Rapid Cycle, Small Scale Testing David M. Williams, Ph.D. Institute for healthcare Improvement

1. Rapid Cycle, Small Scale Testing David M. Williams, Ph.D. Institute for healthcare Improvement

9. P D S A • lease • o • omething • nything!

10. Building Knowledge & • Making Improvement

11. Building Knowledge & • Making Improvement • Aim Statement: • Improve what? • By how much? • By when?

12. Building Knowledge & • Making Improvement Measure(s) Percent 100% 90% 80% 70% 60% 50% 40% 30% 20% 10% 0% 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 weeks

13. Building Knowledge & • Making Improvement • Change Ideas

14. Building Knowledge & • Making Improvement Now, let’s focus on the PDSA part of the MFI and tests of change

15. … the PDSA cycle!

16. Plan, Do, Study, Act Cycle Act Plan Study Do

17. Development of the Shewhart Cycle 1986 1939 1. Design the product (with appropriate tests). 2. Make it; test it in the production line and in the laboratory. 3. Put it on the market. 4. Test it in service, through market research, find out what the user thinks of it, and why the non-user has not bought it. 5. Re-design the product, in the light of consumer reactions to quality and price. Continue around and around the cycle. 1951 Materials courtesy of Ron Moen and Cliff Norman

18. Deming’s Sketch of the Shewhart Cycle - 1985 Walter Shewhart (1891 – 1967)

19. Plan, Do, Study, Act Cycle Act Plan Study Do

20. AIM

21. Plan, Do, Study, Act Cycle Plan Objective Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Act Study Do

22. Plan

23. Plan, Do, Study, Act Cycle Plan Act Do Carry out the plan Document problems and unexpected observations Begin analysis of the data Study

24. Do

25. Do

26. Do

27. Do

28. Plan, Do, Study, Act Cycle Act Plan Study • Complete the • analysis of the data • Compare data to • predictions • Summarise what • was learned Do

29. Study

30. Plan, Do, Study, Act Cycle Act Plan Adopt? Adapt? (New Plan)? Abandon? Do Study

31. Act - Adapt

32. 1) What are we trying to accomplish? 2) How will we know thata change is an improvement? 3) What change can we make that will result in improvement? A P S D D S P A A P S D A P S D Repeated Use of the PDSA Cycle Changes That Result in Improvement DATA Implementation of Change Wide-Scale Tests of Change Hunches Theories Ideas Sequential building of knowledge under a wide range of conditions Follow-up Tests Very Small Scale Test

33. Results PDSA 2

34. Results of PDSA 3

35. Results of PDSA 4

36. A P S D D S P A A P S D A P S D Changes That Result in Improvement Repeated Use of the PDSA Cycle DATA Hunches Theories Ideas

37. The PDSA Cycle for Learning and Improvement What will happen if we try something different? What’s next? Did it work? Let’s try it!

38. PDSA Guidance • Test changes at the smallest level that is possible and reasonable. • One patient – one day – one admit - one doctor. • Test under various conditions before expanding. • What can you do by next Tuesday? • Fail often to succeed sooner.

39. Is a change: Establish a prompt to redose Create a standing order Provide staff with protocol compliance feedback Test placement of alcohol rub dispensers Is NOT a change:(but may be a necessary preliminary task) Planning Having a meeting Educating staff Creating a protocol Assigning responsibility Activity ≠ Change For each change idea, you should have an explicit prediction of how it will impact the outcome.

40. Tips for Testing “What tests can we complete by next Tuesday?” • Use a form to document your test. • Scale down – think “Drop Two” • Oneness • Make changes in parallel • Know the situation in your organization • Year • Quarter • Month • Week • Day • Hour • 1 patient • 1 day • 1 admit • 1 physician

41. Failed Test…Now What? • Be sure to distinguish the reason: • Change was not executed • Change was executed, but not effective • If the prediction was wrong – not a failure! • Change was executed but did not result in improvement • Local improvement did not impact the secondary driver or outcome • In either case, we’ve improved our understanding of the system!

42. The Value of “Failed” Tests • “I did not fail one thousand times; I found one thousand ways how not to make a light bulb.” • -- Thomas Edison

43. P P P P P A A A A A D D D D D S S S S S S S S S S D D D D D A A A A A P P P P P A A A A A P P P P P S S S S S D D D D D P P P P P A A A A A D D D D D S S S S S Aim: Big Dot Early Years Developing parents' skills Project(s) Early Intervention in Maternity Services Project(s) Attachment and Child Development beyond maternity services Project(s) Continuity of care in transitions between services Project(s) 27 - 30 month Child Health review Project(s)

44. Multiple Key Changes for a Single Aim Continuity of care in transitions between services 27 - 30 month Child Health review Attachment and Child Development beyond maternity services Early Intervention in Maternity Services Change Concepts, Theories, Ideas

45. Breakout Sessions Key changes – PDSAs • In the next session… • Learn from examples of small tests (PDSAs) from Pioneer Sites. • Think of ideas for small tests of change in your work. • Develop a plan for a small test you can do by next Tuesday.