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Designing quality improvement initiatives: the action effect method, a structured approach to identifying and articulating programme theory
  1. Julie E Reed,
  2. Christopher McNicholas,
  3. Thomas Woodcock,
  4. Laurel Issen,
  5. Derek Bell
  1. 1NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, London, UK
  1. Correspondence to Dr Julie Reed, NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9HN, UK; Julie.reed02{at}


Background The identification and articulation of programme theory can support effective design, execution and evaluation of quality improvement (QI) initiatives. Programme theory includes an agreed aim, potential interventions to achieve this aim, anticipated cause/effect relationships between the interventions and the aim and measures to monitor improvement. This paper outlines the approach used in a research and improvement programme to support QI initiatives in identifying and articulating programme theory: the action effect method.

Background to method development Building on a previously used QI method, the driver diagram, the action effect method was developed using co-design and iteration over four annual rounds of improvement initiatives. This resulted in a specification of the elements required to fully articulate the programme theory of a QI initiative.

The action effect method The action effect method is a systematic and structured process to identify and articulate a QI initiative's programme theory. The method connects potential interventions and implementation activities with an overall improvement aim through a diagrammatic representation of hypothesised and evidenced cause/effect relationships. Measure concepts, in terms of service delivery and patient and system outcomes, are identified to support evaluation.

Discussion and conclusions The action effect method provides a framework to guide the execution and evaluation of a QI initiative, a focal point for other QI methods and a communication tool to engage stakeholders. A clear definition of what constitutes a well-articulated programme theory is provided to guide the use of the method and assessment of the fidelity of its application.

  • Evaluation methodology
  • Quality improvement methodologies
  • Quality measurement
  • Implementation science
  • Communication

This is an Open Access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:

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