The PDSA Cycle or How Can We Accelerate

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The PDSA Cycle or How Can We Accelerate Improvements in HIV Care? The Quality

The PDSA Cycle or How Can We Accelerate Improvements in HIV Care? The Quality Academy Tutorial 13

Learning Objectives: You will learn about… • • 2 Learning Objectives The importance of

Learning Objectives: You will learn about… • • 2 Learning Objectives The importance of accelerating change The Plan-Do-Study-Act (PDSA) Cycle Concrete examples and tips how to best apply the PDSA Cycle Where to find references

Tips for Viewing This Presentation Read along with the narrator Skip to other slides

Tips for Viewing This Presentation Read along with the narrator Skip to other slides in the presentation Search for keywords in the presentation Review current slide Play, rewind and fast forward 3 Tips for Viewing View full screen

History Question In 1601, it was known that lemon juice prevented the disease scurvy,

History Question In 1601, it was known that lemon juice prevented the disease scurvy, a Vitamin C deficiency. Select the year that the British Navy adopted this proven treatment. A) 1602 B) 1689 C) 1757 D) 1796 Submit 4 Why Accelerate Change?

History Question In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness

History Question In 1601, James Lancaster successfully conducted an experiment to illustrate the effectiveness of lemon juice to prevent scurvy. When did the British Navy adopt this treatment? a) b) c) d) 5 1602 1689 1757 1796 Why Accelerate Change? (195 years later)

Treatment of Scurvy • Stephen J. Bown - Scurvy: How a Surgeon, a Mariner,

Treatment of Scurvy • Stephen J. Bown - Scurvy: How a Surgeon, a Mariner, and a Gentleman Solved the Greatest Medical Mystery of the Age of Sail; St. Martin's Press, 2004 § § § 6 In 1601 lemon juice, as a protective against scurvy, is recorded by James Lancaster In 1612, Woodall recommended citrus fruit for protection against scurvy on sea voyages In 1753 James Lind published A Treatise on the Scurvy which portrays his experiment on-board the ship Salisbury in 1747 From 1772 to 1775 sailors on historic voyages with Captain James Cook remained free from scurvy In 1796 lemon juice was officially introduced in the British Navy as a prophylactic against scurvy In 1865 British Board of Trade adopted the policy for the merchant marine Why Accelerate Change?

History Question How long did the NIH take to recommend the treatment of ulcers

History Question How long did the NIH take to recommend the treatment of ulcers as suggested by Marshall in his 1984 Lancet Article? A) 2 years B) 5 years C) 10 years D) 20 years Submit 7 Why Accelerate Change?

History Question How long did the NIH take to recommend the treatment of ulcer

History Question How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article? a) b) c) d) 8 Why Accelerate Change? 2 years 5 years 10 years 20 years

Treatment of Ulcer – Dr. Marshall Timetable: 1979: Dr. Robin Warren, pathologist at Royal

Treatment of Ulcer – Dr. Marshall Timetable: 1979: Dr. Robin Warren, pathologist at Royal Perth Hospital, Australia found bacteria in stomach of patients 1981: Dr. Barry Marshall starts residency 1982: Marshall cultivates bacteria: Helicobacter pylori, 100% in Duodenal Ulcer and 77% in Gastric Ulcer 1984: first publication in Lancet; presents treatment of ulcer with common antibioticum 1994: National Institute of Health recommends treatment of ulcer as suggested by Dr. Marshall 9 Why Accelerate Change?

History Question In an article in the Journal of Quality Improvement 92 quality improvement

History Question In an article in the Journal of Quality Improvement 92 quality improvement projects were compared. What was the timeframe from problem identification to completion of first pilot? 10 Why Accelerate Change? A) 23 days B) 50 days C) 397 days D) 504 days Submit

History Question In a recent article in the Journal of Quality Improvement 92 quality

History Question In a recent article in the Journal of Quality Improvement 92 quality improvement projects were compared. What was the timeframe from problem identification to completion of first pilot? a) b) c) d) 11 Why Accelerate Change? 23 days 60 days 397 days 504 days

Survey of 92 Quality Improvement Projects in Journal of Quality Improvement • Alemi F,

Survey of 92 Quality Improvement Projects in Journal of Quality Improvement • Alemi F, Safaie F, Neuhauser D. “A Survey of 92 Quality Improvement Projects. ” Journal of Quality Improvement 2001, 27(11): 619 -632 • • 12 Why Accelerate Change? 504 days from problem identification to completion of first pilot 397 days from first team meeting to the end of first cycle 75 days to describe current situation in flowchart 62 days for data collection if change was improvement

Key Question: How can we accelerate change and improvements in HIV programs? 13 Why

Key Question: How can we accelerate change and improvements in HIV programs? 13 Why Accelerate Change?

Why Test? • Increase your confidence that the change will result in improvement in

Why Test? • Increase your confidence that the change will result in improvement in your organization • Learn how to adapt the change to conditions in the local environment • Minimize resistance when you move to implementation 14 The PDSA Cycle

Model for Improvement 15 The PDSA Cycle

Model for Improvement 15 The PDSA Cycle

The PDSA Cycle for Learning and Improvement 16 The PDSA Cycle

The PDSA Cycle for Learning and Improvement 16 The PDSA Cycle

Plan 1. Clarify your Objective 2. Make a prediction • • Formulate theory Objective

Plan 1. Clarify your Objective 2. Make a prediction • • Formulate theory Objective + specificity 3. What is to be done • • • 17 The PDSA Cycle Who What Where When How

Plan: a New Adherence Screening Tool • Objective: how can we screen HIV patients

Plan: a New Adherence Screening Tool • Objective: how can we screen HIV patients for issues that might affect their ability to adhere to their medication regimen, in a way that won’t disrupt patient flow? • Prediction: adding a screening tool will add time to the patient visit, but we can keep this to a minimum • Steps: Joanne and Sally researched and identified possible tools that were reviewed by Sally and Dr. Smith. They selected one tool for Dr. Smith to use with at least three patients in the clinic on Thursday • Necessary tasks: 1. Identify tool. 2. Copy tool and place in patients' charts. 3. Dr. Smith reviews instructions for using tool. 4. Explain tool to patient. 5. Use tool 18 The PDSA Cycle

Do 1. Carry out the plan 2. Document your observations • • Expected Unexpected

Do 1. Carry out the plan 2. Document your observations • • Expected Unexpected 3. Begin analysis 19 The PDSA Cycle

Do: What Happened? • Tool was used on one patient • Administration took 5

Do: What Happened? • Tool was used on one patient • Administration took 5 pages • Added 35 minutes to documentation 20 The PDSA Cycle

Study Complete Compare Summarize 21 The PDSA Cycle

Study Complete Compare Summarize 21 The PDSA Cycle

Study: Our Results (vs. Our Prediction) • Theory still holds • Need to test

Study: Our Results (vs. Our Prediction) • Theory still holds • Need to test more tools 22 The PDSA Cycle

Act 1. Adjustments • • • Changes to previous test? What adjustments? Expand last

Act 1. Adjustments • • • Changes to previous test? What adjustments? Expand last cycle? 2. New cycles • • 23 The PDSA Cycle What are you planning? What are you going to test?

Act: What Will We Do (Based on What We Learned)? We will test two

Act: What Will We Do (Based on What We Learned)? We will test two different tools, each with three patients, by next Wednesday. 24 The PDSA Cycle

The PDSA Cycle for Learning and Improvement 25 The PDSA Cycle

The PDSA Cycle for Learning and Improvement 25 The PDSA Cycle

Method for Change 26 The PDSA Cycle

Method for Change 26 The PDSA Cycle

How Do Tests Lead to Improvements? 27 Applying PDSA

How Do Tests Lead to Improvements? 27 Applying PDSA

Start Small and Do More 28 Applying PDSA

Start Small and Do More 28 Applying PDSA

At the Beginning, Test on a Small Scale • “What change could you implement

At the Beginning, Test on a Small Scale • “What change could you implement by next Tuesday? ” • Use the “Rule of 1”: • 1 facility • 1 office • 1 provider • 1 patient 29 Applying PDSA

Scale Down the Time Frame • • 30 Years Quarters Months Weeks Days Hours

Scale Down the Time Frame • • 30 Years Quarters Months Weeks Days Hours Minutes Applying PDSA Drop down two levels! (years to months, weeks to hours)

Keep the First Tests Simple • Volunteers at first • Useful, not perfect, data

Keep the First Tests Simple • Volunteers at first • Useful, not perfect, data • Use “huddles” to report 31 Applying PDSA

Build Each Cycle on Its Predecessor “The shorter the timeframes between test cycles, the

Build Each Cycle on Its Predecessor “The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge. ” HIVQUAL Workbook 32 Applying PDSA

Key Points The PDSA Cycle: • Helps “test your hunches” • Adapt these changes

Key Points The PDSA Cycle: • Helps “test your hunches” • Adapt these changes to your own environment. • Start small • Lead to more complex cycles 33 Key Points

Resources • http: //www. IHI. org/IHI/Improvement/ Improvement. Methods provides information on improvement methods, strategies,

Resources • http: //www. IHI. org/IHI/Improvement/ Improvement. Methods provides information on improvement methods, strategies, and changes. • Moen, Ronald, Thomas Nolan; “Process Improvement” Quality Progress, 1987, p 62. • Langley, Gerald, Kevin Nolan and Thomas Nolan; “The Foundation of Improvement, ” Quality Progress, June 1994, p. 81. • Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff Norman, and Lloyd Provost; The Improvement Guide. San Francisco, CA; Jossey. Bass, 1996. • Nolan, Kevin; “ASQs Accelerating Change Collaborative Series: A Challenge for Industry, ” Quality Progress, Jan 1999, p 55. 34 Resources

Test Question Which of these would be a good first PDSA Cycle? A) Test

Test Question Which of these would be a good first PDSA Cycle? A) Test a new appointment system in the HIV clinic for two weeks. B) Test a new method for reading PPDs with all the patients who show up for readings from 1011 am on Wednesday. C) Ask all providers to spend more time counseling patients on adherence, and check in at the next staff meeting on how it went. 35 Test Question

Test Question What data should you collect on your test of a new way

Test Question What data should you collect on your test of a new way of reading PPDs? A) How long the client had to wait B) Whether the client complained about waiting C) Whether the staff felt the new method worked well D) All of the above E) It depends on your hypothesis 36 Test Question

Test Question Your group found that changing the PPD reading method cut wait time

Test Question Your group found that changing the PPD reading method cut wait time in half. What would be a good “second cycle” PDSA? A) Implement it fully B) Try it for a full week C) Try the method with other follow-up services 37 Test Question

tra N l o, no N t ve o, r no y m ta

tra N l o, no N t ve o, r no y m ta u t a ch ll tle eu lit N , a es Y Y es , a lo t Please Rate This Tutorial By Indicating How Your Response To The Following Statements. Was this Tutorial helpful to you? Did this Tutorial meet your expectations and goals? Was the Tutorial clearly organized and easy to use? Would you recommend this Tutorial to colleagues of yours? Submit 38 Evaluation

Related Tutorials • To learn more about the Model for Improvement, study Tutorial 12

Related Tutorials • To learn more about the Model for Improvement, study Tutorial 12 • To learn more about how to set up quality team for success, study Tutorial 11 39 Related Tutorials

The Quality Academy For further information, contact: National Quality Center New York State Dept.

The Quality Academy For further information, contact: National Quality Center New York State Dept. of Health 90 Church Street, 13 th floor New York, NY 10007 -2919 Work: 212. 417. 4730 Fax: 212. 417. 4684 Email: Info@National. Quality. Center. org Or visit us online at National. Quality. Center. org 40 In Closing