the integrative review and develops the literature-derived prerequisite set. Section 3 describes the case-based synthesis of published HPO cases. Section 4 reports the case-synthesis results. Section 5 matches the literature-derived and HPO-case findings. Section 6 concludes with contributions, limitations, and directions for future research.

METHODOLOGICAL APPROACH

This section develops the theoretical foundation for identifying front-end conditions that the literature recurrently reports as enabling the successful start of an HPO diagnosis and subsequent transformation. Drawing on the readiness and feasibility literature on QIIs, we synthesize the front-end conditions that enable early traction and clarify the mechanisms through which they operate. This section first outlines the review and coding approach, then positions the HPO diagnosis and transformation - operationalized via de Waal’s HPO framework - as a programmatic QII context, and finally derives prerequisite categories, mechanisms, and their implications for failure modes and sequencing.

The literature review was conducted as an integrative review with the explicit goal of identifying front-end conditions that make the start-up of a QII feasible. The unit of analysis was the individual study. Each study was treated as a source of explicit statements about start conditions portrayed as relevant before or at launch, rather than as an exhaustive checklist. Literature searches were conducted in the Scopus, EMERALD, EBSCO, and Google Scholar databases during January 2026. The core search strategy combined terms for the initiative domain and the start/readiness domain, for example: “Quality Improvement* OR Continuous improvement OR High Performance Organization* OR HPO* OR Lean OR Sigma OR Kaizen AND Prerequisites OR Implementation OR Readiness OR Prerequisites OR Barriers OR Enablers OR Success”. The database search yielded 76 records. After removing 6 duplicates, 70 titles/abstracts were screened, and 30 full texts were assessed for eligibility. Backward and forward citation chasing yielded 4 additional records, resulting in a final sample of 34 studies. Studies were included when they described the implementation of a QII or synthesized evidence across QII implementations, and reported antecedents or starting conditions that were portrayed as relevant before implementation began (e.g., readiness, feasibility, or launch conditions). Studies were excluded when prerequisites were discussed only as sustainment factors after implementation, or when the paper was purely conceptual without linking prerequisites to implementation outcomes.

Duplicate records retrieved across databases were removed manually by comparing author, title, year, and outlet information. Backward and forward citation chasing was applied after the full-text screening stage: references cited by retained papers, and later papers citing them, were considered for inclusion when they met the same eligibility criteria. Because the review integrates heterogeneous QII contexts and study designs, no single formal risk-of-bias tool was applied. Instead, the review used a pragmatic minimum quality threshold by restricting the corpus to peer-reviewed studies with an identifiable QII implementation context and an explicit link between start conditions and implementation outcomes, barriers, or failure patterns. The review should therefore be read as an auditable integrative synthesis rather than as a PRISMA-style effectiveness review.

For each included study, information was extracted on the QII type and setting, the described prerequisites for starting, and any statements connecting these prerequisites to success or failure. Prerequisites were first coded inductively and then clustered into a smaller set of prerequisite categories. For each category, the presence/absence in each study was recorded, and the frequency was calculated as the percentage of studies that mentioned that prerequisite (rounded to whole percentages). Categories are ordered by frequency in Table 1, Appendix 1 in the online supplementary material provides study-level detail. In addition to frequency, each prerequisite category was classified by importance based on how authors framed it: necessary prerequisites were described as critical or go/no-go conditions; helpful prerequisites were described as probability-raising enablers; and mixed/context-dependent prerequisites were portrayed as contingent on the type of QII, sector, or organizational maturity. This classification is intended to support interpretation rather than to imply strict causal necessity.

Because the article combines an integrative review with a separate case-based synthesis of published HPO cases, both components rely on secondary sources; however, they differ in their analytic purposes and units of analysis. The integrative review treats studies as the unit of analysis to derive literature-based prerequisite categories, whereas the case survey treats individual HPO cases as the unit of analysis to examine how these start conditions are reported in practice.

LITERATURE REVIEW

The HPO framework, diagnosis, and transformation

In this study, the HPO diagnosis and transformation are examined through a QII readiness lens. We do not argue that prior HPO research ordinarily classifies HPO as a quality improvement initiative. Rather, we use the QII perspective analytically because an HPO trajectory shares key start-up properties with many organization-wide improvement initiatives: it has a defined launch, requires organizational readiness and feasibility, mobilizes cross-functional participation, and must convert diagnosis into disciplined early action. We operationalize the diagnosis using de Waal’s HPO Framework (de Waal, 2012a, 2012b) because it is a validated framework (Do & Mai, 2020), is widely used across contexts (Iqbal et al., 2022; Xanthopoulou et al., 2023), and is supported by an extensive academic evidence base with 50+ published case studies, making it a strong exemplar for studying an HPO initiative as a QII. De Waal’s HPO Framework conceptualizes ‘high performance’ as a set of 35 empirically derived characteristics, clustered into five factors: Management Quality, Openness and Action Orientation, Long-Term Orientation, Continuous Improvement and Renewal, and Employee Quality. The framework was developed through a large evidence base (including a structured review of 290 high-performance publications) and a worldwide survey, with the final 35 characteristics and five-factor structure resulting from statistical analysis and shown to be positively related to competitive performance. An HPO Diagnosis operationalizes this framework by having management and employees complete the HPO questionnaire, rating how well the organization performs on each of the 35 characteristics on an absolute 1-10 scale; results are then aggregated into average scores per HPO factor (and an overall HPO score). These scores make strengths and areas for improvement visible and provide an evidence-based basis for prioritizing and sequencing subsequent transformation actions (and can be repeated later to track progress).

Prerequisites identified in the integrative review

The literature consistently emphasizes that QIIs do not start from a blank slate: organizations require a minimum level of readiness, feasibility, and implementation infrastructure before launching improvement work (Lameijer et al., 2023; McDermott et al., 2022). The clustering of prerequisites followed three steps. First, all explicit launch-related prerequisite statements were open-coded at the study level. Second, semantically similar codes were merged through constant comparison into provisional higher-order categories; for example, top-management buy-in, executive sponsorship, and senior leadership support were grouped under leadership commitment and sponsorship. Third, categories were refined until they were sufficiently distinct, broad enough to accommodate wording variation across studies, and interpretable as antecedent start conditions. This aggregation was interpretive rather than algorithmic: categories were retained when multiple study-level codes captured the same antecedent start condition and were separated only when merging would have obscured a substantively different start logic.

Table 1 summarizes the prerequisites described across the 34 included studies, clustered into 14 prerequisite categories and ordered by frequency of occurrence. The percentage indicates the share of studies in which a prerequisite was explicitly described as needing to be in place before the QII could start successfully. Percentages are rounded to whole numbers. Case-author framing reflects how the case evidence reported the condition: as stage-gating, enabling, or mixed/context-dependent (depending on the type of QII, sector, or organizational maturity).

Table 1. Reported front-end conditions identified in the integrative review before the QII start

Category	Description	Source-author framing	%
Leadership commitment & sponsorship	Senior/top-management buy-in, active sponsorship, and visible support that legitimizes the QII and removes organizational barriers.	reported as stage-gating	91
Training, skills & improvement competence	Capability to apply the improvement method (Lean/LSS/Kaizen/QI), including training, improvement skills, and coaching/mentoring.	reported as stage-gating	88
Data, measurement & information systems	Availability of usable data, KPIs, measurement routines, and (where relevant) IT/information systems to understand baselines and track progress.	reported as enabling	82
Culture & change readiness	A culture/climate supportive of improvement and openness to change (psychological safety, learning orientation, low resistance).	reported as stage-gating	79
Communication & stakeholder/customer focus	Clear communication of purpose and approach, stakeholder engagement, and attention to customer/patient needs and expectations.	reported as stage-gating	74
Strategic alignment & direction	Clear vision, goals, and alignment of the QII with organizational strategy and priorities.	reported as enabling	68
Resources & capacity (time, people, budget)	Minimum viable resourcing: time, staff capacity, funding, and basic infrastructure to begin improvement work.	reported as stage-gating	65
Employee involvement, engagement & attitudes	Active involvement of staff, positive attitudes, motivation, and buy-in beyond formal leadership.	reported as stage-gating	62
Governance, project selection & staged roadmap	Structured governance, project selection discipline, phased roadmaps, and clarity on how deployment is organized.	reported as enabling	56
Intervention/technology fit & evidence base	The chosen intervention or technology is appropriate, evidence-informed, usable, and fits the local context and users.	mixed / context- dependent	35
Clear need/urgency/motivation	A compelling reason to change (urgency, business case, patient/community benefit) that legitimizes starting the QII.	reported as enabling	29
External environment support & networks	External partners, collaboratives, suppliers, professional or community networks that provide support or compensate for internal gaps.	reported as enabling	26
Change agent/dedicated improvement roles	Presence of champions, facilitators, or dedicated improvement teams coordinating the QII.	reported as enabling	21
Process baseline & standardization/method discipline	Stable processes and disciplined ways of working (e.g., standard work, PDCA/DMAIC) to build improvement on.	reported as enabling	9

Note: “Reported as stage-gating” indicates that source authors described the condition as essential, critical, mandatory, go/no-go, or linked its absence to non-start or severe early derailment. “Reported as enabling” indicates a probability-raising enabler not framed as indispensable. “Mixed/context-dependent” indicates that sources varied in their framing or made the relevance contingent on sector, size/complexity, maturity, or initiative type. These labels summarize source-author or case-author framing and do not constitute formal causal or necessity-test results. Percentages indicate reporting prevalence in the reviewed studies/cases; they are not effect sizes, formal importance weights, or causal rank orderings.

Across the literature, prerequisites cluster around leadership, capability, information, and culture. The most frequently cited prerequisites relate to organizational commitment and the practical ability to run improvement cycles, suggesting that QII success is often shaped before formal implementation begins. Leadership commitment & sponsorship is the most frequently mentioned prerequisite and is typically reported as stage-gating. Training, skills & improvement competence is similarly prominent. Data, measurement & information systems and Culture & change readiness provide the measurement and behavioral foundation to learn and adapt. Communication & stakeholder/customer focus supports shared understanding and early adoption. A second tier of prerequisites concerns organizational focus and operating conditions: Strategic alignment & direction, Resources & capacity, and Employee involvement, engagement & attitudes indicate that a QII needs both clarity of direction and a realistic operating model that protects time and motivates participation. Governance, project selection & a staged roadmap reflects the need for disciplined deployment rather than ad-hoc project selection. Lower-frequency prerequisites should not be read as unimportant; rather, they are often context dependent or implicitly assumed. Intervention/technology fit & evidence base is particularly salient when the QII includes new technologies or clinical/process innovations. Clear need/urgency/motivation is sometimes treated as part of strategic alignment rather than a separate condition. External environment support & networks and dedicated change agent roles are more visible in multi-site collaboratives or resource-constrained settings. Process baseline & standardization/method discipline is rarely called out explicitly, possibly because it is embedded in the chosen improvement methodology or addressed during early implementation.

Frequency and importance are related but not identical. In this synthesis, high-frequency conditions are more often framed by source authors as stage-gating or practically indispensable (e.g., leadership sponsorship, improvement competence, culture, communication), whereas some high-frequency items function primarily as enabling infrastructure (e.g., data and measurement). Conversely, some lower-frequency prerequisites may become necessary in specific contexts (e.g., intervention fit in technology-enabled change). Overall, the categories in Table 1 can be interpreted as practical manifestations of a smaller set of mechanisms through which prerequisites influence QII success.

Mechanisms inferred from the integrative review

Mechanisms provide an explanatory layer between starting conditions and outcomes (Cornelissen & Werner, 2025). Whereas the prerequisite categories in Table 1 describe observable readiness features, mechanisms describe how these features translate into implementation success (Li & George, 2025). Mechanisms were derived in a second-order coding step by regrouping the prerequisite categories under shared ‘how’ logics that explain how they enable an effective start. For example, leadership commitment, strategic alignment, and urgency were grouped under legitimization and prioritization because they jointly authorize action and reduce resistance, whereas data, governance, and direction-setting were grouped under feedback and learning loops because they enable monitoring and course correction. The relationship is intentionally many-to-many: several prerequisite categories can activate the same mechanism, and a single category may contribute to more than one mechanism. Table 2 therefore groups prerequisite categories under shared mechanisms rather than treating each prerequisite as having a completely separate causal pathway.

Table 2. Mechanisms through which prerequisites work

Mechanism	Description	Prerequisite using the mechanism
Legitimization and prioritization	Signals that the QII is worth doing now and has organizational authority. Creates legitimacy, reduces political resistance, and accelerates decisions and escalation when barriers arise.	Leadership commitment & sponsorship; Strategic alignment & direction; Clear need/urgency/motivation
Coordination and accountability	Provides clarity on roles, decision rights, sequencing, and benefit ownership. Reduces fragmentation and ensures that improvement work is organized as a coherent program rather than isolated projects.	Governance, project selection & staged roadmap; Leadership commitment & sponsorship; Change agent/dedicated improvement roles
Capability to execute improvement work	Turns intent into high-quality improvement cycles (problem definition, analysis, experimentation, standardization). Without competence and method discipline, early cycles are slow, inconsistent, or fail to produce learning.	Training, skills & improvement competence; Change agent/dedicated improvement roles; Process baseline & standardization/method discipline
Protected capacity and resourcing	Ensures people have time, staffing, and budget to participate consistently. Prevents “improvement” being crowded out by day-to-day operations and reduces fatigue and drop-out.	Resources & capacity (time, people, budget); Leadership commitment & sponsorship; External environment support & networks
Engagement and psychological safety	Builds willingness to participate, surface problems, and adopt new ways of working. Improves cooperation across professional groups and reduces resistance and workarounds.	Culture & change readiness; Employee involvement, engagement & attitudes; Communication & stakeholder/customer focus
Feedback and learning loops	Creates rapid feedback on whether changes work and why. Enables course correction, makes benefits visible, and sustains momentum through evidence of progress.	Data, measurement & information systems; Governance, project selection & staged roadmap; Strategic alignment & direction
Intervention-context fit and usability	Selects or adapts the intervention so it fits workflows, users, and local constraints, lowering adaptation costs and increasing uptake. External partners and stakeholders can support tailoring and integration.	Intervention / technology fit & evidence base; Communication & stakeholder/customer focus; External environment support & networks

Table 2 reframes the prerequisite categories (Table 1) into seven underlying mechanisms that explain how readiness conditions translate into an effective start of an HPO-related QII. What is analytically useful here is that Table 2 shifts the discussion from a checklist of starting conditions to an explanatory map of causal pathways. It explicitly treats the mapping as many-to-many, meaning that one prerequisite can activate multiple mechanisms (e.g., leadership commitment supports legitimacy, coordination, and resourcing), and multiple prerequisites can jointly activate a single mechanism (e.g., governance + strategy + measurement enabling learning loops). The mechanisms were identified by first synthesizing prerequisites across the integrative review (inductive coding and clustering of prerequisites into the Table 1 categories), and then grouping those categories under shared ‘how’ logics (mechanisms) that link starting conditions to implementation traction, so the mechanisms function as a higher-order explanatory layer rather than additional checklist items. Overall, the table also implies complementarity: legitimacy helps unlock decisions and resources; coordination prevents fragmented ‘project islands’; capability turns intent into disciplined cycles; capacity prevents crowd-out by daily operations; engagement enables honest problem surfacing; measurement creates fast learning; and fit reduces rework and resistance so early success depends on activating a balanced set of these mechanisms rather than maximizing any single prerequisite.

The seven mechanisms in Table 2 represent the literature-derived mechanism set. The HPO case synthesis later adds one further bridging mechanism - translation into actionable focus - because the case material shows that HPO diagnostic outputs must first be converted into a small, shared set of actionable commitments. Section “Match between literature-derived and HPO-case mechanisms” clarifies why this mechanism is analytically distinct from legitimization, engagement, intervention-context fit, and feedback loops.

The influence of organization size/maturity on the prerequisites

Because the reviewed studies do not report organizational size and maturity in a standardized way, this section synthesizes indicative contingency patterns rather than presenting a formal subgroup comparison. Where studies explicitly linked size, complexity, or maturity to prerequisite requirements, those statements were coded and compared to identify recurring patterns. The evidence reviewed in this study suggests that organizational size and maturity do not so much change the type of prerequisite categories as change their configuration, minimum thresholds, and sequencing. Across studies on QII, the same broad prerequisite domains recur (e.g., leadership support, engagement, capability, resources, measurement infrastructure, and governance), but their practical meaning differs by context. In smaller organizations/SMEs, feasibility constraints (limited slack, multi-role staffing, constrained budgets) make early resource-capability checks, cost-conscious training approaches, and careful scoping/pilot selection particularly critical to avoid reputational damage and early stall-out (Akmal et al., 2022; Siegel et al., 2022). In larger and more complex organizations, the binding constraints shift toward coordination prerequisites such as clear organizational embedding, governance and role clarity, stakeholder alignment, and mechanisms for knowledge diffusion across units, This is because scaling and consistency become the dominant start risks (Brock et al., 2024; Kokkinou et al., 2025). Maturity effects are even more consistently emphasized than size: organizations with low operational excellence maturity require stronger readiness-building prerequisites upfront (e.g., reframing/rebranding to reduce stigma, awareness-building, simplified training, and leadership prioritization), while more mature settings face stage-dependent prerequisites, such as renewed leadership emphasis and institutionalized learning to prevent fatigue, plateau, and later decline (Kokkinou et al., 2025; Lameijer et al., 2021). Taken together, this supports a contingent interpretation: the prerequisite set is broadly stable at the category level, yet size/complexity and maturity shape which prerequisites are most binding before launch and which can be developed during implementation, strengthening the case for readiness diagnostics and stage-gated preparation that tailor pre-launch actions to organizational context (Brock et al., 2024; Siegel et al., 2022). These observations should therefore be interpreted as indicative contingency patterns rather than as subgroup-tested regularities.

Failure modes

Much of the prerequisite literature becomes most visible when prerequisites are absent: authors often describe readiness conditions indirectly by documenting the recurrent ways in which QIIs stall, derail, or produce fragile gains. Synthesizing these failure modes is therefore a useful triangulation step in a prerequisite-focused review. It clarifies the practical consequences of starting a QII with weak readiness and helps explain why certain prerequisite domains (Table 1) are repeatedly framed as necessary rather than merely helpful. In this integrative review, failure modes were extracted when included studies explicitly linked barriers or missing conditions to negative implementation outcomes (e.g., low uptake, inability to generate learning, early abandonment, or relapse). These failure modes were inductively coded and clustered into a small set of recurring failure categories. Because studies often report multiple barriers and outcomes, categories are not mutually exclusive; instead, they indicate which failure patterns are most frequently emphasized across the reviewed evidence base. Table 3 lists the failure categories and provides descriptions; Appendix 2 in the online supplementary material provides study-level detail. Failure-mode percentages are calculated within the failure-codable subset of the integrative review (n = 31 of 34 included studies).

Table 3. Failure categories

Failure category	Description	k/31 (%)
Early resistance & low engagement	Resistance, skepticism, fear, low buy-in/participation, culture barriers; QII becomes ‘extra work’ and people disengage.	25/31 (80.6%)
Sustainment/backsliding/ relapse	Initial implementation occurs but gains erode: drift, regression to old practices, failure to hold changes, plateau without renewal.	21/31 (67.7%)
Resource & capacity constraints	Insufficient time/staff/budget/slack; competing operational pressures crowd out QII work; limited capacity to execute alongside day job.	20/31 (64.5%)
Skills/training gaps	Lack of method/tool knowledge, self-efficacy, or digital skills; training not converted into use; capability bottlenecks in teams.	20/31 (64.5%)
Data/measurement/IT/ integration barriers	Weak measurement/feedback systems, data-access/quality problems, IT/integration issues; inability to track progress or run learning loops.	19/31 (61.3%)
Leadership/communication failure	Weak or inconsistent sponsorship, poor senior communication, leadership turnover, lack of sustained attention/priority-setting.	18/31 (58.1%)
Non-start, abandonment & fade-out	Starts prematurely or never ‘takes off’; early stall, non-adoption, abandonment/ceremonial implementations, priority shifts kill momentum.	18/31 (58.1%)
Weak implementation infrastructure/governance/ role clarity/facilitation	Missing CI/QI infrastructure (teams/champions), unclear roles/ownership, weak facilitation, poor governance and coordination routines.	10/31 (32.3%)
Poor planning/goal/ scope/project selection	Unclear goals/targets/scope/problem definition; poor project selection/prioritization; weak planning/requirements leads to rework and overruns.	9/31 (29.0%)
Stakeholder/partnership misalignment	Conflicting stakeholder expectations, weak collaboration/partnerships, misaligned value propositions (‘who pays vs who benefits’).	7/31 (22.6%)
External/regulatory/ compliance constraints	Regulatory/medico-legal/reimbursement constraints, validation burdens, audit/compliance workload and risk aversion blocking change.	6/31 (19.4%)
Method/tool misfit & tool misuse	Wrong methodology/tool choice, tool misuse, over-complexity (‘red tape’), copy-paste solutions, over-technology without fit.	5/31 (16.1%)

Note: Values are calculated within the failure-codable subset of the integrative review (n = 31 of 34 included studies). Three studies contributed prerequisite evidence but did not report codable failure-mode evidence; these studies were excluded from the failure-mode denominator rather than treated as evidence of absence. Percentages indicate reporting prevalence and should not be interpreted as effect sizes, formal importance weights, or causal rank orderings.

Table 3 shows that the most frequently reported failure mode concerns early resistance and low engagement, emphasizing that QIIs commonly fail first in the social system: skepticism, fear, participation fatigue, and the perception of improvement as “extra work” can prevent the initiative from gaining traction, even when a technical intervention is available. This pattern aligns closely with the high-frequency prerequisite domains in Table 1 related to culture and change readiness, employee involvement, and communication and stakeholder focus, and with the mechanism of engagement and psychological safety (Table 2). In other words, a weak ‘implementation climate’ is not only a general background condition; it is one of the most salient early failure pathways reported in the literature.

A second cluster of prominent failures reflects feasibility constraints and the organization’s ability to execute disciplined early cycles. Resource and capacity constraints and skills/training gaps appear as frequently reported failure categories, suggesting that QIIs often fail because organizations attempt to start without sufficient protected time, staffing slack, or minimum improvement competence. This mirrors the prerequisite categories resources & capacity and training/skills & improvement competence and maps directly onto the mechanisms of protected capacity and resourcing and capability to execute improvement work (Table 2). The implication is that ‘starting’ is not simply a decision; it requires a minimum viable operating model in which people can participate consistently and have enough skill and support to convert intent into learning cycles rather than ad-hoc activity.

The table also highlights the centrality of information infrastructure to early traction. Data/measurement/IT/integration barriers is among the most frequently cited failure categories, indicating that weak baselines, poor KPI visibility, and limited feedback routines can block learning loops and undermine credibility (“we cannot show progress”). This corresponds to the prerequisite category data, measurement & information systems and the mechanism of feedback and learning loops (Table 2). Notably, measurement problems function as both a technical and motivational failure pathway: without credible feedback, QIIs cannot adapt effectively and also struggle to maintain engagement and legitimacy.

Failure categories related to authority, prioritization, and governance also recur. Leadership/communication failure and non-start, abandonment and fade-out suggest that many QIIs derail because sponsorship is inconsistent, leadership attention shifts, or escalation pathways are weak, leading to stalled decisions, symbolic launches, or early abandonment when operational pressure rises. These patterns reinforce why leadership commitment and sponsorship is consistently framed as necessary (Table 1) and why legitimacy and prioritization mechanisms matter (Table 2). In addition, weak implementation infrastructure/governance/role clarity/facilitation (32%) and poor planning/goal/scope/project selection (29%) indicate that structural coordination failures are less frequently emphasized than engagement/capability failures, but still represent a meaningful derailment pathway especially in larger or more complex settings where coherent program governance is required to prevent fragmentation into isolated ‘project islands’.

Finally, Table 3 includes several lower-frequency but context-salient failure categories, including external/regulatory/compliance constraints and method/tool misfit and tool misuse. Their lower frequency should not be interpreted as low importance; rather, these failures often become decisive in specific contexts (e.g., regulated environments or technology-enabled change). Together, the distribution of failures supports the broader interpretation that the most common derailment pathways are ‘people-and-capability first’ (engagement, skills, time), followed closely by ‘learning infrastructure’ (measurement), with governance and contextual constraints becoming more binding as organizational complexity and sector increase.

Sequencing effects

The literature indicates that improvement initiatives rarely succeed by treating prerequisites as a static checklist; instead, studies repeatedly describe sequencing paths: recurring order-of-operations patterns that specify when enabling conditions must be established and how improvement work should unfold to create early traction and avoid premature starts (Franken et al., 2021; Kokkinou et al., 2025; Mamoojee-Khatib et al., 2025). Sequencing statements were not reported in every reviewed study. We therefore extracted only those studies that explicitly described phases, stage-gates, or before/then dependencies and synthesized the recurring patterns across that subset. Of the 34 reviewed studies, 18 explicitly discussed sequencing. We identified the paths by extracting those studies in the review that explicitly addressed sequencing (e.g., described phases, stage-gates, or before/then dependencies) and then clustering overlapping patterns into a small set of higher-order pathways.

Five recurring sequencing pathways can be summarized as follows:

1. Diagnosis → readiness-building → stage-gated launch (17/18). Many studies imply a stage-gated lifecycle logic in which readiness is verified and gaps are closed before moving to execution; in our context, this positions the HPO diagnosis as the formal readiness phase and as an evidence-based go/no-go gate for launching an HPO transformation. The practical consequence of this is: treat the HPO diagnosis as the formal ‘prepare/readiness phase’: establish baseline HPO scores and improvement priorities, identify weak prerequisite domains, and use this as a go/no-go gate before launching transformation work at scale.
2. Pilot → learn → standardize → scale (10/18). Studies frequently recommend a pilot–learn–scale sequence, which aligns with an HPO approach in which diagnosis-informed interventions are trialed in a limited scope, refined, standardized, and scaled only then. The practical consequence of this is: use the diagnosis outcomes to design a limited set of transformation interventions, pilot them (e.g., one unit/region/process), learn quickly, standardize what works, and only then scale the HPO transformation program organization-wide.
3. Problem/benefit-led design chain (clarify → fit/capability → feasibility → tool choice) (7/18). The literature consistently signals a problem/benefit-led design chain (clarify the problem and intended benefits first, then assess fit and feasibility before choosing tools), which maps directly onto using the HPO diagnosis to prioritize factor-level gaps and define measurable improvement intent before selecting the transformation design. The practical consequence of this is: use the diagnosis to clarify which performance and HPO-factor gaps matter most and what ‘benefit’ means, then assess contextual fit/capability and feasibility before selecting specific methods (Lean/LSS/Agile/HR interventions, digital enablers) for the transformation design.
4. Foundations first, advanced methods/technology later (6/18). Sources emphasize foundations before advanced methods/technology, aligning with an HPO logic that first strengthens core routines (leadership behaviors, governance rhythm, basic measurement discipline, problem-solving capability) before adding more complex tools. The practical consequence of this is: in early HPO transformation, prioritize foundational capability and routines (problem-solving discipline, leadership routines, measurement cadence, role clarity) before introducing more advanced toolkits or digital solutions; the diagnosis helps pinpoint which foundations are missing and therefore must come first.
5. Climate/engagement early + antecedent-first focus to enable institutionalization (4/18). Studies highlight the importance of establishing implementation climate and engagement early and sequencing work by addressing high-leverage antecedent conditions first, because these enable adoption, institutionalization, and sustained gains. This is precisely the logic underpinning an HPO transformation that must convert diagnostic insights into durable behavioral and process change. The practical consequence of this is: build implementation climate and engagement early (communication, involvement, psychological safety), and sequence actions by addressing the high-leverage antecedents first (e.g., leadership behaviors, governance rhythm, clarity of goals/metrics) that make downstream changes adoptable and sustainable—then institutionalize them into the transformation operating rhythm.

CASE-BASED SYNTHESIS OF PUBLISHED HPO CASES

This section describes a structured case-based synthesis of published HPO evidence rather than a primary empirical field study. The aim is to analyze how start conditions are reported across published HPO cases using a common coding framework.

Design of the published HPO case synthesis

The empirical study was designed as a case-based evidence synthesis (a structured ‘case survey’ style approach) in which a corpus of HPO case studies was converted into a comparable dataset by applying a common coding framework to each case. This design is appropriate because HPO initiatives occur across sectors and countries, most available evidence is reported in descriptive case form rather than in controlled studies, and the research question concerns recurring antecedent conditions and early derailment patterns rather than the effect size of a single intervention (Henkel et al., 2022; Jager et al., 2022; Soto Setzke et al., 2020; Stumpf et al., 2021). Published HPO cases were identified mainly through the Emerald, EBSCO and Google Scholar databases, using combinations of ‘high performance organization’ OR ‘HPO’ And ‘diagnosis’ OR ‘transformation’ OR ‘case study’ OR ‘intervention’ OR ‘implementation’. The search yielded 109 records. After screening and applying the eligibility criteria, 43 publications were retained. Of the 43 retained publications, 35 contributed one case each and 8 contributed multiple separable subcases, together accounting for 34 of the 69 cases in total. The largest clustered sources were the University of Baghdad study (8 faculty level subcases) and the Swagelok study (7 site-level subcases). No publication-collapsed or publication-weighted robustness analysis is reported. The case-level percentages should therefore be interpreted as reporting prevalence within the case corpus rather than as publication-independent breadth estimates. Appendix 3 in the online supplementary material lists the included case sources.

The empirical design followed five steps. First, candidate publications were screened for the presence of an HPO initiative operationalized as an HPO diagnosis and/or an HPO transformation following diagnosis. Publications that used ‘high performance’ only as a research construct (without describing an HPO diagnosis or transformation as an initiative) were excluded from further analysis. Second, the unit of analysis is the case (an organization, organizational unit, or site) rather than the publication. Multi-site publications (e.g., networks of locations) and multi-organization studies, therefore, contributed multiple cases when the text provides case-specific information. Third, for each case, the analysis extracted case context (sector, country/region, size/maturity), whether an HPO diagnosis and/or transformation was described, the described prerequisites that were in place prior to launch, described early failure modes when prerequisites were weak or missing, and explicit sequencing statements (before/then dependencies). Fourth, each case was coded using a structured coding framework. Coding was evidence-based: a prerequisite or failure factor was coded as present only when the case text explicitly described it (or described its absence and consequences). Fifth, after coding all cases, frequencies were calculated as the percentage of cases in which each prerequisite or failure factor was found. In addition, qualitative synthesis was performed to identify the mechanisms through which prerequisites enable early traction, context patterns related to organizational size and maturity, and common sequencing paths across cases. Because case reports vary in richness and focus, the frequencies should be interpreted as the prevalence of explicitly reported prerequisites and failure modes, not as proof that unreported factors were absent. Because the empirical corpus necessarily consists of launched HPO initiatives with a definable start phase, it is better suited to identifying recurrently reported launch conditions and early derailments than to testing true counterfactual necessity. Organizations that never launched, or failed before a visible start phase, are structurally less likely to appear in the published evidence base.

Analysis procedure

The empirical sample consists of 69 individual cases in which an HPO diagnosis and/or HPO transformation is described as an initiative with a definable start phase. The cases span multiple sectors (e.g., public administration, healthcare, education, manufacturing, financial services, telecom, and NGOs) and represent a range of organizational sizes (from SMEs and small units to large multi-site organizations). The sample also includes both transformation-rich cases, where the post-diagnosis transformation is described in detail (governance, interventions, routines, and repeated diagnoses); and diagnosis-focused cases, where the initiative is primarily the HPO diagnosis and related sensemaking and where follow-up actions are described only in broad terms. This mix is analytically useful because the research question is explicitly about the start of an HPO initiative. Diagnosis-focused cases provide strong evidence about entry conditions and feasibility of launch, while transformation-rich cases provide additional evidence about the prerequisites needed to convert diagnosis into early execution (Henkel et al., 2022; Jager et al., 2022; Paavilainen-Mäntymäki & Plakoyiannaki, 2025).

The coding framework was developed as a hybrid deductive-inductive scheme (Fife & Gossner, 2024; Proudfoot, 2022). Deductively, the theoretical prerequisites set out in the Methodological Approach section provided the conceptual foundation (readiness, feasibility, and start-enabling conditions). Inductively, the case evidence was used to refine categories into an HPO-specific prerequisite set that captures how HPO initiatives actually begin in practice. For each case, a prerequisite was coded as present when the case described it as being in place at launch (or deliberately established as part of launch preparation). The coding emphasized antecedence: conditions were counted as prerequisites only if they were portrayed as needed before or at the start of the HPO diagnosis/transformation to make an effective start feasible. Each prerequisite category was also classified by importance using an explicit decision rule. A category was coded as necessary when the case evidence predominantly framed it as essential, critical, mandatory, or as a go/no-go condition for a viable start, or when its absence was explicitly linked to non-start, abandonment, or severe early derailment. A category was coded as helpful when it was portrayed as enabling or probability-raising but not indispensable. A category was coded as mixed/context-dependent when cases differed in their framing or explicitly conditioned the importance of the prerequisite on sector, organizational size/complexity, maturity, or initiative type. These labels are interpretive summary labels rather than formal necessity tests.

To separate what was observed from what was inferred, the analysis used a four-level evidence chain (Table 4). First-order codes record source-text statements about start conditions, derailment pathways, or sequencing dependencies. Second-order categories group recurring first-order codes across studies or cases. Aggregate mechanisms are author-inferred explanations of how these categories appear to enable or derail a successful start. Practical stage-gate implications are recommendations derived from the synthesis and are not treated as directly measured variables.

Table 4. Coding and inference chain

Level	Basis in the data	Manuscript output	Claim status
Source-text evidence	Explicit statements in included studies/cases about antecedent conditions, barriers, or sequencing	Case/study notes and Appendix 5B evidence entries	Observed/reported evidence
First-order codes	Coded source statements using the written codebook; ambiguous or merely implied evidence not up-coded	Binary positive/negative entries in Appendix 5A	Coded observation
Second-order categories	Cross-case grouping of recurring first-order codes	Tables 1, 3, 4, and 6; Appendices 1-4	Analytic categorization
Aggregate mechanisms	Abductive grouping of categories under shared “how it works” logics	Tables 2, 5, and 8	Author-inferred mechanism
Practical stage-gate implications	Interpretive synthesis of reporting-prevalence and conceptual alignment patterns	Sections “Overall analysis” and “Conclusion”	Recommendation/ implication, not direct measurement

For failure factors, the unit of coding is again the case. A failure factor was coded as present when the case explicitly described a derailment pathway or early barrier pattern linked to weak or missing prerequisites. Failure categories are not mutually exclusive: a single case can contribute to multiple failure categories. Size/maturity effects were coded when case texts explicitly linked organizational scale/complexity or maturity to readiness thresholds, prerequisite configuration, or binding constraints. Sequencing effects were coded when cases described explicit ‘before/then’ dependencies.

Credibility and consistency safeguards

Several safeguards were used to increase the credibility and consistency of the empirical synthesis. A written codebook defined each category, inclusion/exclusion rules, and examples of qualifying evidence. The codebook was refined iteratively as new patterns emerged across cases. Cases were coded in an initial pass and then revisited in a second pass to check category boundaries, reduce drift, and ensure consistent application of the antecedence rule (only front-end conditions counted as prerequisites). Case notes recorded the textual basis for each coded category (what was described and where), enabling traceability from aggregated results back to case evidence. The resulting audit trail is reported in Appendix 5A and Appendix 5B. Appendix 5A provides the binary case-by-category coding matrix for all 69 cases, including the diagnosis-focused/transformation-rich split. Appendix 5B provides the positive-code evidence audit trail, including case ID, category, source locator, and a short supporting quotation or evidence summary. These appendices strengthen traceability but do not substitute for independent duplicate coding or intercoder reliability testing. Ambiguous statements were not up-coded (O’Connor & Joffe, 2020). When case texts implied a prerequisite without explicitly describing it as in place at launch, it was not counted. This reduces false positives but may undercount prerequisites that authors assumed rather than reported.

The coding was performed by a single researcher, and no formal intercoder agreement statistics or external audit are reported. This is a limitation and means that the findings should not be read as fully reliability-validated consensus coding. Consistency was instead strengthened through a written codebook, iterative refinement of the categories, two coding passes, traceable case notes, and a conservative rule that ambiguous or merely implied statements were not up-coded (O’Connor & Joffe, 2020). These safeguards support a transparent and auditable expert classification of the published cases, but they do not substitute for independent duplicate coding. Independent recoding of a purposive subset of cases would be the most important next step to strengthen the design further.

Finally, because diagnosis-only cases tend to report entry conditions more than execution infrastructure, lower-frequency prerequisites were interpreted cautiously as potentially reflecting differences in reporting emphasis rather than true absence.

RESULTS OF THE PUBLISHED HPO CASE SYNTHESIS

This section reports the empirical results of the case-based synthesis. This section first presents the empirical prerequisite set and its frequency distribution across cases. It then interprets how these prerequisites operate through recurring mechanisms, how organizational size and maturity shape prerequisite configurations, which failure patterns emerge when prerequisites are missing, and what sequencing paths repeatedly appear across the cases.

Prerequisites identified in the published HPO cases

Table 5 summarizes the prerequisite categories identified across the HPO case synthesis in the stage-gate order used in the coding framework; the k/69 column reports their corpus-wide reporting prevalence. Case-author framing reflects how the case evidence reported the condition: as stage-gating, enabling, or mixed/context-dependent. Appendix 3 in the online supplementary material provides study-level detail.

Table 5. Reported start conditions identified in the published HPO cases

Category	Prerequisite	k/69 (%)	Case-author framing
Method / entry	Structured start: HPO diagnosis + sensemaking that yields actionable attention points	69/69 (100.0%)	reported as stage-gating
Purpose & urgency	Credible ‘why now’ trigger legitimizing start (pressure, ambition, reform, crisis, growth)	69/69 (100.0%)	reported as stage-gating
Leadership & governance	Senior permission/mandate enabling access, participation and start decisions	69/69 (100.0%)	reported as stage-gating
Engagement	Broad participation/early buy-in beyond a small elite (credibility + ownership)	61/69 (88.4%)	mixed
Direction-setting	North star present early (vision/mission/strategic intent anchoring prioritization)	25/69 (36.2%)	reported as enabling
Change ownership	Named internal owner/champion/governance “home” so diagnosis doesn’t remain a report	24/69 (34.8%)	mixed
Measurement design	Fit-for-audience diagnosis design (validity, translation, sampling, confidentiality, logistics)	29/69 (42.0%)	reported as enabling
Change capacity (agents)	Internal change agents exist (coaches/pioneers/project teams) translating attention points into practice	23/69 (33.3%)	mixed
Embedding / integration	QII integrated into routines (review rhythm, planning & control cycle) so it isn’t “extra work”	20/69 (29.0%)	mixed
Change capacity (coverage/quality)	Sufficient coverage + role clarity for change agents (numbers/seniority/reach)	13/69 (18.8%)	mixed
Resourcing	Time/budget capacity for follow-up beyond diagnosis (training, facilitation, improvement time)	17/69 (24.6%)	mixed
External enablement	External mandate/resources (policy, funder, ministry program, central approval)	14/69 (20.3%)	reported as enabling
Peer learning structure	Cross-unit peer learning forum/network to diffuse learning	8/69 (11.6%)	reported as enabling
Organizational infrastructure	Common systems/standardization enabling disciplined follow-up (shared KPIs, reporting, routines)	8/69 (11.6%)	reported as enabling
Culture / learning climate	Baseline learning-from-mistakes / psychological safety already present enough to experiment early	7/69 (10.1%)	reported as enabling

Note: ‘Necessary’ indicates that the underlying studies/cases predominantly described the prerequisite as essential, critical, mandatory, or go/no-go, or linked its absence to non-start or severe early derailment. ‘Helpful’ indicates a probability-raising enabler not framed as indispensable. ‘Mixed/context-dependent’ indicates that sources varied in their framing or made the relevance contingent on sector, size/complexity, maturity, or initiative type. Percentages indicate reporting prevalence in the reviewed studies/cases. They do not represent effect sizes, formal importance weights, or causal rank orderings.

To reflect the fact that the corpus contains both diagnosis-focused cases and transformation-rich cases, the cases were split into diagnosis-focused cases (n = 33) and transformation-rich cases (n = 36). Table 6 reports split-sample frequencies alongside the pooled Table 5 overview. The split-sample comparison supports the two-gate interpretation that prerequisites operate differently at the diagnostic entry versus the conversion-to-execution stage. Method/entry, Purpose & urgency, Leadership & governance, Engagement, and Measurement design are prevalent across both subsets, consistent with conditions that enable an HPO diagnosis to start credibly and generate actionable priorities. By contrast, Change ownership, Change capacity, Embedding/integration, Resourcing, Organizational infrastructure, and Peer learning structure are reported materially more often in the transformation-rich subset than in the diagnosis-focused subset. This pattern indicates that the pooled Table 4 frequencies understate several conversion-stage prerequisites, because diagnosis-focused case descriptions typically provide less detail on execution infrastructure. Accordingly, pooled Table 4 results should be interpreted primarily as a corpus-wide overview of prerequisites across HPO diagnosis and transformation, while Table 6 provides the more precise estimate of prerequisites that become salient once organizations move from diagnosis into sustained transformation execution.

Table 6. Reported start conditions identified in the published HPO cases

Category	Pooled k/69 (%)	Diagnosis-focused k/33 (%)	Transformation-rich k/36 (%)	Δ (Trans–Diag)
Method/entry	69/69 (100.0%)	33/33 (100.0%)	36/36 (100.0%)	0.0
Purpose & urgency	69/69 (100.0%)	33/33 (100.0%)	36/36 (100.0%)	0.0
Leadership & governance	69/69 (100.0%)	33/33 (100.0%)	36/36 (100.0%)	0.0
Engagement	61/69 (88.4%)	26/33 (78.8%)	35/36 (97.2%)	18.4
Direction-setting	25/69 (36.2%)	7/33 (21.2%)	18/36 (50.0%)	28.8
Change ownership	24/69 (34.8%)	0/33 (0.0%)	24/36 (66.7%)	66.7
Measurement design	29/69 (42.0%)	14/33 (42.4%)	15/36 (41.7%)	-0.8
Change capacity (agents)	23/69 (33.3%)	0/33 (0.0%)	23/36 (63.9%)	63.9
Embedding/integration	20/69 (29.0%)	0/33 (0.0%)	20/36 (55.6%)	55.6
Change capacity (coverage/quality)	13/69 (18.8%)	0/33 (0.0%)	13/36 (36.1%)	36.1
Resourcing	17/69 (24.6%)	0/33 (0.0%)	17/36 (47.2%)	47.2
External enablement	14/69 (20.3%)	1/33 (3.0%)	13/36 (36.1%)	33.1
Peer learning structure	8/69 (11.6%)	0/33 (0.0%)	8/36 (22.2%)	22.2
Organizational infrastructure	8/69 (11.6%)	0/33 (0.0%)	8/36 (22.2%)	22.2
Culture/learning climate	7/69 (10.1%)	3/33 (9.1%)	4/36 (11.1%)	2.0

Note: “Reported as stage-gating” indicates that source authors described the condition as essential, critical, mandatory, go/no-go, or linked its absence to non-start or severe early derailment. “Reported as enabling” indicates a probability-raising enabler not framed as indispensable. “Mixed/context-dependent” indicates that sources varied in their framing or made the relevance contingent on sector, size/complexity, maturity, or initiative type. These labels summarize source-author or case-author framing and do not constitute formal causal or necessity-test results. Percentages indicate reporting prevalence in the reviewed studies/cases; they are not effect sizes, formal importance weights, or causal rank orderings.

Table 6 provides a split-sample view of the Table 5 prerequisite taxonomy, comparing diagnosis-focused cases (n = 33) with transformation-rich cases (n = 36), along with the pooled corpus frequencies. The comparison supports the two-gate interpretation: Method/entry, Purpose & urgency, Leadership & governance (and broadly Engagement/Measurement design) are reported across both subsets, consistent with diagnosis-start conditions, whereas Change ownership, change-agent capacity, embedding/integration, resourcing, external enablement in externally mandated or public-sector settings, organizational infrastructure, and peer-learning structures are reported substantially more often in the transformation-rich subset. Accordingly, the pooled Table 5 frequencies should be read as a corpus-wide overview, while Table 6 better indicates which prerequisites become salient when organizations move from diagnosis into disciplined transformation execution.

Across the empirical cases, three features are universally reported in the sampled HPO starts: a structured entry method (diagnosis plus sensemaking), a credible ‘why now’ trigger, and leadership permission/mandate to participate and decide. This pattern suggests that, within the published HPO start narratives in this corpus, starting is less about declaring ambition and more about creating minimum viable implementation feasibility: a workable entry method, a legitimizing reason to start, and authority to mobilize attention and participation. The 100% values for ‘Method/entry’ and ‘Purpose & urgency’ should, however, be read cautiously. They indicate that these elements were explicitly present in all published start narratives in this corpus; they do not demonstrate that these conditions are universally required across all possible HPO starts. In part, these high percentages reflect corpus construction and publication genre, because a published HPO case almost always contains both a definable entry method and an articulated rationale for launch.

A second tier of prerequisites concerns the transition from ‘measurement’ to ‘movement’. Engagement, direction-setting, and change ownership indicate that early traction depends on whether the diagnosis becomes a shared story with ownership rather than remaining a report. Importantly, these prerequisites are often described as mixed because they depend on how the initiative is framed and on the organization’s maturity and structure. For example, broad participation may be straightforward in small units but requires deliberate design in distributed organizations; similarly, ‘ownership’ can be satisfied by a single sponsor in a small organization but requires a governance home and cross-unit coordination in larger settings.

A third tier of prerequisites relates to execution capacity and institutionalization: change agents, embedding into routines, adequate coverage of facilitation roles, and resourcing. These show lower frequencies partly because not all cases report the transformation in equal detail (diagnosis-focused cases often contain less information about post-diagnosis capacity design). Nonetheless, when reported, these prerequisites are strongly linked to whether early improvements translate into disciplined cycles rather than fragmented activity. Finally, several prerequisites appear at low frequency but remain practically important in the contexts where they are binding: cross-unit peer learning, organizational infrastructure, and baseline psychological safety. Their lower frequency should not be interpreted as low importance; rather, these factors are often either assumed by authors, treated as transformation outcomes rather than starting conditions, or become decisive only in specific organizational forms (e.g., multi-site settings where diffusion and standardization are challenging). Overall, the empirical results support a ‘contingent interpretation’: while a small core of conditions is recurrently reported as stage-gating within the published HPO start narratives, many other prerequisites act as probability-raising enablers whose importance depends on sector, organizational complexity, and maturity (Bokrantz & Dul, 2023; Furnari et al., 2021).

Mechanisms through which the published HPO-case prerequisites work

To move from a checklist interpretation to an explanatory understanding, the empirical prerequisite categories can be grouped into a smaller set of start-enabling mechanisms. These mechanisms parallel those identified in the theoretical section but are tailored to what the HPO case evidence emphasizes at launch: translating HPO into concrete attention points, mobilizing authority and commitment, creating ownership and coordination, enabling early learning loops, and preventing early stall. The mechanisms in Table 7 were not coded as directly measured variables in the source cases. They are abductive, author-inferred explanations derived from recurring clusters of coded start conditions and failure patterns. In particular, “translation into actionable focus” is inferred from repeated source descriptions of diagnosis, facilitated sensemaking, attention-point selection, and first commitments; it should therefore be read as an interpretive bridging mechanism between diagnosis output and execution onset.

Table 7. Mechanisms through which the published HPO-case prerequisites work

Mechanism	Description	Prerequisite using the mechanism
Legitimation and prioritization	Creates the mandate and attention to start now; reduces political resistance and accelerates decisions	Purpose & urgency; Leadership & governance; Direction-setting
Translation into actionable focus	Converts “HPO” from an abstract ambition into a small number of workable attention points and first actions	Method/entry (diagnosis + sensemaking); Measurement design
Coordination and ownership	Clarifies who owns follow-up and how work is coordinated so the diagnosis becomes execution	Change ownership; Embedding/integration; Organizational infrastructure
Engagement and psychological safety	Builds willingness to participate, speak up, and adopt new routines; reduces fear-based non-adoption	Engagement; Culture/learning climate; (and sensemaking elements of Method/entry)
Capability to execute improvement work	Provides people and roles that can translate attention points into disciplined improvement cycles	Change capacity (agents); Change capacity (coverage/quality)
Protected capacity and resourcing	Prevents improvement being crowded out by operational pressure; enables consistent participation	Resourcing; Leadership & governance; External enablement
Feedback and learning loops	Enables rapid learning about whether changes work and why; supports course correction and credibility	Measurement design; Embedding/integration; Peer learning structure; Organizational infrastructure

The empirical evidence reinforces that these mechanisms are complementary. For example, legitimacy without translation creates rhetorical commitment without action; translation without ownership produces a ‘report effect’; ownership without protected capacity produces overload and disengagement; and early actions without feedback loops produce activity without learning. Therefore, a successful start is best understood as the activation of a balanced mechanism set, not as maximizing any single prerequisite.

Influence of organizational size and maturity on the prerequisite configuration

Because standardized information on organizational size and maturity was not available for all published HPO cases, the analysis below is exploratory rather than a formal cross-case subgroup test. We coded size- or maturity-related contingencies only when case authors made these implications explicit. The patterns reported should therefore be read as indicative rather than statistically generalizable. The empirical evidence indicates that organizational size and maturity rarely change the names of prerequisite categories, but they strongly influence which prerequisites become binding constraints at launch, the minimum threshold required for a viable start, and the sequencing through which prerequisites must be built. Three recurring patterns appear across cases:

• small organizations and units (SMEs, small departments). In smaller settings, the binding constraints are typically feasibility-related: limited slack, multi-role staffing, and dependency on a few key individuals. This increases the importance of clear entry method and prioritization (to avoid initiative sprawl), a visible sponsor/owner, and integration into routine rhythms so the initiative does not compete with daily work;
• large and distributed organizations. In larger, multi-site, or functionally fragmented organizations, the binding constraints shift toward coordination prerequisites: clear ownership, explicit governance home, role clarity, and sufficient coverage of change agent capacity. Engagement also becomes harder to achieve without deliberate segmentation and communication architecture, because broad participation cannot be assumed when distance, professional silos, and local subcultures exist;
• maturity effects (operational excellence and change maturity). Low-maturity organizations often require stronger readiness-building before launching at scale (e.g., simplified scoping, explicit sensemaking, capability building, and leadership role modeling). More mature organizations tend to face stage-dependent prerequisites: they may need renewed urgency and ‘next benchmark framing’ to prevent fatigue or plateau, and more institutionalized learning loops (repeat diagnosis, review rhythms) to sustain traction over time.

In sum, size and maturity shape which prerequisites are most binding at the start, supporting the practical use of the HPO diagnosis not only as a performance baseline, but also as a readiness diagnostic to identify which prerequisites must be strengthened before scaling a transformation.

Failure factors identified in the published HPO cases

Empirical failure factors provide a complementary window into prerequisites: missing starting conditions become visible through the recurrent ways initiatives stall, derail, or produce fragile gains. Table 8 lists the failure factors coded across the cases and their frequencies. Failure categories are not mutually exclusive: a single case can contribute to multiple failure categories. Because the corpus consists of launched HPO initiatives, some failures (especially pure non-start) are structurally less visible than breakdowns that occur after launch or during early follow-through. Appendix 4 in the online supplementary material provides study-level detail.

Table 8. Failure factors identified in the published HPO cases

Failure category	What fails	k/69 (%)
Communication & trust breakdown	Weak transparency / one-way communication → distrust, rumors, low candor, low willingness to act	36/69 (52.2%)
Governance & follow-through gap	Diagnosis doesn’t translate into disciplined execution (weak cadence/closure, unclear ownership)	33/69 (47.8%)
Engagement deficit	Low involvement/empowerment → resistance, slow uptake, QII remains “management’s thing”	29/69 (42.0%)
Leadership commitment failure	Compliance-only / inconsistent leadership support → credibility loss; execution stalls	14/69 (20.3%)
Psychological safety/mistake fear	Blame/lose-face/fear → silence, low learning, conservative decisions	15/69 (21.7%)
Project overload / too many initiatives	Too many parallel programs → dilution, fatigue, “start-happy/finish-poor”	11/69 (15.9%)
Change-agent design failure	Too few/wrong-fit/unclear coach roles → bottlenecks, fragility, resentment	9/69 (13.0%)
Resource starvation	No time/budget capacity → plans remain symbolic; improvement stalls	9/69 (13.0%)
Management inconsistency across units	Units apply different rules → fragmentation, fairness concerns, coordination problems	15/69 (21.7%)
Embedding failure (bolt-on effect)	QII experienced as “extra work” → operations crowd it out	6/69 (8.7%)
Measurement fit failure	Instrument/sampling/interpretation issues → weak legitimacy and learnability	7/69 (10.1%)
Leadership continuity shock	Sponsor/CEO turnover collapses priority/protection → momentum evaporates	2/69 (2.9%)
Change rejection/not-invented-here	Local unit rejects QII -> HPO as “not for us” → business-as-usual	1/69 (1.4%)

Note: Percentages indicate reporting prevalence in the reviewed studies/cases. They do not represent effect sizes, formal importance weights, or causal rank orderings.

Two patterns stand out. First, the most frequent failure factors concern the social and relational infrastructure of starting: trust, communication, and engagement. This indicates that many HPO initiatives fail early, not because the diagnostic tool is unavailable, but because people do not believe the initiative is fair, safe, or meaningful. Second, an equally frequent failure factor is a governance and follow-through gap, where diagnosis results do not translate into disciplined early execution. This reinforces the empirical importance of change ownership, embedding into routines, and capacity/role design; prerequisites that prevent the initiative from stalling after initial enthusiasm. Lower-frequency failures (e.g., measurement fit, continuity shocks, not-invented-here) remain context-salient: they may be decisive in specific settings even if not broadly reported across cases.

Sequencing effects: Recurring order-of-operations patterns

The cases show that prerequisites do not operate as a static checklist. Instead, they appear as recurring narrative pathways: descriptive order-of-operations patterns that case authors repeatedly use to explain how traction was achieved or why premature starts derailed. They should therefore be read as descriptive regularities in the published cases, not as universal stage laws or mandatory prescriptions. Five such pathways recur across the empirical cases:

• legitimize → diagnose → sensemake → commit. Successful starts typically involve an explicit mandate and urgency framing, followed by diagnosis and facilitated sensemaking that produces a small number of attention points and clear commitments;
• ownership and cadence early, before scaling. Cases repeatedly suggest that the transition from diagnosis to execution depends on installing a governance home (owner/champion) and a review rhythm early; scaling without cadence increases drift and report-only outcomes. A report-only outcome occurs when a QII produces a report and perhaps presentations/action lists, but does not translate into sustained execution and operational change (Bromley and Powell, 2012);
• pilot → learn → standardize → scale. Where transformation actions are described, successful starts often begin with pilots or limited-scope interventions, rapid learning, standardization of what works, and then expansion;
• foundations first, advanced interventions later. Many cases imply that foundational routines (role clarity, leadership behaviors, basic feedback cadence, and disciplined closure) should precede more complex toolkits or broader culture programs;
• repeat diagnosis as a learning and renewal loop. In longer journeys, repeated HPO diagnoses function as a governance mechanism: they make progress visible, refresh urgency, and support adaptation of the transformation design as maturity increases.

These sequencing patterns indicate that the HPO diagnosis can be positioned as the formal readiness and prioritization phase of an HPO initiative, and that organizations can reduce time-to-impact by staging the transformation: create legitimacy, translate diagnosis into a small set of owned actions, protect capacity, and embed early learning loops before attempting broad scaling.

MATCHING THE INTEGRATIVE REVIEW WITH THE HPO CASE SYNTHESIS

This section compares the theoretical prerequisite set and mechanisms derived from the general QII readiness/feasibility literature with the empirical patterns found in published HPO diagnosis and transformation cases. The aim is not to obtain numerical equivalence between the two datasets - because the theoretical synthesis is based on 34 studies while the empirical synthesis is based on 69 cases - but to assess conceptual alignment, identify systematic gaps, and refine the understanding of which prerequisites matter at the start of an HPO initiative.

Match between literature-derived prerequisites and HPO-case reported start conditions

Table 9 provides a crosswalk between the integrative-review prerequisite categories in Table 1 and the HPO case-synthesis start-condition categories in Table 5. The matching is many-to-many: some theoretical prerequisites map to multiple HPO categories, and some HPO categories consolidate multiple theoretical ideas. Because the HPO corpus contains both diagnosis-focused and transformation-rich cases, lower HPO-side frequencies should be read as reporting prevalence rather than evidence that a condition is unimportant or absent. The crosswalk is therefore interpretive and should not be read as a formal gap analysis or necessity test.

Table 9. Crosswalk between integrative-review and HPO case-synthesis reported start conditions

Integrative review prerequisites (Table 1)	HPO case synthesis prerequisites (Table 5)
Leadership commitment & sponsorship - reported as stage-gating; 31/34, 91.2%	Leadership & governance - reported as stage-gating; 69/69, 100.0%. This is often framed as senior mandate, permission, and governance support enabling access, participation, and start decisions. It is complemented by Change ownership - mixed/context-dependent; 24/69, 34.8% - when a named internal owner, champion, or governance “home” is explicitly described.
Training, skills & improvement competence - reported as stage-gating; 30/34, 88.2%	Change capacity (agents) - mixed/context-dependent; 23/69, 33.3% - and Change capacity (coverage/quality) - mixed/context-dependent; 13/69, 18.8%. In the HPO cases, improvement capability is less often described as already in place at diagnostic entry and more often becomes visible when cases move from diagnosis to disciplined transformation execution.
Data, measurement & information systems - reported enabler; 28/34, 82.4%	Measurement design - reported enabler; 29/69, 42.0% - supported by Organizational infrastructure - reported enabler; 8/69, 11.6%. In HPO cases, the HPO diagnosis itself often provides the baseline measurement structure, which reduces explicit emphasis on pre-existing KPI or IT infrastructure at the start.
Culture & change readiness - reported as stage-gating; 27/34, 79.4%	Culture / learning climate - reported enabler; 7/69, 10.1% - and Engagement - mixed/context-dependent; 61/69, 88.4%. Supportive culture is rarely stated as a precondition in the HPO case corpus; many HPO initiatives start precisely because culture or learning climate is perceived as weak. The high Engagement frequency captures participation and buy-in more directly than generalized readiness culture.
Communication & stakeholder/customer focus - reported as stage-gating; 25/34, 73.5%	No single direct HPO prerequisite category. The closest empirical expression is indirect, through Method/entry - reported as stage-gating; 69/69, 100.0% - and Engagement - mixed/context-dependent; 61/69, 88.4%. Communication appears more strongly as a failure mode than as a stated prerequisite, especially in Communication & trust breakdown in Table 8 - 36/69, 52.2%.
Strategic alignment & direction - reported enabler; 23/34, 67.6%	Direction-setting - reported enabler; 25/69, 36.2% - and, partly, Purpose & urgency - reported as stage-gating; 69/69, 100.0%. The corrected HPO frequency for Direction-setting is lower than previously reported, suggesting that strategic direction is often embedded in the “why now” trigger rather than separately described as an explicit start condition.
Resources & capacity - reported as stage-gating; 22/34, 64.7%	Resourcing - mixed/context-dependent; 17/69, 24.6% - and, especially in public-sector or externally sponsored settings, External enablement - reported enabler; 14/69, 20.3%. The lower HPO frequency is consistent with diagnosis-heavy reporting and with resourcing becoming most visible when organizations move from diagnosis to implementation.
Employee involvement, engagement & attitudes - reported as stage-gating; 21/34, 61.8%	Engagement - mixed/context-dependent; 61/69, 88.4% - is the direct empirical match. With the corrected percentage, Engagement is more prominent in the HPO case synthesis than in the integrative-review table, reinforcing early participation and buy-in as a central HPO start condition.
Governance, project selection & staged roadmap - reported enabler; 19/34, 55.9%	Change ownership - mixed/context-dependent; 24/69, 34.8% - Embedding/integration - mixed/context-dependent; 20/69, 29.0% - and Organizational infrastructure - reported enabler; 8/69, 11.6%. These categories are especially visible in transformation-rich cases and are less often described as already present at diagnostic entry.
Intervention / technology fit & evidence base - mixed/context-dependent; 12/34, 35.3%	No direct standalone HPO equivalent. In the HPO cases, the HPO framework is usually the selected intervention, so “fit” is often implicit. Where fit is explicit, it is reflected mainly in Measurement design - reported enabler; 29/69, 42.0% - and in how Method/entry - reported as stage-gating; 69/69, 100.0% - is operationalized.
Clear need / urgency / motivation - reported enabler; 10/34, 29.4%	Purpose & urgency - reported as stage-gating; 69/69, 100.0% - is a strong empirical amplification of this prerequisite in the HPO corpus. Every HPO case contains a trigger, ambition, pressure, crisis, reform, growth rationale, or other “why now” condition legitimizing the start.
External environment support & networks - reported enabler; 9/34, 26.5%; whole-percentage value: 26%	External enablement - reported enabler; 14/69, 20.3% - and Peer learning structure - reported enabler; 8/69, 11.6%. Peer learning captures networked diffusion and cross-unit learning, sometimes as an internalized equivalent of external network support.
Change agent / dedicated improvement roles - reported enabler; 7/34, 20.6%	Change capacity (agents) - mixed/context-dependent; 23/69, 33.3% - and Change ownership - mixed/context-dependent; 24/69, 34.8%. The HPO synthesis distinguishes between the people who facilitate or execute improvement work and the accountable owner or governance home that keeps follow-up active.
Process baseline & standardization / method discipline - reported enabler; 3/34, 8.8%	Organizational infrastructure - reported enabler; 8/69, 11.6% - and Embedding/integration - mixed/context-dependent; 20/69, 29.0%. In the HPO cases, process discipline is more often described as something built during the transformation than as a fully established pre-start condition.

Note: Some apparent theory-practice mismatches may reflect reporting structure rather than substantive absence, especially where diagnosis-focused cases provide less detail on post-diagnosis execution infrastructure.

Key alignment patterns

There is a strong alignment at the ‘domain level’. Most theoretical prerequisite domains recur empirically in recognizable form: leadership, engagement, direction, governance/ownership, capacity, resourcing, and measurement. The empirical dataset therefore supports the theoretical claim that QII success is shaped by front-end readiness and feasibility conditions. Next, a consistent ‘translation gap’ explains why empirical prerequisites look different. The empirical cases repeatedly treat Method/entry (diagnosis + sensemaking) as the core start enabler. This is not a single category in the general QII prerequisite literature, but it effectively operationalizes several theoretical ideas at once: establishing a baseline (measurement), creating shared understanding (communication/engagement), prioritizing attention points (strategy/governance), and initiating an early learning loop. Finally, there is empirical amplification of urgency. ‘Clear need/urgency’ is only mid-frequency in the general QII literature yet becomes universal in the HPO cases (Purpose & urgency, 100%). A plausible interpretation is that HPO initiatives, because they are typically organization-wide and culture-relevant, require a stronger legitimacy trigger to mobilize attention and participation.

Key divergence patterns

First, culture & change readiness is high-frequency and often necessary in general QII literature but baseline psychological safety/learning climate is rarely described as present at the start of HPO journeys. This is consistent with HPO initiatives being launched specifically to address cultural deficits; i.e., the initiative can start in a low-readiness culture, but must quickly build engagement and safety to avoid predictable derailment. Second, training/skills and data systems are less often reported as already in place at the start of HPO initiatives. Two of the most frequently reported prerequisites - improvement competence and measurement systems - appear empirically in more modest start condition form (change agent capacity; measurement design). This is consistent with diagnosis-heavy reporting and the HPO diagnosis itself, which provides a structured baseline, allowing organizations to start even when broader improvement capabilities and KPI infrastructures are still underdeveloped. Third, governance and embedding show up later in practice unless the case is transformation-rich. Governance/project selection is common in the general QII literature; in HPO cases, governance clarity becomes highly salient as a failure mode (governance & follow-through gap: 33/69, 47.8%), even though explicit embedding as a prerequisite is of lower frequency. This supports the interpretation that governance is often insufficiently pre-established, and therefore becomes visible primarily through breakdowns in execution.

Match between literature-derived and HPO-case mechanisms

Table 10 compares the mechanisms identified in the integrative review synthesis (Table 2) with those in the HPO case synthesis (Table 7). Mechanism-level comparison is helpful because it reduces sensitivity to differences in terminology and category granularity.

Table 10. Match of the mechanisms

Integrative review mechanisms (Table 2)	HPO case synthesis mechanisms (Table 7)
Legitimization and prioritization	Legitimation and prioritization (direct match).
Coordination and accountability	Coordination and ownership (high match; empirical cases emphasize ownership and follow-through as the operational expression of accountability).
Capability to execute improvement work	Capability to execute improvement work (direct match; operationalized through change agents and role coverage).
Protected capacity and resourcing	Protected capacity and resourcing (direct match; empirically visible as resourcing needs and as crowd-out/overload failures).
Engagement and psychological safety	Engagement and psychological safety (direct match; also mirrored by the most frequent empirical failure factors).
Feedback and learning loops	Feedback and learning loops (direct match; empirically connected to repeated diagnosis and integration into routines).
Intervention-context fit and usability	No one-to-one match; empirically, the closest functional equivalents are Translation into actionable focus and (secondarily) Measurement design—reflecting that in HPO initiatives, “fit” is often achieved through sensemaking and translation rather than through technical customization alone.

At the mechanism level, the overlap is strong: both theory and practice suggest that successful starts require activating a balanced mechanism set, not a single ‘magic factor’. However, the empirical HPO cases add a mechanism that is relatively under-specified in general QII prerequisites: translation into actionable focus. In HPO work, this mechanism is activated by combining diagnosis with facilitated sensemaking to convert scores into a small set of attention points and initial commitments. This translation mechanism helps explain why HPO initiatives can often begin even when broader improvement competence or mature KPI infrastructures are not yet in place: the start phase creates an actionable focus that substitutes (temporarily) for missing implementation infrastructure, provided that ownership and follow-through are quickly established.

This mechanism overlaps with several established constructs, but is not identical to them. Compared with broad sensemaking, translation into actionable focus is narrower and more operational: it turns diagnostic outputs into a small, shared set of attention points and first commitments. Compared with prioritization or framing, it not only signals what matters but also specifies what can be acted on first. Compared with intervention-context fit, it does not primarily tailor a method or technology to local workflows; it converts an already accepted HPO diagnostic into locally actionable targets. Compared with feedback and learning loops, it occurs earlier: at the boundary between diagnosis and first commitment, before routine experimentation and monitoring are fully installed. We therefore treat translation into actionable focus as a bridging mechanism between diagnosis output and execution onset.

Match of size- and maturity-related contingency patterns

Both the theoretical synthesis and the empirical results converge on the same core conclusion: size and maturity do not fundamentally change the prerequisite domains, but they change which prerequisites become binding constraints, what minimum thresholds apply, and how prerequisites must be sequenced. Three matched patterns stand out:

1. Small organizations/units (low slack, high key-person dependency). Theory predicts that feasibility constraints make scoping, protected time, and sponsor visibility critical. Empirically, small-unit cases show the same vulnerability: initiatives are easier to mobilize socially, but fragile when ownership or protected capacity is missing, and prone to ‘initiative sprawl’ unless priorities are narrowed early.
2. Large, multi-site, or fragmented organizations (coordination complexity). Theory emphasizes governance/embedding, role clarity, diffusion, and consistency. Empirically, coordination failures manifest as the governance & follow-through gap, management inconsistency across units, and the need for peer learning and integration routines.
3. Maturity effects (change maturity/operational excellence maturity). Theory predicts stronger readiness-building requirements in low-maturity settings and stage-dependent requirements in mature settings (to prevent fatigue/plateau). Empirically, repeated diagnosis and governance cadence function as maturity-sensitive mechanisms: low maturity needs foundational routines first; higher maturity needs renewal loops and next benchmark framing.

Overall, the size/maturity comparison supports a contingent interpretation: prerequisite categories are stable, but a ‘one-size-fits-all’ launch checklist is not. Instead, HPO initiatives benefit from using the diagnosis as a readiness diagnostic that identifies which prerequisites are most binding for the specific organizational form before scaling the transformation.

Match between literature-derived and HPO-case failure factors

Failure factors triangulate prerequisites by showing what breaks when prerequisites are weak. A key interpretive limitation is that pure non-start is structurally underobservable in the empirical corpus, because the case sample necessarily consists of initiatives that achieved a visible start phase. Accordingly, the empirical evidence of failure is stronger for early post-launch derailments than for failures that prevented launch altogether. Table 11 matches the integrative review failure categories (Table 3) with the HPO case synthesis failure factors (Table 8). Because the empirical dataset focuses on start and early execution, it unsurprisingly contains fewer sustainment/long-horizon failures.

Table 11. Crosswalk between integrative-review and HPO case-synthesis reported failure factors

Integrative-review failure factors (Table 3)	HPO case-synthesis failure factors (Table 8)
Early resistance & low engagement - 25/31, 80.6%	Engagement deficit - 29/69, 42.0%; Communication & trust breakdown - 36/69, 52.2%; and Psychological safety / mistake fear - 15/69, 21.7%. This is a strong conceptual match. The HPO case synthesis splits the broad integrative-review category into more specific relational and participatory breakdowns.
Sustainment/backsliding/relapse - 21/31, 67.7%	No direct equivalent in the HPO start-phase failure list. This is an expected mismatch because the HPO coding emphasized launch, diagnosis-to-action conversion, and early execution rather than long-term sustainment or relapse. Some partial overlap is visible in Embedding failure (bolt-on effect) - 6/69, 8.7% - and Governance & follow-through gap - 33/69, 47.8%, where failure to institutionalize follow-up threatens durability.
Resource & capacity constraints - 20/31, 64.5%	Resource starvation - 9/69, 13.0%; Project overload / too many initiatives - 11/69, 15.9%; and Embedding failure (bolt-on effect) - 6/69, 8.7%. The match is partial. In the HPO cases, capacity problems are more often reported as crowd-out, overload, or lack of protected follow-through capacity than as a generic absence of resources.
Skills/training gaps - 20/31, 64.5%	Change-agent design failure - 9/69, 13.0% - and, indirectly, Governance & follow-through gap - 33/69, 47.8%. The match is partial. In the HPO cases, capability problems are less often framed as formal training gaps and more often as insufficient internal facilitation, weak change-agent coverage, or inadequate ownership of implementation routines.
Data/measurement/IT/integration barriers - 19/31, 61.3%	Measurement fit failure - 7/69, 10.1% - and, indirectly, Governance & follow-through gap - 33/69, 47.8% - where measurement does not translate into action or feedback routines. The match is partial. Because the HPO diagnosis itself supplies a measurement structure, the HPO cases report fewer generic IT, data-access, or baseline-measurement barriers than the wider QII literature.
Leadership/communication failure - 18/31, 58.1%	Leadership commitment failure - 14/69, 20.3%; Communication & trust breakdown - 36/69, 52.2%; Management inconsistency across units - 15/69, 21.7%; and Leadership continuity shock - 2/69, 2.9%. This is a strong conceptual match, but the HPO synthesis separates leadership credibility, communication quality, cross-unit consistency, and leadership turnover into distinct empirical failure modes.
Non-start, abandonment & fade-out - 18/31, 58.1%	Closest HPO equivalents are Governance & follow-through gap - 33/69, 47.8%; Embedding failure (bolt-on effect) - 6/69, 8.7%; and Change rejection / not-invented-here - 1/69, 1.4%. The match is conceptual rather than direct. Pure non-start is structurally underobservable in the HPO corpus because included cases had already reached a visible diagnostic or launch stage.
Weak implementation infrastructure/governance/role clarity/facilitation - 10/31, 32.3%	Governance & follow-through gap - 33/69, 47.8%; Change-agent design failure - 9/69, 13.0%; and Management inconsistency across units - 15/69, 21.7%. This is a strong match. The HPO cases especially emphasize the conversion problem: diagnosis produces attention points, but implementation weakens when ownership, cadence, decision rights, and closure routines are unclear.
Poor planning/goal/scope/project selection - 9/31, 29.0%	Project overload / too many initiatives - 11/69, 15.9% - and, indirectly, Governance & follow-through gap - 33/69, 47.8%. The match is partial. The HPO cases more often describe this failure mode as overload, weak prioritization, or lack of disciplined follow-through than as poor planning per se.
Stakeholder/partnership misalignment - 7/31, 22.6%	No strong direct HPO equivalent. Partial overlap appears in Communication & trust breakdown - 36/69, 52.2% - and Engagement deficit - 29/69, 42.0%, where misalignment manifests internally as distrust, limited participation, or weak ownership. The absence of a stronger match likely reflects the HPO corpus’s stronger focus on internal organizational transformation than on interorganizational partnerships.
External/regulatory/compliance constraints - 6/31, 19.4%	Not prominent in the HPO start-phase failure dataset. This is a weak match. External pressures often appear in the HPO cases as triggers for change rather than as coded failure factors that block launch or early execution.
Method / tool misfit & tool misuse - 5/31, 16.1%	Measurement fit failure - 7/69, 10.1%. The match is partial. Because the HPO cases typically begin from a standardized HPO diagnostic framework, method/tool misfit is less frequently reported than in the broader QII literature. Where it does appear, it is mainly expressed as measurement fit, interpretation, or translation difficulty.

Note: Integrative-review failure-factor percentages are calculated within the failure-codable subset of the integrative review, n = 31. HPO case-synthesis failure-factor percentages are calculated across the full HPO case corpus, n = 69. The crosswalk is interpretive and many-to-many: one integrative-review failure category may correspond to several more granular HPO failure factors, and some HPO factors may partially match several integrative-review categories. The comparison should therefore be read as a reporting-prevalence and conceptual-alignment table, not as a causal test.

The comparison shows strong agreement that the most common derailments occur first in the social system (engagement, trust, psychological safety) and in execution infrastructure (governance, ownership, follow-through). Where the theoretical literature emphasizes sustainment/backsliding and long-run capability/maturity problems, the empirical HPO cases emphasize the conversion problem: how to move from diagnosis results to owned actions with disciplined closure (Svejvig & Schlichter, 2020; Williams et al., 2025).

Match of sequencing patterns

The theoretical review and the empirical synthesis show substantial overlap in sequencing logic:

• Theory: Diagnosis → readiness-building → stage-gated launch.

Empirical: Legitimize → diagnose → sensemaking → commit; plus repeated diagnosis as a governance mechanism.

• Theory: Pilot → learn → standardize → scale.

Empirical: Pilot → learn → standardize → scale (direct match).

• Theory: Foundations first, advanced methods/technology later.

Empirical: Foundations first, advanced interventions later (direct match).

• Theory: Problem/benefit-led design chain (clarify → fit/capability → feasibility → tool choice).

Empirical: Achieved largely through the HPO diagnosis and the translation mechanism: the diagnosis clarifies the “problem landscape” and attention points before selecting interventions (functional match even if not explicitly labeled).

• Theory: Climate/engagement early + antecedent-first focus to enable institutionalization.

Empirical: Reinforced by high-frequency early failures in communication/trust and engagement, and by explicit emphasis on ownership/cadence before scaling (match).

Two refinements appear empirically:

1. Ownership and cadence as an explicit ‘before scaling’ gate. Empirical cases repeatedly highlight that scaling without a governance rhythm produces drift and report-only effects.
2. Repeat diagnosis as an institutionalized learning loop. Empirical cases treat re-diagnosis not merely as evaluation, but as a mechanism to refresh urgency, make progress visible, and adapt the transformation design as maturity changes.

Overall analysis

Bringing the comparisons together, the theoretical and empirical results are largely consistent in what matters, but differ in how prerequisites are operationalized and when they are required.

A two-stage interpretation reconciles the main frequency divergences

A central reason for divergence is that an HPO initiative is inherently two-part: diagnosis and transformation. The empirical cases include many diagnosis-focused reports, which means some prerequisites appear less frequently as ‘in place at launch’, even though they become crucial for converting diagnosis into execution. This suggests a practical refinement: distinguish between prerequisites for starting the diagnosis and prerequisites for starting/scaling the transformation. This yields the following two-gate structure. The start gate for the HPO diagnosis consists of: a structured entry method (diagnosis + sensemaking), a credible “why now”, and leadership mandate/permission to participate and decide. For the start/scaling gate for an HPO transformation (conversion into disciplined execution): ownership/governance home; change agent capacity and role clarity; protected capacity and resourcing; embedding into routines; learning-loop infrastructure (repeat diagnosis, review cadence); and (depending on context) diffusion structures and standardization. This two-stage framing preserves the theoretical emphasis on capability, measurement infrastructure, culture/climate, and resourcing, while explaining why the empirical HPO cases often show a narrower set of ‘start-of-diagnosis’ conditions.

The empirical contribution: ‘translation into actionable focus’ as a distinct start mechanism

General QII theory includes intervention fit/usability and feedback loops, but the empirical HPO cases show that translation - turning the diagnostic outputs into a small, owned, workable set of attention points - is a distinct and critical mechanism for reducing early stall and time-to-impact. This mechanism plausibly explains why HPO initiatives can begin in low-readiness contexts: translation creates shared focus and first commitments even when broader improvement capability and data infrastructures are incomplete.

Practical implications for go/no-go decisions

The matched evidence supports a practical go/no-go logic: do not postpone diagnosis solely because culture or CI competence is weak; diagnosis plus facilitated sensemaking can be used as a readiness-building step. However, do postpone scaling the transformation if ownership and governance cadence are absent, if protected capacity is not credible, or if follow-through discipline is structurally infeasible, because the dominant empirical failure mode is the governance & follow-through gap. In addition, use failure-factor patterns as diagnostic signals: repeated trust/communication breakdowns and engagement deficits signal that the initiative must invest early in implementation climate and psychological safety before expecting experimentation and adoption.

Theoretical refinement

The comparison suggests that the theoretical prerequisite set for successful starts benefits from an HPO-specific refinement. This entails retaining the broad QII prerequisite domains (leadership, engagement, culture/climate, capability, measurement, governance, resources, fit), but explicitly modeling entry method + translation as a front-end stage gate, and treating several prerequisites (culture readiness, improvement competence, measurement infrastructure) as frequently co-evolving with early implementation rather than always pre-existing. This refined perspective supports interpreting HPO initiatives as behaving like programmatic QIIs when viewed through this analytical lens, while also indicating that the resulting model is HPO-specific and interpretive rather than a universally verified start theory.

CONCLUSION

This study addressed the following RQ: What front-end conditions are recurrently reported as enabling the successful start of an HPO diagnosis and subsequent transformation? By integrating a theoretical synthesis of QII readiness/feasibility prerequisites and a case-based synthesis of published HPO diagnosis/transformation cases, the combined evidence supports interpreting a successful start as a stage-gated process rather than a single launch moment. More specifically, it supports a heuristic distinction between two recurrently reported start gates: (1) a diagnosis-start gate and (2) a transformation-start/scaling gate. The most common early derailments map directly to these gates: communication/trust breakdown, engagement deficits, and governance and follow-through gaps where diagnosis outputs fail to translate into owned execution.

The study does not verify which conditions are formally necessary in a causal or configurational sense; rather, it proposes an HPO-specific interpretive model of recurrently reported start conditions. The contribution of the study is analytical rather than taxonomic: it shows what becomes visible when HPO diagnosis and transformation are examined through a QII readiness lens, rather than claiming that HPO has historically been studied as a QII. The claims of the article are therefore limited to HPO diagnosis and transformation cases anchored in de Waal’s framework and are offered as an HPO-specific refinement of QII readiness thinking, not as a universally generalizable model for all quality improvement initiatives. Further, the study contributes theoretically by refining prerequisites as front-end readiness and feasibility conditions for a successful start, identifying translation into actionable focus as an HPO-specific start mechanism (diagnosis + sensemaking as mobilization), and distinguishing prerequisites needed to start diagnosis from those needed to start and scale transformation. Practically, the results support clearer go/no-go discussions: organizations can often start diagnosis early to create focus and legitimacy, but should stage-gate scaling until ownership, cadence, and capacity are credible.

This study has several limitations. First, the empirical synthesis relies on published case descriptions, which can introduce reporting bias (e.g., selective emphasis, retrospective rationalization, and overrepresentation of more ‘write-up-worthy’ trajectories). Therefore, the reported frequencies should be interpreted as the prevalence of explicitly reported prerequisites and failure modes, not as proof that unreported conditions were absent. Second, case richness differs: many sources report the diagnosis phase more fully than the transformation operating model. This likely undercounts some transformation-start prerequisites and helps explain why several execution infrastructure items show lower empirical prevalence. Third, the study does not provide causal identification. The ‘reported stage-gating / reported enabling / mixed-context-dependent’ classification reflects how sources framed conditions (go/no-go versus probability-raising) rather than formal necessity testing; prerequisites are interdependent and may be confounded by latent factors (e.g., managerial capability, slack, prior improvement maturity). Fourth, standardized data on size, complexity and maturity are not consistently available in case reports, limiting the precision of contingency claims. Fifth, the empirical design cannot observe the full population of ‘non-starts’. As a result, the case material is stronger for identifying recurrent launch conditions and early derailments than for distinguishing between conditions that are truly required for starting and those that are simply common in published HPO narratives. Sixth, several source publications contributed multiple subcases. Although this is appropriate for a case-level synthesis when case-specific evidence is available, it may have inflated frequencies through clustered reporting styles. The reported percentages should therefore be read as case-level reporting prevalence, not as publication-independent estimates of breadth. Seventh, the coding was conducted by one researcher without formal intercoder agreement testing or an external audit. Although consistency was strengthened through a written codebook, iterative refinement, two coding passes, traceable case notes, and a conservative rule against up-coding implied evidence, the findings remain a transparent expert classification rather than a fully reliability-validated consensus coding. Finally, the empirical operationalization is anchored in de Waal’s HPO diagnosis logic and in a start-phase focus. Some findings (e.g., the prominence of diagnosis + sensemaking as a start mechanism) may be framework-specific, and sustainment dynamics are less visible than in broader QII literature.

Future research can strengthen and extend this study in five directions. First, prospective longitudinal studies should test the proposed two-gate logic (diagnosis-start versus transformation-start/scaling) using observable start milestones. Second, researchers should examine thresholds and configurations of prerequisites (rather than single-factor checklists) to identify multiple ‘successful start recipes’ and context-bound necessity patterns (e.g., multi-site complexity, low CI maturity). Third, comparative work should test sequencing alternatives and evaluate effects on early conversion from diagnosis to disciplined execution. Fourth, the prerequisite model should be translated into and validated as a brief HPO readiness assessment separating diagnosis-start from transformation-start readiness, with predictive validity for early traction and time-to-impact. Finally, replication across other HPO/high-performance frameworks and links to longer-run outcomes (benefits realization, institutionalization, sustainment/backsliding) would strengthen external validity and connect start conditions to durable performance effects.

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Biographical note

André de Waal is Academic Director of the HPO Center, an organization that conducts research on high-performance organizations. André has been a consultant and partner with Arthur Andersen for 16 years. André was also 13-year Associate Professor of Organizational Effectiveness at the Maastricht School of Management. André teaches and does projects in the field of high performance organizations and performance management in countries such as China, Vietnam, Bangladesh, Mongolia, Nepal, Mexico, Peru, Ecuador, Suriname, the United States, the UK, Italy, Belgium, Portugal, Poland, Saudi Arabia, Yemen, United Arab Emirates, Palestine, South Africa, Namibia, Tanzania, Zambia, and Australia. He was selected by managementboek.nl as one of the Dutch Masters in Management, ten people who have most influenced management thinking in the Netherlands over the past decade. André has published more than 500 articles (among which more than 140 academic publications) and 36 books. His articles can be read on www.hpocenter.com and www.andredewaal.eu.

Author contribution statement

André de Waal: Conceptualization, Data Curation, Formal Analysis, Methodology, Visualization, Writing – Original Draft Preparation, Writing – Review & Editing.

Conflicts of interest

The author declares no conflicts of interest.

Citation (APA Style)

de Waal, A. (2026). From high-performance organization diagnosis to transformation: A stage-gated organizational readiness model. Journal of Entrepreneurship, Management and Innovation, 22(4), 67-92. https://doi.org/10.7341/20262244

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Received 3 February 2026; Revised 31 March 2026, 9 May 2026; Accepted 18 May 2026.

This is an open-access paper under the CC BY 4.0 license (https://creativecommons.org/licenses/by/4.0/legalcode).