The Model for Improvement: Using PDSA Cycles

1. The Model for Improvement:Using PDSA Cycles Presented by: Margaret Enright, MPH, CDE menright@okqio.sdps.org (405) 840-2891 Oklahoma Foundation for Medical Quality

2. Act Plan Study Do 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. A P S D D S P A A P S D A P S D Rapid Cycle Change (Repeated Use of the Cycle) Changes That Result in Improvement DATA DIFFICULTY Hunches Theories Ideas TIME

6. D S P A A P S D D S P A A P S D A P S D 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. D S P A A P S D D S P A A P S D A P S D 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 1:Develop 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 • Don’t 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 stafftraining 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