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Chris McNicholas, Professor Derek Bell, Dr Julie Reed

Opening the "black box" of PDSA cycles: Achieving a scientific and pragmatic approach to improving patient care. Chris McNicholas, Professor Derek Bell, Dr Julie Reed

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Chris McNicholas, Professor Derek Bell, Dr Julie Reed

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  1. Opening the "black box" of PDSA cycles: Achieving a scientific and pragmatic approach to improving patient care Chris McNicholas, Professor Derek Bell, Dr Julie Reed National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Imperial College London The Health Foundation United Kingdom

  2. A more sceptical and scientifically rigorous approach to the development, evaluation and dissemination of QI methodologies is needed, in which a combination of theoretical, empirical and experiential evidence is used to guide and plan their uptake. 

  3. Outline Theory • Theory of PDSA (Systematic Review) • Reality of PDSA (International Observational Study) • Revisiting Theory PDSA Empirical Experiential

  4. PDSA Cycles – Why the interest?

  5. Research Questions • What are the perceived functions and benefits of PDSA method? • Are these functions and benefits applied in practice? • How do social and organisational contextual factors influence the improvement work and the use of PDSA in practice?

  6. An International Observational Study • 4 International Sites • Specific improvement initiatives, Organisational improvement support, Broader organisational context • Methods: Interviews (65), Observations (70 hours), Focus groups (6), Document analysis (PDSA cycles) • Technical, Social and Contextual research lenses MUSIQ (Model for Understanding Success in Quality) Kaplan et al, 2013)

  7. Observing the reality of PDSA Selected Themes from Preliminary Analysis • Using quantitative data to inform progression of cycles • Managing complexity of emergent learning- scaling up and iterative cycles • Social factors influencing PDSA use

  8. Using quantitative data to inform progression of cycles The nitty gritty of having data metrics in a database… …we had a concept, we revisited it and we said we need this; by the way, that data isn’t currently being captured…that had to be designed, that had to be added, the data started being collected… and maybe three, four, five months goes by when all that is happening and now our data just started last week… And then, of course, the physicians will get frustrated, because it’s, like - ‘I thought we defined this months ago’.

  9. Scale Up and the Disappearing PDSA DATA ? Daily verbal reminders Reminders in notes Scale of testing Formal education All patients for another week All patients for one week 5 patients 3 patients 1 patient Time

  10. Unpacking a “single” large scale PDSA Doctor Availability Macrosystem • Coding of • Patient Notes Job Plans Scale of testing Data Availability Sphere of contextual influence Process 2 Not Following Plan Ward A Process 1 Following Plan Completion of Post Take Notes Microsystem Time

  11. “its all about social skills – the technical are important but you wont be successful without social skills” Using the Plan to negotiate different perspectives Prior QI experience “That’s actually where I think the most value comes in… you have to have a conversation with people to realise most of us don’t hold with all of it, right? …that’s a two-hour conversation sometimes …just getting to that point is what takes a long time, but also where… the most valuable conversation can happen.” Engagement tactics No Prior QI experience "If I got my laptop out in the meeting and went through a PDSA, people wouldn't come back. It's a fine line between being useful and pushing people away”

  12. Enhancing the theory of PDSA Theory • PDSA as complex social-technical tool • PDSA as boundary object between different groups • Using quantitative data in social and contextual dependent world • How can we structure the management of PDSA cycles? • How do we prepare people for the reality of using PDSA? • What are the generic implications for change management, learning organisations and knowledge mobilisation? Empirical Experiential 12

  13. Structuring ComplexityLearning and Improvement ? Sustainability (self-sufficient) Daily verbal reminders ‘Maintaining’ Reminders in notes Scalability Scale of testing Formal education Ability to measure “Implementing” All patients for another week Applicability All patients for one week “Testing” Usability 5 patients 3 patients Current process 1 patient Time

  14. Walshe, K. (2009). Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. International journal for quality in health care, 21(3), 153-159. Taylor, M. J. et al (2013) Systematic review of the application of the plan-do-study-act method.BMJ Quality & Safety. doi: 10.1136/bmjqs-2013-001862 Kaplan, H. C. et al (2012) The Model for Understanding Success in Quality (MUSIQ). BMJ Quality & Safety, 21(1), 13-2 Ogrinc, G., & Shojania, K. G. (2013). Building knowledge, asking questions. BMJ quality & safety, bmjqs-2013. Funders: National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London The Health Foundation

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