Table 1

Definition of action effect diagram features

(and appearance on diagram)
Aim (single box on left-hand side of diagram)▸ Describes the overall aim of the improvement effort
▸ Indicates aspiration (e.g. to improve, to reduce, to increase)
▸ Defines scope: including patient group in which improvement is targeted
▸ Agreed by all stakeholders 
Contributing factors (boxes to the right of the aim and left of interventions)▸ Represent concepts proposed to causally link the interventions to the aim. Contributing factors that feed directly to the aim:
 ▸ Referred to as 'major contributing factors'
 ▸ Cover a comprehensive view of activities sufficient to achieve the aim 
Interventions (boxes to the right-hand side of contributing factors)▸ Specify clearly the changes being made in order to achieve the aim
▸ Intended to become part of routine service delivery
Implementation activities (boxes to the right of interventions and contributing factors)▸ Represent activities supporting the implementation of an intervention
▸ Not intended to necessarily become part of the routine service delivery
▸ Directly controllable by the team running the improvement initiative 
Cause/effect arrows (arrows connecting pairs of boxes)▸ Indicate the direction of cause and effect: the head of the arrow is connected to the effect, the other end to the cause
▸ Connect boxes that are clearly related, with no tacit knowledge necessary to understand the connection
▸ Point from right to left in the diagram 
Cause/effect chains
(sequence of boxes, each connected to the next by a cause/effect arrow)
▸ Indicate how the implementation activities and interventions are proposed to influence contributing factors and, in turn, the achievement of the aim
▸ Comprehensible to the target audience without additional information
▸ Moves from factors under direct control on the right of the diagram, through to indirect influence on the left of the diagram 
Measure concepts (numbered list accompanying diagram, circled numbers added to associated boxes)▸ Associated with one or more boxes (aim, contributing factors, interventions, implementation activities) that are to be measured
▸ Described concisely and clearly to allow team members to understand the association(s)
▸ Distributed across the diagram, capturing process and outcome