Transcript The Model for Improvement and Using PDSA Cycles

The Model for Improvement
and Using PDSA Cycles
Presented by:
September 30, 2010
Nicole Van Borkulo, MEd
Qualis Health
Practice Improvement Specialist
Everything I need to know, I
learned in kindergarten?
2
William Edwards Deming
“Put everybody in the organization to
work to accomplish the
transformation. The transformation is
everybody's work.”
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Objectives
 Identify the components of the Model for
Improvement
 Understand how to use PDSA cycles for rapid
cycle improvement
 Learn tools/examples for teaching this model
to others
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Improvement: What was, what is!
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Three Fundamental
Questions for Improvement
1. What are we trying to accomplish?
2. How will we know that a change is an
improvement?
3. What changes can we make that will result in
improvement?
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Model for Improvement
What are we trying to
accomplish?
How will we know that a change
is an improvement?
What change can we make that
will result in improvement?
Act
Act
Plan
Plan
Study
Do
Study
Do
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
Model for Improvement
A Quality Improvement Strategy
What are we trying to
accomplish?
Aim
How will we know that a change
is an improvement?
Measures
What change can we make that
will result in improvement?
Ideas
Act
Act
Plan
Plan
Study
Do
Study
Do
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
Model for Improvement
What are we trying to
accomplish?
Aim
How will we know that a change
is an improvement?
Measures
What change can we make that
will result in improvement?
Ideas
Act
Plan
Study
Do
Study
Do
Act
Plan
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
Aim:
What are we trying to accomplish?
Improved care and improved outcomes for
our patients.
Transformation into a PCMH.
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Why an Aim Statement?
 Answers and clarifies “What are we trying to
accomplish?
 Creates a shared language to communicate about
the project
 Facilitates organizational conversations and
understanding
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Aim Statements include:
 What is expected to happen
 The system to be improved or the population
of patients
 Specific numerical goals
 Time frame
 Guidance for activities, such as strategies for
the effort, or limitations
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Model for Improvement
What are we trying to
accomplish?
Aim
How will we know that a change
is an improvement?
Measures
What change can we make that
will result in improvement?
Ideas
Act
Plan
Study
Do
Study
Do
Act
Plan
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
Ideas:
What changes can we make that will lead to
improvement?
 Key Changes for improved care based on:
• The best available evidence
• Knowledge of front line workers
• Experiences of experts
 Within the structure of the PCMH
• Changes in each of the eight Change Concepts
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Model for Improvement
What are we trying to
accomplish?
Aim
How will we know that a change
is an improvement?
Measures
What change can we make that
will result in improvement?
Ideas
Act
Plan
Study
Do
Study
Do
Act
Plan
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
Measurement:
How Do We Know a Change is an Improvement?
Improvement is about making changes to systems; it is
about changing an organization’s approach to improving
the health of patients.
It is not about measurement.
So, why would we want to spend time on measures?
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Measurement:
But measurement plays an important role:
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One - Key measures are required to assess progress toward
the aim - (Global)
Two - Specific measures can be used for learning during
PDSA cycles – can be qualitative or quantitative (Local)
Balancing measures are needed to assess whether the
system as a whole is being improved
Data from the system (including from patients and staff)
can be used to focus improvement and refine changes
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Model for Improvement
What are we trying to
accomplish?
Aim
How will we know that a change
is an improvement?
Measures
What change can we make that
will result in improvement?
Ideas
Act
Plan
Study
Do
Study
Do
Act
Plan
From: Associates in Process Improvement
The Safety Net Medical Home Initiative
The PDSA Cycle
for Learning and
Improvement
 What changes
are to be made?
 Next cycle?
Questions and
predictions (why)
 Plan to carry out the
cycle (who, what,
where, when)
 Plan for data
collection
Act Plan
Study
Do
 Complete the
 Carry out the plan
analysis of the data
 Compare data to
predictions
 Summarize what
was learned
 Document problems
and unexpected
observations
 Begin analysis of
the data
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PDSA: Break it Down/Simplify…
Plan - Figure out the questions you want to answer, plan a
way to answer the questions, and predict results
Do - “Just do it” (i.e. do the plan); collect the data
Study - What did you learn?
Act - What will you do with the knowledge you learned?
What do you want to do next?
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Why PDSA measurement?
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Recent observations tend to be more heavily weighted in our
minds.
New observations depend on previous observations. (e.g. if
used to a room of 30 degrees, 60 degrees feels warm but not
if used to 95 degrees).
Our minds automatically filter perceptions. Sometimes we
observe what we want or expect to observe.
Because of the first three issues, groups learn better from
data based on measurements than observations.
From Associates in Process Improvement, The Improvement Handbook, Model, Methods, and Tools for
Improvement, copyright 1990-2005, Associates in Process Improvement
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Use the PDSA Cycle for:
 Developing a change
 Testing or adapting a change idea
 Implementing a change
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Repeated Use of
the PDSA Cycle
Changes That
Result in
Improvement
Model for Improvement
What are we trying to
accomplish?
A P
S D
How will we know that a
change is an improvement?
What change can we make that
will result in improvement?
Implementation of
Change
Test new conditions
Hunches
Theories
Ideas
A P
SD
Small Scale
Testing
Multiple PDSA Cycles -Sequential Building of
Follow-up Knowledge – include a wide
Tests
range of conditions in the
sequence of tests before
implementing the change
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Routine use of Action
Plan for Better SelfManagement
Aim: Improve quality of
life for children with
asthma
AP
SD
Cycle 5: Monitor
implementation –
continued use by MAs
Cycle 4: Train for Implementation
AP
SD
Cycle 3: Revise and test with patients/families who are
from different cultural backgrounds or speak ESL.
Cycle 2: Revise and test with 2 MAs and 6 patients/families
Introduce
Written
Action Plans
Cycle 1: Test with 1 MA/1 patient/family
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When to use PDSA?
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For trying changes to existing processes
For trying new processes
For trying new tools
For trying new measures
Don’t need to use PDSA:
 For specific project tasks
 For gathering data or information (unless you want to learn
about the data process)
 For general “planning” or setting goals, objectives
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Why Test?
 Increase your belief that the change will result in
improvement
 Opportunity for learning from “failures” without
impacting performance
 Document how much improvement can be expected
from the change
 Learn how to adapt the change to conditions in the
local environment
 Evaluate costs and side-effects of the change
 Minimize resistance upon implementation
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Tips for Testing Changes
Identify changes that will assist the team
to reach goals
 Harvest good ideas and adapt them to your setting
 Solicit team members ideas
 Start with changes that are easy to test
 Collect and study useful data during each test
 Learn from “failed” tests
 Eventually test over a wide range of conditions
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Failure is just succeeding at learning
what doesn’t work!
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Objectives of Cycles for Testing
 Decide if change will work in actual environment
 Decide on combination of changes for desired effect
 Evaluate cost, social impact, side effects
 Evaluate how much improvement we can expect
 Increase degree of belief
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Successful Cycles to Test and Adapt
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Scale down size of test (# of patients, location)
Conduct the test over a short time period
Test with volunteers
Do not try to get buy-in or consensus for the test
Collect useful data during each test
Think a couple of cycles ahead
Plan multiple cycles to test and adapt change
In later cycles, test over a wide range of conditions
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Initially use Smaller Scale Tests:
The power of “one”
Conduct the initial test with…
 one facility
 one office
 one doc
 one patient
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Move Quickly to Testing Changes
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Year
Quarter
Month
Week
Day
Hour
“What tests can we
complete by next
Tuesday?”
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The Safety Net Medical Home Initiative
Some misuses of PDSAs
 Tendency to do too much in one PDSA, instead of
several cycles
 Tendency to use PDSAs for information gathering or
collecting data on a measure rather than beginning to
test an idea for change
 Tendency to use PDSAs to complete all ‘tasks’ on the
project
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Clarification of Terms
 Task: An activity that needs to be completed or something that
needs to get done, i.e. find a sample Management Plan or print
a list of patients.
 Test: Trying a change on a small scale to see if the change
results in improvement. A test of change involves complete
Plan-Do-Study-Act cycles, including a question and a
prediction. The specific change idea is being used in the clinic
on a temporary basis because at this stage it is only a test.
Collecting baseline data, meeting, brainstorming, and/or
planning to change are not tests of change. These are
examples of getting ready to test or planning to test.
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Testing vs. Implementing
Testing – Trying and adapting
existing knowledge on small
scale. Learning what works in
your system.
Implementation – Making
this change a part of the dayto-day operation of the system
in the pilot site. Usually not
after just one or two tests!
More Tests:
Including wide range
of conditionsdayshift/night shift
weekdays/weekends
different cultures
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From Charles Darwin:
“It is not the strongest of the species that
survive, nor the most intelligent, but the
one most responsive to change.”
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On-line Model for Improvement
 To review the Model for Improvement or share
with colleagues, visit the IHI’s website
 http://www.ihi.org/IHI/Topics/Improvement/Im
provementMethods/HowToImprove/
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Thank you!
Madlen Caplow, Neil Heffron, Lloyd Provost,
NICHQ, the IHI and others from whom I
‘shamelessly’ stole some of these slides.
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For more information:
www.qhmedicalhome.org/safety-net
Nicole Van Borkulo, MEd
Phone: 206-288-2573
E-mail: [email protected]
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References
“A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.
“Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality
Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.
“Building Measurement and Data Collection into Medical Practice”, Eugene Nelson, Mark Splaine, Paul
Batalden, Stephen Plume. Annals of Internal Medicine Vol 128; no16, March 15, 1998.
“How to Take Multiple Measures to Get a Complete Picture of Organizational Performance.” Provost,
Lloyd and Leddick, Susan National Productivity Review. Autumn 1993. pp. 477-490.
Quality Improvement Through Planned Experimentation. 2nd edition R. Moen, T. Nolan, L. Provost,
McGraw-Hill, NY, 1998.
The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. G. Langley, K.
Nolan, T. Nolan, C. Norman, L. Provost. Jossey-Bass Publishers., San Francisco, 1996.
“The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Solberg,
Leif I., Mosser, Gordon and McDonald, Susan Journal on Quality Improvement. March 1997, Vol.23,
No. 3.
“Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990.
A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.
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