Developing and refining a theory of change to improve time to antibiotic administration for febrile pediatric oncology patients in real-world settings.
Authors: Pershad Alisha Ria , Echeandia Abud Naomi , Duran Francis , Gonzalez-Guzman Miriam , Houston Logan Cole , Enriquez-Chavez Cecilia , Aristizabal Paula , Arrieta Jafet , Friedrich Paola 
Published: June 2022

e18708 Background: From May 2019 to November 2020, 23 institutions participated in the first Mexico in Alliance with St. Jude Golden Hour Quality Improvement Collaborative (MAS Collaborative) and successfully reduced the TTA in fPHOP from 156.8 minutes to 59.4 minutes and demonstrated improved clinical outcomes The MAS Collaborative followed the Institute for Healthcare Improvement’s Breakthrough Series (BTS) model, which involves using a shared Theory of Change (TOC). This report describes the process followed to develop and refine the TOC, which is currently being used at-scale in the second MAS Collaborative. Methods: The theory of change was built over the course of four phases: pilot testing, driver diagram refinement, multisite deployment, and consolidation and dissemination. A driver diagram (DD) was used to organize and visualize the TOC. The first version of the TOC was built based on the experience of four institutions that piloted the Golden Hour in Mexico in 2018. It was then refined based on the input from a multidisciplinary expert panel. The DD was shared with teams from participating institutions and teams used Plan-Do-Study-Act cycles to test and adapt change ideas to their local context using. At the end of the first MAS Collaborative, teams reported the change ideas they tested and their degree of belief (low to high) that the change ideas had led to improved outcomes. This information was used to refine the TOC, which was validated with a second expert panel in preparation for the second MAS Collaborative. Results: The initial DD included five primary drivers, 16 secondary drivers, and 32 change ideas. The primary drivers were effective availability of medications and supplies, dynamic data learning systems, early detection of fever, process reliability, and effective teamwork. The 23 teams tested change ideas for all primary drivers and 34 of the change ideas were reported as having a high degree of belief. Based on the experience and feedback from participating teams, two secondary drivers were added to the DD for the second MAS Collaborative: 1) promoting wellbeing and resilience and 2) promoting early detection of fever at home. The final DD included five primary drivers, 18 secondary drivers, and 97 change ideas. A refined and robust TOC is currently being used for the second MAS Collaborative. Conclusions: The multiphase process followed to develop the TOC was key to the success of the first MAS Collaborative. Contrary to more prescriptive approaches to project implementation, the inherent flexibility of this TOC allowed teams to operate with a greater sense of agency, developing, adapting and testing implementing changes. This TOC provides practitioners with practice-based evidence to reduce TTA and improve clinical outcomes for children with cancer in resource-limited real-world settings in the context of the second MAS Collaborative and beyond.