Fundamental Questions for Improvement

1
Accelerating Improvement PDSA Cycles to Test,
Adapt, and Implement Innovations
Donna M. Daniel, PhD Learning Session 1, October
21, 2003 Prepared with assistance from Lloyd
Provost, Associates in Process Improvement and
the Institute for Healthcare Improvement.
2
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?
3
The PDSA Cycle for Learning and Improvement
Act
Plan

• Objective
• Questions and
• predictions (why)
• Plan to carry out
• the cycle (who, what, where, when)

• What changes are to be made?
• Next cycle?

Study
Do

• Complete the
• analysis of the data
• Compare data to
• predictions
• Summarize what
• was learned

• Carry out the plan
• Document problems
• and unexpected
• observations
• Begin analysis
• of the data

4
Small-Scale, Rapid PDSA Cycle

• Purpose
• Increase protein in residents diet
• Plan
• Add protein powder to all dessert recipes

• To Do
• Collect data
• Educate staff
• Experiment with recipes
• Purchase protein powder

5
Small-Scale, Rapid PDSA cycle continued

• Do
• Study
• Act
• Adopt?
• Adapt?
• Abandon?

6
Repeated Use of the Cycle
Changes That Result in Improvement
DATA
Spread
Implementation of Change
Wide Scale Tests of Change
Hunches Theories Ideas
Follow-up Tests
Very Small Scale Test
7
Cycles for Testing ChangesPurpose

• Cycle 1 -
• Cycle 2 -
• Cycle 3 -
• Cycle 4 -
• Cycle 4 -
• Cycle 5 -

8
Q What changes can we make that will result in
an improvement? A Improvement Strategies
9
Why Test?

• To answer questions
• Will change result in improvement?
• How much improvement?
• Need to adapt the change?
• Any costs and/or side-effects?
• Other reasons
• Opportunity for failures
• Minimizes resistance upon implementation

10
Why not start with implementation?

• The change is permanent - need to develop all
  support processes to maintain change.
• High expectation to see improvement (no
  failures).
• Increased scope will lead to increased
  resistance.
• Generally takes more time than tests.

11
Successful Cycles to Test and Adapt Changes

• Scale down size of test ( of residents,
  location)
• Conduct multiple cycles to test adapt change
• Test with volunteers
• Do not try to get buy-in, consensus, etc.
• Be innovative to make test feasible
• Collect useful data during each test
• Test over a wide range of conditions

12
Decrease the Time Frame for a PDSA Test Cycle

• Years
• Quarters
• Months
• Weeks
• Days
• Hours
• Minutes

Drop down two levels to plan test cycle!
13
Overall Aim Implement the Prevention
Treatment Model at Your Nursing Home
Assessment Monitoring
Prevention Strategies
Organizational Commitment
Treatment Interventions
Community
Develop Strategies for Each Component of the Model
14
AIM- Improve Prevention Treatment of Pressure
Ulcers
Concept D
Concept C
Concept B
Concept A
Change Concepts, Theories, Ideas
15
Improving by NEXT Tuesday!

• Willing to compromise on
• scope,
• size,
• rigor, and
• sophistication, but the cycle should include one
  resident and must be completed by Tuesday.

Report cycle on e-mail list by October 28th, 2003.
16
The Power of One
17
References

• 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,
  Chapter 6.
• Quality Improvement Through Planned
  Experimentation. 2nd edition R. Moen, T. Nolan,
  L. Provost, McGraw-Hill, NY, 1998.
• Accelerating the Pace of Improvement - An
  Interview with Thomas Nolan, Journal of Quality
  Improvement, Volume 23, No. 4, The Joint
  Commission, April, 1997.
• Understanding Variation, Quality Progress, Vol.
  13, No. 5, T. W. Nolan and L. P. Provost, May,
  1990.