Table 1 The OUTCOME Framework: principles, structures, theory, and application in the PUMA study

 Improvement is directed towards achieving an agreed outcome or goal

Specification of the collective action to be targeted for improvement and its overarching goal.

TMT

The goal of the PUMA study was to improve collective action in relation to the afferent component of a paediatric early warning system, which detects deterioration and triggers timely and appropriate action, and excluded the efferent component, which consists of the people and resources providing a response

 Improvement is oriented towards the functions necessary to achieve the goal

Specification of the core components, mechanisms of action and their relationships necessary to achieve the overarching goal.

TMT

Collective action in detecting and acting in response to deterioration includes detection (monitoring, recording, interpreting), preparation (reviewing, planning) and action (escalation, evaluation).

 Improvement is focused on the socio-material system required to enact the functions necessary to achieving the goal

Minimum standards required to achieve the goal across contexts are specified (e.g. socio-material resources - people, materials, knowledge, processes and mechanisms)

TMT

In PUMA the minimal standards for a system for detecting acting on deterioration was specified in propositional model structured around the 7 core functions

 Improvement is focused on the development of locally appropriate initiatives to achieve the goals

Tools developed to assess systems against the standard

TMT/NPT

Staff System Assessment Tool

Family Feedback Tool

 Improvement capitalises on the expertise and knowledge of those delivering services

Five step process to support improvement:

1) Form an improvement team

2) Assess the system

3) Select and plan improvement initiatives

4) Implement and review initiatives

5) Sustain progress

NPT

Model for Improvement.

Improvement guide Structured facilitation

On-going support

 Improvement is sustained by the creation of a learning system to optimise outcomes through the application of system assessment tools, to keep systems under review, and structures for supporting local leadership.

System Assessment Tools to enable reflexive monitoring

Framework to support improvement process drawn from the Model for Improvement.

TMT

NPT

Improvement Guide provided guidance on repeating the system assessment every 12–24 months to reflexively monitor performance, select and plan initiatives and implement and review initiatives.