What we know about designing an effective improvement intervention (but too often fail to put into practice)

To cite: Marshall M, de Silva D, Cruickshank L, et al. BMJ Qual Saf Published Online First: [please include Day Month Year] doi:10.1136/bmjqs-2016006143 INTERVENING TO CHANGE HEALTH SYSTEM PERFORMANCE FOR THE BETTER It is temptingly easy to treat improvement interventions as if they are drugs—technical, stable and uninfluenced by the environment in which they work. Doing so makes life so much easier for everyone. It allows improvement practitioners to plan their work with a high degree of certainty, funders to be confident that they know what they are buying and evaluators to focus on what really matters— whether or not ‘it’ works. But of course most people know that life is not as simple as that. Experienced improvers have long recognised that interventions—the specific tools and activities introduced into a healthcare system with the aim of changing its performance for the better—flex and morph. Clever improvers watch and describe how this happens. Even more clever improvers plan and actively manage the process in a way that optimises the impact of the improvement initiative. The challenge is that while most improvers (the authors included) appreciate the importance of carefully designing an improvement intervention, they (we) rarely do so in a sufficiently clever way. In this article, we describe our attempts as an experienced team of practitioners, improvers, commissioners and evaluators to design an effective intervention to improve the safety of people living in care homes in England. We highlight how the design of the intervention, as described in the original grant proposal, changed significantly throughout the initiative. We outline how the changes that were made resulted in a more effective intervention but how our failure to design a better intervention from the start reduced the overall impact of the project. Drawing on the rapidly expanding literature in the field and our own experience, we reflect on what we would do differently if we could have our time again.