Table 2 The EPOCH trial Quality Improvement (QI) programme theory

Motivation for change created amongst stakeholders and improvement goals clearly understood

QI leads hold a stakeholder meeting after activation

(QI strategy 1)

1. Pre-activation checklist (providing guidance for planning of stakeholder meeting)

2. Evidence for QI and need for change provided

3. Presentation on achieving engagement

• Improvement projects require attention to the social context in which improvements are to be made which in turn requires relevant stakeholders to be informed and engaged (e.g. evidence from both Michigan Keystone and Enhanced Recovery programmes [19, 48])

• Data feedback can create cognitive dissonance if it is at variance from self-assessed or perceived performance, which in turn can lead to motivation for change [49].

Inter-professional collaboration (IPC) fostered

Each hospital to form an inter-professional improvement team

(QI strategy 2)

4. Team approach promoted

5. QI leads encouraged to invite colleague to EPOCH meetings

6. EPOCH VLE open to all local QI team members

• There is sound theoretical and empirical evidence for the specific role of clinically-led quality improvement teams in successful QI [42, 50].

Shared view of current performance created (‘situational awareness’)

QI leads analyse their own data (NELA data +/− case note reviews and local audit data) and feed this back to colleagues regularly

(QI strategy 3)

7. Case-note review tool

8. Training on data for improvement

9. Training on how to access and analyse NELA data

10. Excel workbook programmed to create run charts from NELA data

11. Secure data sharing site created on VLE

• Creating situational awareness regarding clinical performance is seen as fundamental to The Model for Improvement [51] and is the foundation of Feedback Intervention Theory [49, 52]

• Recent empirical data points to data feedback as central to success of several key QI projects [13, 19, 53]

• Cochrane reviews on data feedback indicate a positive impact on quality improvement if feedback is appropriate and timely and when a path to improvement is proposed [35, 52].

Frontline teams develop and use basic QI skills to effect change

QI leads and other team members:

Use time-series charts (‘run-charts’)

(QI strategy 4)

Segment the patient pathway

(Qi strategy 5)

Use the Plan-Do-Study-Act (PDSA) cycles

(QI strategy 6)

12. Introduction to QI skills training provided

13. Links to further reading and training resources for QI

14. Telephone and email support

• Application of improvement science approaches such as the Model for Improvement require at least some basic skill acquisition, and evidence points to a deficit in this area putting significant strain on the ability of an improvement project to achieve its potential [38, 54].

• Time-series charts (‘run-charts’) are a simple and robust method of analysing and presenting (for data feedback) changes to care processes [55].

• Segmentation of the proposed patient pathway involves introducing interventions within the pathway in an iterative fashion. Pathway segmentation makes the clinical element of this intervention less complex, more compatible with current systems and may makes process changes more trial-able and lower risk [34]

• The IHI’s Model for Improvement, incl. The PDSA cycle, is an internationally accepted approach to quality improvement [51, 56].