Criteria for evaluating programme theory diagrams in quality improvement initiatives: a structured method for appraisal.

BACKGROUND: Despite criticisms that many quality improvement (QI) initiatives fail due to incomplete programme theory, there is no defined way to evaluate how programme theory has been articulated. The objective of this research was to develop, and assess the usability and reliability of scoring criteria to evaluate programme theory diagrams. METHODS: Criteria development was informed by published literature and QI experts. Inter-rater reliability was tested between two evaluators. About 63 programme theory diagrams (42 driver diagrams and 21 action-effect diagrams) were reviewed to establish whether the criteria could support comparative analysis of different approaches to constructing diagrams. RESULTS: Components of the scoring criteria include: assessment of overall aim, logical overview, clarity of components, cause-effect relationships, evidence and measurement. Independent reviewers had 78% inter-rater reliability. Scoring enabled direct comparison of different approaches to developing programme theory; action-effect diagrams were found to have had a statistically significant but moderate improvement in programme theory quality over driver diagrams; no significant differences were observed based on the setting in which driver diagrams were developed. CONCLUSIONS: The scoring criteria summarise the necessary components of programme theory that are thought to contribute to successful QI projects. The viability of the scoring criteria for practical application was demonstrated. Future uses include assessment of individual programme theory diagrams and comparison of different approaches (e.g. methodological, teaching or other QI support) to produce programme theory. The criteria can be used as a tool to guide the production of better programme theory diagrams, and also highlights where additional support for QI teams could be needed.

A pilot survey of junior doctors' attitudes and awareness around medication review: time to change our educational approach?

OBJECTIVES: Our aim was to explore junior doctors' attitudes and awareness around concepts related to medication review, in order to find ways to change the culture for reviewing, altering and stopping inappropriate or unnecessary medicines. Having already demonstrated the value of team working with senior doctors and pharmacists and the use of a medication review tool, we are now looking to engage first year clinicians and undergraduates in the process. METHOD: An online survey about medication review was distributed among all 42 foundation year one (FY1) doctors at the Chelsea and Westminster Hospital NHS Foundation Trust in November 2014. Descriptive statistics were used for analysis. RESULTS: Twenty doctors completed the survey (48%). Of those, 17 believed that it was the pharmacist's duty to review medicines; and 15 of 20 stated the general practitioner (GP). Sixteen of 20 stated that they would consult a senior doctor first before stopping medication. Eighteen of 20 considered the GP and consultant to be responsible for alterations, rather than themselves. Sixteen of 20 respondents were not aware of the availability of a medication review tool. Seventeen of 20 felt that more support from senior staff would help them become involved with medication review. CONCLUSIONS: Junior doctors report feeling uncomfortable altering mediations without consulting a senior first. They appear to be building confidence with prescribing in their first year but not about the medication review process or questioning the drugs already prescribed. Consideration should be given to what we have termed a 'bottom-up' educational approach to provide early experience of and change the culture around medication review, to include the education of undergraduate and foundation doctors and pharmacists.

Spatial integration of optic flow information in direction of heading judgments.

While we know that humans are extremely sensitive to optic flow information about direction of heading, we do not know how they integrate information across the visual field. We adapted the standard cue perturbation paradigm to investigate how young adult observers integrate optic flow information from different regions of the visual field to judge direction of heading. First, subjects judged direction of heading when viewing a three-dimensional field of random dots simulating linear translation through the world. We independently perturbed the flow in one visual field quadrant to indicate a different direction of heading relative to the other three quadrants. We then used subjects' judgments of direction of heading to estimate the relative influence of flow information in each quadrant on perception. Human subjects behaved similarly to the ideal observer in terms of integrating motion information across the visual field with one exception: Subjects overweighted information in the upper half of the visual field. The upper-field bias was robust under several different stimulus conditions, suggesting that it may represent a physiological adaptation to the uneven distribution of task-relevant motion information in our visual world.

Designing quality improvement initiatives: the action effect method, a structured approach to identifying and articulating programme theory.

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.

Decoupling eye and hand movement control: visual short-term memory influences reach planning more than saccade planning.

When reaching for objects, humans make saccades to fixate the object at or near the time the hand begins to move. In order to address whether the CNS relies on a common representation of target positions to plan both saccades and hand movements, we quantified the contributions of visual short-term memory (VSTM) to hand and eye movements executed during the same coordinated actions. Subjects performed a sequential movement task in which they picked up one of two objects on the right side of a virtual display (the "weapon"), moved it to the left side of the display (to a "reloading station") and then moved it back to the right side to hit the other object (the target). On some trials, the target was perturbed by 1° of visual angle while subjects moved the weapon to the reloading station. Although subjects did not notice the change, the original position of the target, encoded in VSTM, influenced the motor plans for both the hand and the eye back to the target. Memory influenced motor plans for distant targets more than for near targets, indicating that sensorimotor planning is sensitive to the reliability of available information; however, memory had a larger influence on hand movements than on eye movements. This suggests that spatial planning for coordinated saccades and hand movements are dissociated at the level of processing at which online visual information is integrated with information in short-term memory.