What is Program Theory and Why Is It Important to Perioperative Quality Improvement?

Introduction: What Is Program Theory?

Those undertaking quality improvement (QI) in perioperative care are understandably concerned with knowing whether their interventions work. Increasingly, the importance of understanding how interventions work is recognized, too. In this chapter, we outline the importance of program theory—which is principally concerned with the how question—for improving quality in perioperative care.

Theory is a word that attracts many definitions, many of them competing, contradictory, or even intimidating. In the context of QI, the concept of a program theory is a particularly useful one and is based on the principle that the design and implementation of interventions are always a reflection of underlying assumptions about a particular problem and how it can be addressed. Surfacing those assumptions and formalizing them into a program theory is an important responsibility of improvers because the assumptions are fundamental to understanding the goals of the intervention, the mechanisms through which it is intended to work, and the resources and activities needed to deliver it.

A program theory is a characteristically small theory : It is specific to an intervention, rather than operating at a higher level of abstraction; it seeks to explain how the intervention is intended to lead to desired outcomes; and it is practical and accessible. A program theory may involve two things. First, it can offer a theory-of-change that narratively explains the rationale and assumptions about mechanisms that are intended to link what is happening in the intervention to the intended outcomes, as well as identifying the stakeholders and identifying the conditions for success. For instance, an intervention to reduce mortality after emergency abdominal surgery was founded in an explicit program theory that identified the desired outcomes, the QI strategies to be used, the activities and resources, and the supporting evidence.

To help in these tasks, the program team used IF-THEN-SO THAT statements such as the following:

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  IF key professionals come together to form an improvement team and

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  IF relevant data are reviewed and feedback is provided to teams regularly,

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  THEN professionals can work as a team to define and achieve local improvement goals and

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  THEN basic QI approaches can be employed to achieve the improvement goals

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  SO THAT mortality after emergency laparotomy can be reduced.

Second, a program theory can use logic models, driver diagrams, or other visual methods to show the relationship between the intended outcomes and the components of the intervention. Depending on the approach chosen, these techniques may simply depict inputs, resources, activities, and outcomes and show the relationship between them, but they can also include other features of the program (e.g., relating to the contexts, the nature of the problem, assumptions, and rationale for change, and outputs and impacts). For instance, a QI initiative to involve families in patients’ care after surgery developed a visual logic model showing the situation (including inadequate involvement of family caregivers), external factors (including ward cultures and family dynamics), the inputs needed, the intervention, the activities, and the immediate, intermediate, and ultimate outcomes. Driver diagrams offer a more focused analysis of the outcomes sought (usually on the left of the diagram), the primary drivers (the broad areas requiring attention), and the secondary drivers (often relating to processes), as shown in the example in Fig. 21.1 , aimed at improving surgery for older people.

Why Use Program Theory in Perioperative Quality Improvement?

A key feature of improvement work, of course, is that those undertaking it are always, consciously or not, working with a set of assumptions and rationales about how their intervention is going to work, but using theory explicitly is helpful at every stage of a QI initiative.

• Planning the intervention: Planning of QI greatly benefits from articulating a program theory. It improves clarity around what the intervention is attempting to accomplish, the mechanisms of change, who the stakeholders might be, and the relevant contexts. By encouraging improvers to be clear about the goals, inputs and resources, processes and activities, expected outputs and outcomes, relevant evidence, and what might facilitate or hinder the effort, program theory can support appropriate intervention development and anticipation of the resources needed, the actions to be taken, and the likely barriers. Developing a logic model may be especially valuable in revealing elements that have not been thought through sufficiently or where there are differences of stakeholder opinion and where weaknesses or incoherence in the proposed intervention's causal logic might lie.

• Data: An explicit program theory helps to identify what data are needed and from whose perspective. For example, an initiative to reduce surgical site infections might begin by suggesting that data should be collected on variables such as 30-day occurrence, antibiotics used, timing of initial dose and re-dose, and operation type and length. Articulating the program theory, however, might reveal the importance of clinician behaviors and practices and thus reconfigure understanding of the types of data likely to be relevant. Articulating the program theory may also be important in identifying when patient-reported data is needed.

• Implementation: QI initiatives frequently experience challenges of implementation. Explicit articulation of a theory about how they will be introduced into practice, the influences on implementation, and the contextual influences is therefore helpful. Further, QI initiatives may not be delivered exactly as planned. Describing how the program was supposed to be carried out and subsequently recording how it actually was performed provides learning about to support future implementation. Having a program theory can support assessment of whether the program was implemented with fidelity to the plan and can enable curation of evolution and mutation over time.

• Evaluation: An explicit account of intervention components, processes, and assumptions underpinning an intervention provides a robust framework for both summative and process evaluation. Process evaluation can allow assessment of whether the assumptions and rationales underpinning implementation actually play out in practice, thus enabling analysis of whether any problems were because of failures of implementation or failures of theory, supporting replication of successful programs, and highlighting what adaptations might need to be made to less successful efforts.