The Model for Improvement: Using PDSA Cycles

1
The Model for ImprovementUsing PDSA Cycles

• Presented by
• Margaret Enright, MPH, CDE
• menright_at_okqio.sdps.org
• [phone]
• Oklahoma Foundation for Medical Quality

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
Use the PDSA Cycle to

• Help answer the first two questions of the model
• Develop a plan for change
• Test a change
• Implement a change
• Evaluate the change
• Decide on Next Steps, based on experience

4
The PDSA Cycle for Learning and Improvement
Act
Plan

• What changes
• are to be made?
• Next cycle?
• Adopt, adapt,
• or abandon??

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

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

5
Rapid Cycle Change (Repeated Use of the Cycle)
Changes That Result in Improvement
DATA
DIFFICULTY
Hunches Theories Ideas
TIME
6
The PDSA Cycle for Learning and Improvement

Changes that result in improvement
DATA
Cycle 5 Spread to other physicians, units, etc.
Cycle 4 Implementation of system change(s)
Cycle 3 Wider scale tests of change
Hunches, theories, ideas
Cycle 2 Follow up Tests with larger study group
Cycle 1 Very Small Scale Test
7
How Do We Know That A Change is an Improvement?

• Are specific measures tested during the pdsa
  cycles demonstrating desired results?
• Does the change facilitate the overall goal(s) of
  the practice?
• Can this change be attained (and maintained)
  without undue interference with other important
  practice goals?

8
Aim Improve Blood Sugar Levels of the Population
of Patients w/Diabetes
Proactive glycemic control an integral part of
the system
DATA
Cycle 5 Implement protocol (w/needed
alterations) system wide
Cycle 4 Test protocol with additional units
Cycle 3 Test protocol with one physician unit
Develop successful approaches to improve glycemic
control
Cycle 2 Establish draft protocol for HgbA1C
testing and targeted treatment
Cycle 1Develop system for regularly obtaining
and tracking HgbA1Cs
9
Plan

• State the Objective of the plan
• Plan the Change (what, who, when, where?)
• Predictions (what is expected to happen?)
• Data Collection (who,what,when, where?)

10
Do

• Carry out the change/test and begin data
  collection and analysis-
• What will actually be tested?
• What happens?
• Additional observations
• Were there unexpected problems/barriers?

11
Study

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

12
Act

• (This step of the cycle could also be called the
  accept, adapt, or abandon step)
• Should we make changes in the plan prior to the
  next test cycle?
• Are we ready to implement the change and plan for
  spread of the change??

13
Skills Which Support Real Improvement

• Challenge the boundaries (creative thinking)
• Visualize the ideal
• Remove the current way of doing things as an
  option (think outside the box)
• Always go back to the overall practice goals to
  guide the PDSA cycles

14
Example PDSA Cycle for Delivery System Design
Change

• Plan Five office nurses will perform complete
  foot screenings on diabetes patients. (Predict
  increased examination rate.)
• Do Nurses are taught monofilament exam
  technique. Exams on 20 patients completed.
• Study Patients were accepting, nurses competent
  to perform exams, increase from 33 to 67 in
  foot screenings accomplished, abnormal exams
  referred appropriately
• Act Expand to all diabetes patients. Expand to
  remaining nursing staff.

15
Common Reasons for Failed PDSA Cycle Tests

• The plan for change is not well executed
• The pilot test subjects are not early adopters
• The support processes are not adequate
• The original hypothesis/prediction is wrong

16
Successful Cycles typically

• Start small
• Involve early adopters who believe that the
  change can create improvement
• Have the general support of the leadership
• Dont get bogged down in collecting mountains of
  data, but concentrate only on useful, pertinent
  data

17
To Accelerate Improvement

• Develop focused, important objectives
• Strive for usefulness in the data collection and
  analysis
• To obtain buy in begin with evidence-based
  goals
• Test first on a small scale and spread the good
  or well-adapted plans for change

18
Useful Strategies to Hold the Gains

• Establish and document new processes
• Make formal changes to job descriptions
• Use regular measurements and audits
• Factor new goals/processes into staff training
  and new hire orientation
• Assign ownership of new processes
• Address the social aspects of change

19
Important to Address the Social Aspects of
Change

• Provide and disseminate widely information on why
  the change is being adopted
• Give specific information on how the change will
  affect people
• Seek and use input from others, (especially those
  directly affected by the change), and encourage
  their support
• Publicize the PDSA results and what was learned
  from them
• Understand and address the causes of resistance
  to change