Transcript PDSA Cycles Kyrie Shomaker, MD February 3, 2009  Features:    Small-scale Temporary Methodical  Allows you to:    Adjust your belief in the change Gain buy-in Try it out.

PDSA Cycles
Kyrie Shomaker, MD
February 3, 2009
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Features:
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Small-scale
Temporary
Methodical
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Allows you to:
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Adjust your belief
in the change
Gain buy-in
Try it out
PDSA Cycles
Model for Improvement
PDSA Planning Worksheet
Team Name: __________________________________________
Cycle: ___________
Date:_______________________
Act
Study
Plan
Do
PLAN
Objective for this cycle:
Questions:
Predictions:
Plan for change or test: who, what, when, where:
Plan for collection of data: who, what, when, where:
DO Carry out the change or test. Collect data and begin analysis. Describe observations, problems
encountered, and special circumstances.
STUDY Complete analysis of data. Summarize what was learned.
ACT Are we ready to make a change? Plan for the next cycle.
Example 1
Example 1
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Overall aim:
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Most pressing problem:
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To use non-work time more efficiently
Too many trips to the store and
nothing for dinner
Ideas for change:
1) Buy more stuff
 2) Make a weekly dinner menu
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Example 1
Model for Improvement
PDSA Planning Worksheet
Team Name: __________________________________________
Cycle: ___________
Date:_______________________
Act
Study
Plan
Do
PLAN
Objective for this cycle:
Questions:
Predictions:
Plan for change or test: who, what, when, where:
Plan for collection of data: who, what, when, where:
DO Carry out the change or test. Collect data and begin analysis. Describe observations, problems
encountered, and special circumstances.
STUDY Complete analysis of data. Summarize what was learned.
ACT Are we ready to make a change? Plan for the next cycle.
PDSA Ramps
A P
S D
A P
S D
A P
S D
Theories,
hunches,
& best practices
A
S
P
D
Breakthrough
Results
Appropriate Scope for PDSA
Readiness to Make Change
Current Situation
Resistant
Indifferent
Ready
Very Small Scale Test
Very Small Scale Test
Very Small Scale Test
Very Small Scale Test
Very Small Scale Test
Small Scale Test
Very Small Scale Test
Small Scale Test
Cost of failure
large
Low Confidence that
change idea will lead
to Improvement
Cost of failure
small
Large Scale Test
Cost of failure
large
High Confidence that
change idea will lead
to Improvement
Small Scale Test
Cost of failure
small
Large Scale Test
Implement
Example 2: Duty Hours
Resident Violations of the 30-hour Rule
July-November
11
9
Number of Violations
7
5
3
1
-1
Block 1
july 21-27 July 28-
Aug 4-10 Aug 11-17 Aug 18-24 Aug 25-31
Sep 1-7
Sep 8-21 Sep 15-21 Sep 22-28 Sep 29-
Aug 3
oct 5
Time (weeks)
Oct 6-12 Oct 13-19 oct 20-26
oct 27-
nov 3-nov
nov 2
9
Example 2: Duty Hours
Problems/Barriers
Residents do not understand importance of issue (i.e. single
violation can result in probabtion)
Rounds are lasting too long
Interns not rounding first
Interns have too many tasks after rounds
Interns are spending time after rounds to work with and review
medical student notes
Solutions
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
Make residents aware of survey and repercussions
Increase repetition of importance (weekly email, tips in
lounge)
Remind attendings of the importance of duty hours and duty
hour intiative (i.e. weekly emails, direct feedback on
violations)
Limit post call tasks to notes only (plus TPN in the NICU).
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No calling consults
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No updating families
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No answering pages
Post call work is not delegated well
Double sign out (sign out during rounds and then again prior to
leaving)
Make a policy to interrupt rounds at a set time (i.e. 11 am) or
create culture where rounds can be interrupted at any time
Family centered rounds make it difficult to finish early
Overall resident efficiency still needs improvement
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Make a list of efficiency skills &post in visible locations
Write notes the night before
Write the whole note in hospital course so that not
toggling between screens.
Example 2: Duty Hours
Improvement Planning Form
Name: Duty Hours Improvement
Aim: To eliminate duty-hours violations for all residents on pediatric rotations; including compliance with 30hr, 80-hr, 10-hr, and “no new patients” rules.
Measures (goals): Self-reported violations (hours log), violations reported by chief phone call, violations
reported on RRC survey
Cycle
No.
Change Tested
Person
Responsible
1
Compare 30-hr data from
GME1 and chief phone calls
Sarah
2
Limit post-call intern duties to
notes (& TPN in NICU)
?
3
Week
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
18
Key Points
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For initial cycles,
Use the smallest scale possible
(“cycle of one” is best!)
 Failed cycles are good learning
opportunities when small
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For implementation cycles,
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Test under many different conditions
(busy days, different staff, things naysayers worry about)
Activity
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Given an aim and a list of
brainstormed ideas, have each group
come up with an initial PDSA cycle to
test a selected change
Make your own PDSA
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Aim
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Problem
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To free up more beds in the Children’s Hospital by increasing throughput.
Even when the discharge date is known in advance, patients often do not vacate their
room until afternoon, creating delays in the work-up and management of incoming patients.
Ideas for change:
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Complete the brief summary and any other necessary paperwork the night before
Schedule a ride for the patient in the morning
Round on the patients to be discharged first (beginning at 9am)
Round on the patients to be discharged earlier (i.e. before morning conference)
Have the night team discharge the patient
Tell the charge nurse the night before that the patient is to be discharged
Communicate the discharge goals to the family/nurses in writing (i.e. the “discharge board”)
Communicate the discharge goals to the nurses with an anticipate discharge order (i.e.
“anticipate discharge when…”)
Move the patients out of their rooms to a waiting area once they are discharged so the
rooms can be cleaned and used again
Other ideas?