Power of the PDSA

One PACE programs experience of using the

PDSA to streamline intake and enrollment.

Emily Tupper, LCSW and Lynette Grefrath

Sutter SeniorCare PACE, Sacramento, CA

Sutter SeniorCare PACE participated in

the PACE 2.0 West Coast Collaborative

The PDSA work outlined herein was a direct

result of our participation in the collaborative.

Sutter SeniorCare Pace

West Coast PACE 2.0 Collaborative Members

• Lynette Grefrath – Marketing and Enrollment Supervisor

• Emily Tupper – Community Services Manager

• Dhawal Bhanushali – Center Manager

• Pamela Ansley – Finance Manager

• Karli Holkko – Project Manager

What is the PDSA all about?

• Plan-Do-Study-Act (PDSA) Cycles provide a structure to test ideas, problem solve and improve quality in any setting or system.

• PDSA is both a qualitative and quantitative study.

• The origin of the PDSA was work done by two statisticians, Walter Shewart and Edward Denning, who developed an iterative process that eventually became known as the four stage PDSA.

• Learning is achieved through the PDSA method by following a 4 stage cyclic approach to change and make improvements.

Deming WE. Out of the crisis, 1986. Cambridge, MA;

Massachusetts Institute of Technology Center for Advanced Engineering Study xiii, 1991;507.

Taylor MJ, McNicholas C, Nicolay C, et alSystematic review of the application of the plan–do–study–act method to improve quality in healthcareBMJ Quality & Safety 2014; 23:290-298.

The PDSA Stages Defined

• Plan Stage: A change designed for improvement is

identified.

• Do Stage: The change is tested.

• Study Stage: The success of the change is studied.

• Act Stage: Identifies adjustments and next steps to inform

the next cycle.

• The cycle repeats.

Taylor MJ, McNicholas C, Nicolay C, et al

Systematic review of the application of the plan–do–study–act method to improve quality in healthcare

BMJ Quality & Safety 2014; 23:290-298.

Taylor MJ, McNicholas C, Nicolay C, et alSystematic review of the application of the plan–do–study–act method to improve quality in healthcareBMJ Quality & Safety 2014; 23:290-298.

How may the PDSA assist PACE?

• PDSA promotes the use of small scale, repetitive cycles

to test interventions.

• Rapid assessment provides immediate feedback and

flexibility to adapt the change until you ensure solutions

are developed.

• It offers an opportunity to build evidence for change and

engage your stakeholders as your study demonstrates

quality improvement.

Taylor MJ, McNicholas C, Nicolay C, et al

Systematic review of the application of the plan–do–study–act method to improve

quality in healthcare

BMJ Quality & Safety 2014; 23:290-298.

How to approach your first PDSA

• Think small. Small change tests will help you achieve your

larger goal; you may risk significant resource involvement in

interventions that have not yet been tested if you start too big.

• Any idea can be tested; involve your staff teams in creativity

and brainstorming to build both their buy-in and desire to

learn and improve.

• There are NO failures, only learning; a desired outcome not

being achieved means you have something to act on in your

next cycle.

Sutter SeniorCare – PDSA

Initial Care Planning Pre-Enrollment IDT Meetings

• Question: Does holding a pre-enrollment IDT meeting

have a positive impact on IDT staff perceptions of their

readiness to complete initial care plan assessments?

– Prediction: IDT will be better prepared for assessments.

Respect and trust may build between intake team and IDT

members.

• 3 IDT Teams - each team already meets separately for 30 minutes each weekday morning.

• Survey provided to staff at end of meeting – 3 questions/5 point Likert Scale:

1. Being able to spend time discussing new prt for next month has better prepared me to complete my initial care planning assessments.

2. I have a basic understanding of the medical problems for the new enrollee.

3. I have a basic understanding of the psychosocial needs of the new enrollee.

4. Comments/Suggestions to improve meeting – open space to respond.

PDSA Cycle 1

• 15 minutes added to morning IDT meeting one day of the week, the week prior to enrollment start date.

• Intake Manager prepared mini case presentations covering IDT disciplines anticipated areas of interest:– Home Care and DME

– Behavioral health considerations &

potential for partnership

– Dietary needs

– Attendance day considerations

– Housing situation

– Medical conditions covered briefly; review of care plan dx

0

5

10

15

20

25

30

35

1=Strongly Disagree 2=Disagree 3=Neither agree nor disagree 4=Agree 5=Strongly Agree

March 2019

Q1: Being able to spend time discussing new prt for next month betterprepared me to complete my initial care planning assessments

Q2: I have a basic understanding of the medical needs of the newenrollees

Q3: I have a basic understanding of the psychosocial needs of the newenrollees

N = 44

PDSA Cycle 2

• Add 30 minutes to existing morning IDT meeting one day

of the week, the week prior to enrollment start date.

• Improve quality of EHR demographics for each case

reviewed.

• Created improved structure of case presentation with

input from disciplines about what is important to them.

0

5

10

15

20

25

30

35

40

45

50

1=Strongly Disagree 2=Disagree 3=Neither agree nor disagree 4=Agree 5=Strongly Agree

April 2019

Q1: Being able to spend time discussing new prt for next month betterprepared me to complete my initial care planning assessments

Q2: I have a basic understanding of the medical needs of the newenrollees

Q3: I have a basic understanding of the psychosocial needs of the newenrollees

N = 61

PDSA Cycle 3

• Use existing Friday morning IDT meeting, the last two Fridays of the month; 20 minutes of the 30 minute meeting.

• List of names of cases to be reviewed sent ahead of meeting so IDT could prepare questions in advance, based on their own review of records.

• Maintain improved quality of EHR demographics for each case reviewed.

• Formalized structure of case presentation

with input from disciplines for prioritizing.

• Intake RNs took over case presentations.

https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwjh_P6kh9biAhWvHDQIHRYrB5QQjRx6BAgBEAU&url=https://www.mememaker.net/meme/teamwork-3142&psig=AOvVaw0J0FMq3Kn9lzWPGEAeQSGX&ust=1559951723904130https://www.google.com/url?sa=i&rct=j&q=&esrc=s&source=images&cd=&ved=2ahUKEwjh_P6kh9biAhWvHDQIHRYrB5QQjRx6BAgBEAU&url=https://www.mememaker.net/meme/teamwork-3142&psig=AOvVaw0J0FMq3Kn9lzWPGEAeQSGX&ust=1559951723904130

0

2

4

6

8

10

12

14

16

18

1=Strongly Disagree 2=Disagree 3=Neither agree nor disagree 4=Agree 5=Strongly Agree

May 2019

Q1: Being able to spend time discussing new prt for next month betterprepared me to complete my initial care planning assessments

Q2: I have a basic understanding of the medical needs of the newenrollees

Q3: I have a basic understanding of the psychosocial needs of the newenrollees

N = 19

PDSA Cycles 4 & 5

• Due to growth, Cycle 4 &5 meetings occurred weekly for all approved members who will enroll on the first of the next month; the existing morning IDT meeting was the venue, any day of the week that time permits.

• Cycle 4 resulted in the same trends for data and a sample size of 53.

• Cycle 5 was the final study and there was not an actual survey utilized for results;– Learn from our experience and plan ahead! Have surveys printed in

advance so you don’t end up with a cycle without concrete data to study.

Outcomes of PDSA

• SSC IDT and intake now meet weekly to discuss any

approved enrollments for initial care planning

considerations; staff look forward to it!

• IDT experience of work is improved.

• Participants are assessed by an informed

member of IDT at each initial care plan assessment.

SSC PDSA Cycle Results

• The struggle between intake teams and IDT is real.

It requires daily work to intervene and support

partnership of these staff teams.

• Sharing concise information about new enrollees with the IDT, prior to enrollment, better prepares IDT for assessing new enrollees.

• Trust building between IDT and Intake teams can happen and the participant’s will benefit from the work to get your teams there.

Considerations for your own PDSA

• Think small and simple – anything can be tested! Don’t get

caught up in making it bigger/”perfect” before you begin, just

try one simple test and learn as you go.

• Empower your teams to develop their own PDSAs – it doesn’t

have to be complicated or something leadership designed to

be tested. Team buy-in will matter in your success.

• Have your study plans ready before you initiate your PDSA –

if you don’t have a plan for how you will study things then you

may not study anything at all.

References

• Taylor MJ, McNicholas C, Nicolay C, et al Systematic review of the application of the plan–do–study–act method to improve quality in healthcare BMJ Quality & Safety 2014; 23:290-298.

• Langley G., Moen R., Nolan K., Nolan T., Norman C., Provost L. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance 2nd Edition. San Francisco, CA. Jossey-Bass. 2009.

• Deming WE. Out of the crisis, 1986. Cambridge, MA; Massachusetts Institute of Technology Center for Advanced Engineering Study xiii, 1991;507