Often initiatives to improve quality and safety in healthcare are short lived or affect no real change. For those that are successful, it is usually the case that they are not capable of being replicated. One reason for this is the theory can mystify us, and this discourages its use in our work. Or we can think the theory is far removed from the realities of implementation.

In fact, we all use theory on a daily basis. Informal theory can create change as people base their reasoning on intuition derived from experience, however, when this is successful the lack of formal theory means that there is no strong evidence base to learn from and so it cannot be translated into a model for a wider audience. A further issue with an informal theory is that our intuition is often bias, distorted and limited in scope.

The formal theory, however, is often seen as a barrier to change. We can see it as intimidating, irrelevant and something which academics are concerned with. Formal theory is regarded as time-consuming, and we will often wish to move straight to the implementation stage.

Sometimes we need to make explicit the formal and informal theories we are using. From this, others can understand the rationale for change as well as the process. Failure to utilise formal theory can frustrate the efficacy and understanding of improvement interventions. Hypotheses can be tested and lessons learned, making it easier to adapt rather than having to start again from the beginning if improvement is not achieved. Without this explicit declaration of relevant theories, there is simply an attempt at change that is either successful or not. There can also be a lack of awareness which can lead to skewed data because the reasoning behind the change is missed and so data is not collated in an appropriate manner and contradictory results can emerge.

Developing a programme theory appears daunting to many; however, the process is usually one that people go through informally, and many of the tasks are straightforward. Theories are not used in isolation, and it is rare to proceed to action based solely on formal theory. Improvement teams are well-advised and able to sketch out interventions, then identify the components and the link between the application and the desired outcome.

It is important to understand the role that informal theory plays when developing an improvement plan. Personal experience is a powerful tool and a combination of informal and formal theory be more effective than either type of theory used by itself. The ability to blend these two types of theory at all stages of the improvement interventions is a skill that sets asides the expert from the novice in improvement.

It is necessary that we demystify theory when it comes to improvement and affecting change. We can then realise that the use of theory on a daily basis and by formalising the approach we allow ourselves to build a strong foundation on which to develop, learn and share best practice.

To read more http://qualitysafety.bmj.com/content/24/3/228
Davidoff F, Dixon-Woods M, Leviton L, et al Demystifying theory and its use in improvement BMJ Qual Saf 2015;24:228-238.

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