Table 1

PDSA analysis of four salient components of the programme during Cycle-1

	Patient information	Preoperative class	Physiotherapy protocol	Anaesthetic/analgesic protocols
Plan	Update existing patient information booklet and exercise sheets.	Develop MDT led class to provide education, reassurance, explain patient journey and teach exercises, sling use and so on.	Update existing physiotherapy protocol.	Review, update and streamline anaesthetic and analgesic protocol for TSA.
Do	Changes agreed with consultants. New documents drafted, using arthroplasty messages from L/L materials. Focus on expectation management.	Structure of class proposed, involving physio, OT and nurses. Meetings to discuss content, logistics, staffing, capacity and creation of informative DVD.	MDT agreement of a new protocol allowing ‘safe-zone’ mobilisation of shoulder immediately post-op and sling use ‘for comfort’ only.	MDT agreement of new draft protocol based on existing L/L ER principles.
Study	New documents circulated for comments from MDT. Second drafts created and agreed. Language and readability reviewed with patient information team.	Existing L/L ER group and DVD observed. Administrative pathways analysed and adapted. Feasibility of staffing assessed. Demand and capacity estimated.	No published evidence of adverse events from safe-zone mobilisation (limited external rotation and elevation). Patient reports of inconvenience of sling reinforced change.	Protocol shared with wider team for comments. Attempts to reach consensus made, but universal agreement on one protocol not possible.
Act	Final drafts agreed and ordered to replace existing stocks.	DVD filmed and edited with AudioVisual department, and MDT. Final structure of group agreed (figure 3), including location, timings and administrative processes.	Protocol changed as above. Meetings held with inpatient and outpatient teams to explain changes and communicated with community partners. New protocol uploaded to website and start-date agreed.	New protocol agreed allowing some flexibility in anaesthetic regime. Cohort study planned for initial stages of roll-out to determine the most effective practices.

ER, enhanced recovery; L/L, lower-limb; MDT, multidisciplinary team; OT, occupational therapist; PDSA, plan–do–study–act; TSA, total shoulder arthroplasty.