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The Model for Improvement and Using PDSA Cycles
Presented by: Nicole Van Borkulo, MEd
Qualis Health Practice Improvement Specialist
September 30, 2010
Everything I need to know, I learned in kindergarten?
2
The Safety Net Medical Home Initiative
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
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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
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 Plan
Study Do From: Associates in Process Improvement
Act Plan
Study Do
Model for Improvement
The Safety Net Medical Home Initiative
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 Plan
Study Do From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
Model for Improvement A Quality Improvement Strategy
The Safety Net Medical Home Initiative
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 Plan
Study Do From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
Model for 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.
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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
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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
Aim Statements include:
The Safety Net Medical Home Initiative
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 Plan
Study Do From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
Model for Improvement
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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
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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 Plan
Study Do From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
Model for 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?
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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
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 Plan
Study Do From: Associates in Process Improvement
Aim
Measures
Ideas
Act Plan
Study Do
Model for Improvement
The Safety Net Medical Home Initiative
The PDSA Cycle for Learning and Improvement
Act
What changes are to be made?
Next cycle?
Plan
Questions and predictions (why) Plan to carry out the cycle (who, what, where, when) Plan for data collection
Study Complete the analysis of the data Compare data to predictions Summarize what was learned
Do Carry out the plan Document problems and unexpected observations Begin analysis of the data
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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?
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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
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Use the PDSA Cycle for:
Developing a change Testing or adapting a change idea Implementing a change
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Repeated Use of the PDSA Cycle
Hunches Theories
Ideas
Changes That Result in
Improvement
A P S D
Small Scale Testing
Follow-up Tests
Test new conditions
Implementation of Change
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?
Model for Improvement
Multiple PDSA Cycles -- Sequential Building of Knowledge – include a wide range of conditions in the sequence of tests before implementing the change
A P S D
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Introduce Written
Action Plans
Routine use of Action Plan for Better Self-
Management
A P S D
A P S D
Cycle 1: Test with 1 MA/1 patient/family
Cycle 2: Revise and test with 2 MAs and 6 patients/families
Cycle 3: Revise and test with patients/families who are from different cultural backgrounds or speak ESL.
Cycle 4: Train for Implementation
Cycle 5: Monitor implementation – continued use by MAs
Aim: Improve quality of life for children with asthma
The Safety Net Medical Home Initiative
When to use PDSA?
For trying changes to existing processes
For trying new 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
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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
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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
The Safety Net Medical Home Initiative
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The Safety Net Medical Home Initiative
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Failure is just succeeding at learning what doesn’t work!
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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
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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
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Initially use Smaller Scale Tests: The power of “one”
Conduct the initial test with… one facility one office one doc one patient
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Move Quickly to Testing Changes
Year
Quarter
Month
Week
Day
Hour
“What tests can we complete by next Tuesday?”
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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
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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.
Clarification of Terms
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Testing vs. Implementing
Testing – Trying and adapting existing knowledge on small scale. Learning what works in your system.
More Tests:
Including wide range of conditions-
dayshift/night shift weekdays/weekends
different cultures
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!
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From Charles Darwin:
“It is not the strongest of the species that survive, nor the most intelligent, but the
one most responsive to change.”
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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/ImprovementMethods/HowToImprove/
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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
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For more information:
www.safetynetmedicalhome.org/
Nicole Van Borkulo, MEd Phone: 206-288-2573 E-mail: nicolevb@qualishealth.org
The Safety Net Medical Home Initiative
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; no16, 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. 2nd edition R. Moen, T. Nolan, L. Provost,
McGraw-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 McDonald, 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.
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