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Plan-Do-Study-Act!
W. Edwards Deming1900-1993
https://deming.org/
Quality is everyone’s responsibility.
The Model for Improvement…
Start small and work your way up!
We don’t need to climb
Mount Everest to achieve change!
We can take small steps and
still make progress!
The PDSA Cycle
Plan:• What additional data do you need?
• How will you implement / test the redesigned process?
Do:• Implement redesigned process or test, collecting
data as you go.
• Specify time periods for data collection / review (under Study).
PDSA Cycle
Study:• Review the data you collected. What impact did the
changes have?
• What lessons did you learn in implementing the redesigned process or test?
• Remember - positive and negative results are just results.
Act:• Should the redesigned process be continued? How will
you anchor the changes?
• What additional improvements to the process are possible?
• What is the next process to be mapped and possibly redesigned?
Ready, set…
Remember to ask the following questions:
• What are you trying to accomplish?
• How will we know if a change is an improvement?
• What changes can result in an improvement?
Then…
Write your AIM Statement, Plan and Do.
A Real Example with Multiple PDSA Cycles
• Topic: Childhood obesity prevention in a preschool
• A preschool CQI team (school principal, preschool teacher, teacher’s aide, and parents) recognized that most children were drinking sugar-sweetened beverages at snack and during lunch.
• Test of change: Can we eliminate sugar-sweetened beverage consumption among preschool children and replace it with water?
Model for Improvement’s 3 Fundamental Questions• What are we trying to accomplish? To eliminate sugar-sweetened beverages and
increase water consumption in the Preschool Center between April and May, 2012.
• How will we know if a change is an improvement?
We will measure: the percent of children who bring sugar-sweetened beverages to school each day the number of glasses of water consumed per child each day
• What changes can we make that will result in improvement? Sugar-sweetened beverages will no longer be allowed to be consumed in the classroom. Any
sugar-sweetened beverages that are sent to school with the child will be sent home unopened in their backpacks, with an explanation that there is a new school policy prohibiting sugar-sweetened beverages and promoting water consumption in an effort to prevent obesity.
At the same time, the team will make a pitcher of water and glasses available for children to serve themselves throughout the day. Children did not have easy access to water before this effort.
The team ran 5 consecutive Plan-Do-Study-Act (PDSA) Cycles, and each one incorporated the learning from the previous cycles to make an adjustment to the intervention.
PDSA Health – Obesity preventionClassroom Centro Parvulario
Plan & DoGoal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms
A P
S D
A P
S D
Cycle 1: Make a pitcher of water & individual cups available to children.
Cycle 2: Communicate to parents that juices and soda are no longer permitted – send home beverages sent to school.
Cycle 4: Serve water with lunch.
Cycle 3: Develop simple , child-centered measurement.
Cycle 5: Use plants to show scientificbenefits to drinking water over soda.
UCL
LCL0%
10%
20%
30%
40%
50%
60%
4/2
/12
4/3
/12
4/4
/12
4/5
/12
4/9
/12
4/1
0/1
2
4/1
1/1
2
4/1
2/1
2
4/1
3/1
2
4/1
6/1
2
4/1
7/1
2
4/1
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4/1
9/1
2
4/2
0/1
2
4/2
3/1
2
4/2
4/1
2
4/2
5/1
2
4/2
6/1
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4/2
7/1
2
5/2
/12
5/3
/12
5/4
/12
5/5
/12
5/7
/12
5/8
/12
5/9
/12
5/1
0/1
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1/1
2
5/1
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5/1
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5/1
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% of Children who brought Sugar-Sweetened Beverageto School
Percent
UCL
LCL
0
0.5
1
1.5
2
2.5
4/2
/12
4/3
/12
4/4
/12
4/5
/12
4/9
/12
4/1
0/1
2
4/1
1/1
2
4/1
2/1
2
4/1
3/1
2
4/1
6/1
2
4/1
7/1
2
4/1
8/1
2
4/1
9/1
2
4/2
0/1
2
4/2
3/1
2
4/2
4/1
2
4/2
5/1
2
4/2
6/1
2
4/2
7/1
2
5/2
/12
5/3
/12
5/4
/12
5/5
/12
5/7
/12
5/8
/12
5/9
/12
5/1
0/1
2
5/1
1/1
2
5/1
4/1
2
5/1
5/1
2
5/1
6/1
2
5/1
7/1
2
N of Glasses of Water Drunk per Children Present
PDSA Health – Obesity preventionClassroom Centro Parvulario
StudyGoal: To eliminate sugar-sweetened beverages and increase water consumption in preschool classrooms
Sugar sweetened beverages
Water consumption
Water available
Parents informed
policy change
Child-centered measure
ment
Water served w
lunch
Plant demonstration
benefits of water over soda
Water available
Parents informed
policy chage
Child-centered measure
ment
Water served w
lunch
Plant demonstration benefits of water over soda
1. The CQI team answered the Three Questions of the Model for Improvement and, therefore, they had a clearly defined the aim, indicators, and change idea to test.
2. The CQI team ran a new PDSA cycle every week. They measured the process and outcome indicators every day, and they used the data to inform their work.
3. The CQI team graphed their data over time, and included annotations on the graph to indicate when each change idea was tested.
Notice several characteristics that make this an excellent Test of Change
4. The CQI team involved everyone affected by the system on the team in weekly reflection and planning which:a) contributed to the creativity you see in the change ideas they
tested.b) led to an idea to introduce child-centered measurement, that
served two purposes. It allowed the children to have an active role in the test of change by letting them see their own water consumption each day. Also, it solved a problem of measurement for the teachers who didn’t want to interrupt their teaching activities to keep track of all of the water children served themselves throughout the day.
Notice several characteristics that make this an excellent Test of Change
The Importance of Objective Data
https://www.youtube.com/watch?v=IGQmdoK_ZfY
As you watch this video, remain silent so that everyone can concentrate. You will be making observations and collecting data, so carefully follow the instructions on the screen.
Why measure?
• Separates what you think is happening from what is actually
happening
• Establishes a baseline
• Helps to avoid putting ineffective solutions in place
• To monitor improvements and prevent slippage
Run Charts… small, but useful data
1. A powerful instrument for improvement
2. Describe a process over time, in contrast to snapshot of a moment in time
3. Reveal tendencies occurring in a process
4. When careful annotation is used, show the impact of changes tested
From Arbour, 2014, Role of Measurement
Essential Components of Run Charts
• Objective should be clearly defined… What are you measuring? Is up or down better?
• Show what ideas were tested and, most importantly, when.
• Axis labels: X axis is time (e.g. days); Y axis is the numeric value (e.g. percentage of visits completed)
• Median: the middle number in any given sequence of numbers (e.g. 1, 3, 4 ,8, 9 = 4)
12
15
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13 MEDIAN
Day #1 122 153 194 175 146 197 168 149 16
10 1011 1012 1113 1114 1215 1116 12
MEDIAN 13
• No expensive software to buy!
• No tricky formulas
• Everyone can do it, and some will even enjoy it!
Got Excel?
This is all you need.
Look for these signals of change:
Trend: Five or more consecutive points all goingup or all going down. If two or more consecutive points are the same, ignore the repeats and go to the next value.
Shift: Six or more consecutive points either above or below the centerline (median). Points on the centerline do not make or break a run. In other words, skip values that fall on the median and continue counting.
How will we know a change is an improvement?
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16
Nu
mb
er
of
Can
celle
d H
om
e V
isit
s
Days of the Month
Objective: Decrease the # of Cancelled Home Visits
Began texting to confirm the day before the appointment.
