The Model for Improvement and Using PDSA Cycles

The Model for Improvement and Using PDSA Cycles Presented by: September 30, 2010 Nicole Van Borkulo, MEd Qualis Health Practice Improvement Specialist

Everything I need to know, I learned in kindergarten? 2

William Edwards Deming “Put everybody in the organization to work to accomplish the transformation. The transformation is everybody's work. ” The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Improvement: What was, what is! The Safety Net Medical Home Initiative

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? The Safety Net Medical Home Initiative

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? Act Study Plan Do Do From: Associates in Process Improvement The Safety Net Medical Home Initiative

Model for Improvement A Quality Improvement Strategy What are we trying to accomplish? Aim How will we know that a change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do From: Associates in Process Improvement The Safety Net Medical Home Initiative

Model for Improvement What are we trying to accomplish? Aim How will we know that a change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do Act Plan From: Associates in Process Improvement The Safety Net Medical Home Initiative

Aim: What are we trying to accomplish? Improved care and improved outcomes for our patients. Transformation into a PCMH. The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Aim Statements include: § 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 The Safety Net Medical Home Initiative

Model for Improvement What are we trying to accomplish? Aim How will we know that a change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do Act Plan From: Associates in Process Improvement The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Model for Improvement What are we trying to accomplish? Aim How will we know that a change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do Act Plan From: Associates in Process Improvement The Safety Net Medical Home Initiative

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? The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Model for Improvement What are we trying to accomplish? Aim How will we know that a change is an improvement? Measures What change can we make that will result in improvement? Ideas Act Plan Study Do From: Associates in Process Improvement The Safety Net Medical Home Initiative

The PDSA Cycle for Learning and Improvement § What changes are to be made? § Next cycle? §Questions and predictions (why) § Plan to carry out the cycle (who, what, where, when) § Plan for data collection Act Plan Study Do § Complete the § Carry out the plan analysis of the data § Compare data to predictions § Summarize what was learned § Document problems and unexpected observations § Begin analysis of the data The Safety Net Medical Home Initiative

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? The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Use the PDSA Cycle for: § Developing a change § Testing or adapting a change idea § Implementing a change The Safety Net Medical Home Initiative

Repeated Use of the PDSA Cycle Changes That Result in Improvement 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? ce n ide DS PA Ev A S Hunches Theories Ideas & ta a D D P d n ga v o r p Im A P S D t e n e m Implementation of Change Test new conditions Multiple PDSA Cycles -n A P i n Sequential Building of r a S D Le Follow-up Knowledge – include a wide Tests range of conditions in the Small Scale sequence of tests before Testing implementing the change The Safety Net Medical Home Initiative

Aim: Improve quality of life for children with asthma Routine use of Action Plan for Better Self. Management A T A D AP SD Introduce Written Action Plans A S P D DS PA AP SD DS PA Cycle 5: Monitor implementation – continued use by MAs Cycle 4: Train for Implementation Cycle 3: Revise and test with patients/families who are from different cultural backgrounds or speak ESL. Cycle 2: Revise and test with 2 MAs and 6 patients/families Cycle 1: Test with 1 MA/1 patient/family The Safety Net Medical Home Initiative

When to use PDSA? § § For trying changes to existing 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 The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

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Failure is just succeeding at learning what doesn’t work! 37 The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Initially use Smaller Scale Tests: The power of “one” Conduct the initial test with… § one facility § one office § one doc § one patient The Safety Net Medical Home Initiative

Move Quickly to Testing Changes § § § Year Quarter Month Week Day Hour “What tests can we complete by next Tuesday? ” The Safety Net Medical Home Initiative

H C AT ! ! T OU W The Safety Net Medical Home Initiative

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 The Safety Net Medical Home Initiative

Clarification of Terms § 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. The Safety Net Medical Home Initiative

Testing vs. Implementing Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system. 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! More Tests: Including wide range of conditionsdayshift/night shift weekdays/weekends different cultures The Safety Net Medical Home Initiative

From Charles Darwin: “It is not the strongest of the species that survive, nor the most intelligent, but the one most responsive to change. ” The Safety Net Medical Home Initiative

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/Im provement. Methods/How. To. Improve/ The Safety Net Medical Home Initiative

Thank you! Madlen Caplow, Neil Heffron, Lloyd Provost, NICHQ, the IHI and others from whom I ‘shamelessly’ stole some of these slides. The Safety Net Medical Home Initiative

For more information: www. qhmedicalhome. org/safety-net Nicole Van Borkulo, MEd Phone: 206 -288 -2573 E-mail: nicolevb@qualishealth. org The Safety Net Medical Home Initiative 49

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; no 16, 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. 2 nd edition R. Moen, T. Nolan, L. Provost, Mc. Graw-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 Mc. Donald, 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. The Safety Net Medical Home Initiative