QI 101 - The Model for Improvement and Using PDSA Cycles · The Model for Improvement and Using PDSA Cycles. Presented by: Nicole Van Borkulo, MEd . Qualis Health . Practice Improvement

The Model for Improvement and Using PDSA Cycles

Presented by: Nicole Van Borkulo, MEd

Qualis Health Practice Improvement Specialist

September 30, 2010

Everything I need to know, I learned in kindergarten?

2

The Safety Net Medical Home Initiative

William Edwards Deming

“Put everybody in the organization to work to accomplish the

transformation. The transformation is everybody's work.”


Objectives

Identify the components of the Model for Improvement

Understand how to use PDSA cycles for rapid cycle improvement

Learn tools/examples for teaching this model to others


Improvement: What was, what is!


Three Fundamental Questions for Improvement

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What changes can we make that will result in 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?

Act Plan

Study Do From: Associates in Process Improvement

Act Plan

Study Do

Model for Improvement





Act Plan


Aim

Measures

Ideas

Act Plan

Study Do

Model for Improvement A Quality Improvement Strategy





Act Plan


Aim

Measures

Ideas

Act Plan

Study Do



Aim: What are we trying to accomplish?

Improved care and improved outcomes for our patients. Transformation into a PCMH.


Why an Aim Statement? Answers and clarifies “What are we trying to

accomplish?

Creates a shared language to communicate about the project

Facilitates organizational conversations and understanding


What is expected to happen

The system to be improved or the population of patients

Specific numerical goals

Time frame

Guidance for activities, such as strategies for the effort, or limitations

Aim Statements include:





Act Plan


Aim

Measures

Ideas

Act Plan

Study Do



Ideas: What changes can we make that will lead to

improvement?

Key Changes for improved care based on: • The best available evidence

• Knowledge of front line workers

• Experiences of experts

Within the structure of the PCMH • Changes in each of the eight Change Concepts





Act Plan


Aim

Measures

Ideas

Act Plan

Study Do



Measurement: How Do We Know a Change is an Improvement?

Improvement is about making changes to systems; it is about changing an organization’s approach to improving the health of patients.

It is not about measurement. So, why would we want to spend time on measures?


Measurement:

But measurement plays an important role: One - Key measures are required to assess progress toward

the aim - (Global)

Two - Specific measures can be used for learning during PDSA cycles – can be qualitative or quantitative (Local)

Balancing measures are needed to assess whether the system as a whole is being improved

Data from the system (including from patients and staff) can be used to focus improvement and refine changes





Act Plan


Aim

Measures

Ideas

Act Plan

Study Do



The PDSA Cycle for Learning and Improvement

Act

What changes are to be made?

Next cycle?

Plan

Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection

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

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


PDSA: Break it Down/Simplify… Plan - Figure out the questions you want to answer, plan a

way to answer the questions, and predict results

Do - “Just do it” (i.e. do the plan); collect the data

Study - What did you learn?

Act - What will you do with the knowledge you learned?

What do you want to do next?


Why PDSA measurement? Recent observations tend to be more heavily weighted in our

minds. New observations depend on previous observations. (e.g. if

used to a room of 30 degrees, 60 degrees feels warm but not if used to 95 degrees).

Our minds automatically filter perceptions. Sometimes we observe what we want or expect to observe.

Because of the first three issues, groups learn better from data based on measurements than observations.

From Associates in Process Improvement, The Improvement Handbook, Model, Methods, and Tools for Improvement, copyright 1990-2005, Associates in Process Improvement


Use the PDSA Cycle for:

Developing a change Testing or adapting a change idea Implementing a change


Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P S D

Small Scale Testing

Follow-up Tests

Test new conditions

Implementation of Change





Multiple PDSA Cycles -- Sequential Building of Knowledge – include a wide range of conditions in the sequence of tests before implementing the change

A P S D


Introduce Written

Action Plans

Routine use of Action Plan for Better Self-

Management

A P S D

A P S D

Cycle 1: Test with 1 MA/1 patient/family

Cycle 2: Revise and test with 2 MAs and 6 patients/families

Cycle 3: Revise and test with patients/families who are from different cultural backgrounds or speak ESL.

Cycle 4: Train for Implementation

Cycle 5: Monitor implementation – continued use by MAs

Aim: Improve quality of life for children with asthma


When to use PDSA?

For trying changes to existing processes

For trying new processes

For trying new tools

For trying new measures

Don’t need to use PDSA:

For specific project tasks

For gathering data or information (unless you want to learn about the data process)

For general “planning” or setting goals, objectives


Why Test?

Increase your belief that the change will result in improvement

Opportunity for learning from “failures” without impacting performance

Document how much improvement can be expected from the change

Learn how to adapt the change to conditions in the local environment

Evaluate costs and side-effects of the change Minimize resistance upon implementation


Tips for Testing Changes

Identify changes that will assist the team to reach goals

Harvest good ideas and adapt them to your setting

Solicit team members ideas

Start with changes that are easy to test

Collect and study useful data during each test

Learn from “failed” tests

Eventually test over a wide range of conditions











Failure is just succeeding at learning what doesn’t work!

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Objectives of Cycles for Testing

Decide if change will work in actual environment

Decide on combination of changes for desired effect

Evaluate cost, social impact, side effects

Evaluate how much improvement we can expect

Increase degree of belief


Successful Cycles to Test and Adapt

Scale down size of test (# of patients, location) Conduct the test over a short time period Test with volunteers Do not try to get buy-in or consensus for the test Collect useful data during each test Think a couple of cycles ahead Plan multiple cycles to test and adapt change

In later cycles, test over a wide range of conditions


Initially use Smaller Scale Tests: The power of “one”

Conduct the initial test with… one facility one office one doc one patient


Move Quickly to Testing Changes

Year

Quarter

Month

Week

Day

Hour

“What tests can we complete by next Tuesday?”



Some misuses of PDSAs

Tendency to do too much in one PDSA, instead of several cycles

Tendency to use PDSAs for information gathering or collecting data on a measure rather than beginning to test an idea for change

Tendency to use PDSAs to complete all ‘tasks’ on the project


Task: An activity that needs to be completed or something that needs to get done, i.e. find a sample Management Plan or print a list of patients.

Test: Trying a change on a small scale to see if the change results in improvement. A test of change involves complete Plan-Do-Study-Act cycles, including a question and a prediction. The specific change idea is being used in the clinic on a temporary basis because at this stage it is only a test.

Collecting baseline data, meeting, brainstorming, and/or

planning to change are not tests of change. These are examples of getting ready to test or planning to test.

Clarification of Terms


Testing vs. Implementing

Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system.

More Tests:

Including wide range of conditions-

dayshift/night shift weekdays/weekends

different cultures

Implementation – Making this change a part of the day-to-day operation of the system in the pilot site. Usually not after just one or two tests!


From Charles Darwin:

“It is not the strongest of the species that survive, nor the most intelligent, but the

one most responsive to change.”


On-line Model for Improvement

To review the Model for Improvement or share with colleagues, visit the IHI’s website

http://www.ihi.org/IHI/Topics/Improvement/ImprovementMethods/HowToImprove/


Thank you!

Madlen Caplow, Neil Heffron, Lloyd Provost, NICHQ, the IHI and others from whom I ‘shamelessly’ stole some of these slides.


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For more information:

www.safetynetmedicalhome.org/

Nicole Van Borkulo, MEd Phone: 206-288-2573 E-mail: [email protected]

http://www.safetynetmedicalhome.org/

mailto:[email protected]�


References “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996. “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality

Improvement, Volume 23, No. 4, The Joint Commission, April, 1997. “Building Measurement and Data Collection into Medical Practice”, Eugene Nelson, Mark Splaine, Paul

Batalden, Stephen Plume. Annals of Internal Medicine Vol 128; no16, March 15, 1998. “How to Take Multiple Measures to Get a Complete Picture of Organizational Performance.” Provost,

Lloyd and Leddick, Susan National Productivity Review. Autumn 1993. pp. 477-490. Quality Improvement Through Planned Experimentation. 2nd edition R. Moen, T. Nolan, L. Provost,

McGraw-Hill, NY, 1998. 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. “The Three Faces of Performance Measurement: Improvement, Accountability and Research.” Solberg,

Leif I., Mosser, Gordon and McDonald, Susan Journal on Quality Improvement. March 1997, Vol.23, No. 3.

“Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990. A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.

Documents

QI 101 - The Model for Improvement and Using PDSA Cycles · The Model for Improvement and Using PDSA Cycles. Presented by: Nicole Van Borkulo, MEd . Qualis Health . Practice Improvement