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.