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1/6/2018
1
The Model for Improvement
and PDSA in Action
Virginia (Ginna) Leigh Hamilton Crowe, RN, BA, MS, Ed.D
Principal, Hamilton Consulting, LLC
ASPHN Children’s Healthy Weight CoIIN
January 2018
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 1
Learning Objectives
• Familiarize participants with the Model for
Improvement (MFI)
• Discuss application of MFI in Public Health
• Practice use of the PDSA Cycle
• Strengthen the participants’ ability to
problem solve using the PDSA Cycle
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 2
1/6/2018
2
Who is Here?
How many of you looove Improvement?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 3
Who started the modern improvement
movement?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 4
1/6/2018
3
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?
1. 1602
2. 1689
3. 1757
4. 1796Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
National Quality Center TOT
7
How long did the NIH take to recommend the
treatment of ulcer as suggested by Marshall in
his 1984 Lancet Article?
1. 2 years
2. 5 years
3. 10 years
4. 20 yearsVirginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
National Quality Center TOT
10
1/6/2018
4
In an article in the Journal of Quality
Improvement 92 QI projects were compared.
What was the timeframe from problem
identification to completion of first pilot?
1. 23 days
2. 60 days
3. 397 days
4. 504 daysVirginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
National Quality Center TOT
13
How can we accelerate
change that lead toward
real improvements in
Healthcare?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 16
1/6/2018
5
Many Improvement Methods!
• Six Sigma (DMAIC)
• Lean
• TJC- 10 Step
• TJC - PDMAI
• Turning Point
• ADDIE Model
• FOCUS PDCA
• Model For
Improvement (MFI)
P
DS
A
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 17
ActAdapt?
Adopt ?
Abandon?
Next cycle?
PlanObjective, questions &
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Next Cycle?
StudyComplete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
DoCarry out the plan
(on a small scale)
Document problems
and unexpected
observations
Begin analysis
The PDSA Cycle
W.E.Deming referred to this as the Shewhart Cycle 18
1/6/2018
6
“Negative results on the fish…
Let’s try rubbing two sticks together.”
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 19
Plan
The PDSA Cycle
DoStudy
Act
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 20
1/6/2018
7
Change Method
The Model for Improvement
(MFI)
is a method to help accelerate change
…and increase the odds that the
changes we make are an
improvement .
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 21
Model for Improvement* (MFI)
Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
*Developed by the Associates in Process Improvement. Building on the work of W.E.Deming and Walter Shewhart
Langley et al, The Improvement Guide, 1996, 201122
1/6/2018
8
Model For Improvement
3 Approaches
– Standardization
– Incremental
Improvement
– Innovation
– W.E.Deming (attributed)
Robust in Scale
• Small QI
• Large QI
• And anywhere in
between!
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 23
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
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 24
1/6/2018
9
Theory of Change Concept Map
AIM
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 25
Theory of Change Concept Map
Support
Working
BF Mothers
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 26
1/6/2018
10
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
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 27
Theory of Change Concept Map
Measurement
Support
Working
BF Mothers
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 28
1/6/2018
11
Theory of Change Concept Map
Percent of Organizations
that have BF Support Policy Goal 50%
Percent attend Training (goal?)
Percent create structure to support BF (Goal75%)
Support
Working
BF Mothers
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 29
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
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 30
1/6/2018
12
Change
Improvement
usually requires
change…..
however not all
change is an
Improvement!
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 31
Where do we find Change Ideas? Change
Ideas
Team
Creativity Tools
?
Other people
QI
Tools
Literature
Change Packages
Virginia Leigh Hamilton Crowe RN Ed.D Principal, Hamilton Consulting, LLC
32
1/6/2018
13
Theory of Change Concept Map
AIM
Processes
Measurement
Strategy
Structure
Methods
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 33
Theory of Change Concept Map
Percent of Organizations
that have BF Support Policy Goal 50%
Percent attend Training (goal?)
Percent create structure to support BF (Goal75%)
Support
Working
BF Mothers
Policy Development Process
Education and Training
Building Will for BF
Structure: Pumping Room...
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
34
1/6/2018
14
Virginia Leigh Hamilton Crowe RN Ed.DPrincipal, Hamilton Consulting, LLC
35
and then .........
ActAdapt?
Adopt ?
Abandon?
Next cycle?
PlanObjective, 3
Questions and
predictions (why)
Plan to carry out the cycle
(who, what, where, when)
Next cycle?
StudyComplete the
analysis of the data
Compare data to
predictions
Summarize what
was learned
DoCarry out the plan
(on a small scale)
Document problems
and unexpected
observations
Begin analysis
The PDSA Cycle
for Learning and Improvement
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 36
1/6/2018
15
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
A P
S D
Process and Balancing Measures
Outcome Measures
PDSA Measures
Learning with the PDSA cycle
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
Institute for Healthcare Improvement
37
Why Test ?
• Increase your confidence that the change
will result in improvement in your
organization
• Learn to adapt the change to conditions in
the local environment
• Minimize resistance when you move to
implementation
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 38
1/6/2018
16
This is different!
The Cycles Build on Each Other…
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very small scale
test
Follow-up tests
Wide-scale tests of
change
Implementation of
change
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
Institute for Healthcare Improvement
39
Side Bar
Test or Task
• Test:
– Change in a process from way it has
been done. (Hand washing process)
– Change in a structure from way it has
been done (sink for washing and hand
sanitizer available)
• Task:
– Getting sample Hand Sanitizer
– Teaching how to use Sanitizer
• Test or Task:
– Teaching?
• Different but not mutually exclusive
– How are we teaching? And how might
we teach more effectively?
Applying PDSA
• What is your work? What
are your processes,
structures, methods?
• Those are what you have
control over (in large part)
to change (by testing) to
facilitate change in others
environment.
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 40
1/6/2018
17
Our Work
My thoughts....
• Partnership
• Policy Development
• Building Will
• Education and Training
• Communication
You add...
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 41
This is different!
The Cycles Build on Each Other…
Hunches
Theories
Ideas
Changes That
Result in
Improvement
A P
S D
A P
S D
Very small scale
test
Follow-up tests
Wide-scale tests of
change
Implementation of
change
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 42
Start Here
1/6/2018
18
Concept Map
AIM
Process
Measurement
Strategy
Education and Training
Strucure
Building Will
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 43
Given our work what processes, structures, methods might
we change that will lead to improvement? (testing first)
• Partnership
• Policy development
• Building Will
• Education and Training
– Do walk around with Leader / Manager / Director and have them
set up and wash up a breast pump in bathroom
• Communication
• Policy Development Meetings– Use QI tools in meetings to brainstorm with one leadership team ...how
might we question? Or develop a process map of a mom pumping and
barriers to pumping. Or identify policy barriers to Pumping using NGT.
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 44
1/6/2018
19
Theory of Change Concept Map
Percent of Organizations
that have BF Support Policy Goal 50%
Percent attend Training (goal?)
Percent create structure to support BF (Goal75%)
Support
Working
BF Mothers
Policy Development Process
Education and Training
Building Will for BF
Structure: Pumping Room
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
45
PDSA Exercise
• Partnership
• Policy Development
• Building Will
• Education and Training– Do walk around with Leader / Manager / Director and have them set up
and wash up a breast pump in bathroom
• Communication
• Policy Development Meetings– Use QI tools in meetings to brainstorm with one leadership team ...how
might we question? Or develop a process map of a mom pumping and
barriers to pumping. Or identify policy barriers to Pumping using NGT.
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 46
1/6/2018
20
How Do Tests Lead to
Improvements?• You learn something from each test
• That knowledge gets incorporated into the next test
• Over time, as you build knowledge and expertise, you design a change that will (more likely ☺ ) result in improvement in your environment
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
National Quality Center
47
PDSA STORY
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 48
1/6/2018
21
Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
How small is small?
49
Model for Improvement* (MFI)
Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
*Developed by the Associates in Process Improvement. Building on the work of W.E.Deming and Walter Shewhart
Langley et al, The Improvement Guide, 1996, 201150
1/6/2018
22
Both
Good changes and a robust model for
improvement (one that incorporates
learning and action ) are both needed to
help accelerate change and increase the
odds that the changes we make are an
improvement .
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 51
What questions do you have?
• I have one for you …
– Do you have any ideas for
a next cycle.. ?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 52
1/6/2018
23
Let’s have some fun and learn!
Experiential learning
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 53
Experiential learning
• Work in groups of 8
– 7 people represent key
steps in the process
(development of a
policy?)
– Aim Measures: time
and error free
– 1 person is the quality
officer and data
collector
• Need experience
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 54
1/6/2018
24
Experiential Learning
• Organization
– 7 form a circle representing
the steps in the process
– 1 stand aside and
observes/ records data
• Quality Officer
• Equipment
– Tennis ball (orange)
– Stop watch or watch with
second hand or digital
seconds to measures time
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 55
Process
• One person throws the
ball to the person across
from him/her in the circle.
• Remember to whom you
threw it.
• The receiver throws it to
another person, again
remembering to whom it
is thrown.
• The last person passes it
to the start person.
• Rules– Start and stop with same
person
– Maintain the same sequence
– Don’t drop the ball
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 56
1/6/2018
25
Process
The quality officer: 1. Records time from
beginning to end
2. Enforces all rules
• Start and stop wrong person
– Start over
• Sequence violated
– start over
• Ball dropped
– start over
3. Judgment Call
• Execution done incorrectly in any other manner
– start overVirginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 57
No where good enough!
Need to cut the time in half!
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 58
1/6/2018
26
St. Elsewhere does it better!
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 59
Debrief our experience
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 60
1/6/2018
27
Teams and Goals
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 61
3 Approaches
• Improvement
– Standardization
– Incremental
Improvement
– Innovation
Standardization
Improvement Innovation
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 62
1/6/2018
28
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
A P
S D
Process and Balancing Measures
Outcome Measures
Repeated Use of the PDSA Cycle and PDSA Measures
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 63
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 64
PDSA TIPS......
1/6/2018
29
START WITH THE WILLING!
PDSA TIP....
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 65
Volunteers at first; move to others
RULE OF 1!
PDSA TIP....
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 66
• 1 facility
• 1 office
• 1 provider
• 1 patient
1/6/2018
30
JUST START!
PDSA TIP....
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 67
“What change could you test by next Tuesday?”
Appropriate Scope for next PDSA Cycle(concept developed by Lloyd Provost)
Current Situation Resistant Indifferent Ready
Low
Confidence
that current
change idea
will lead to
Improvement
Cost of
failure
large
Very Small
Scale Test
Very Small
Scale Test
Very Small
Scale Test
Cost of
failure
small
Very Small
Scale Test
Very Small
Scale Test Small Scale
Test
High
Confidence
that current
change idea
will lead to
Improvement
Cost of
failure
large
Very Small
Scale Test Small Scale
Test
Large Scale
Test
Cost of
failure
small
Small Scale
Test
Large Scale
TestImplement
Staff Readiness to Make Change
68Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
1/6/2018
31
MEASURE
PDSA TIP....
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 69
Useful, not perfect, data
Hunches Theories
Ideas
Changes That Result in
Improvement
A P
S D
A P
S D
Process and Balancing Measures
Outcome Measures
Repeated Use of the PDSA Cycle and PDSA Measures: Often qualitative
Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
70
1/6/2018
32
KEEP ON KEEPIN’ ON
PDSA TIP....
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 71
Shepherd your PDSA’s with Prediction and scope
Robust Testing
4. Implementation
testing
1. Early tests are simple
and designed to learn
then succeed
2. Then test over a variety of
conditions to understand scalability
and identify weaknesses
3. Later tests are
designed to predict
and prevent failures
Virginia Leigh Hamilton Crowe
RN Ed.D Principal, Hamilton
Consulting, LLC
A P
S D
A P
S D
A P
S D
72
1/6/2018
33
QUESTIONS?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 73
Team Work Session:
• Opportunity for you all to
do some “real work“ on
your project.
• Ideas for Agenda
– Concept Map
– List of Tasks “To Do”
– List of Change Ideas
– PDSA development (plan)
for one of the change ideas
you listed
• What can you do by next
Tuesday?
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 74
• Forms to help:
– Blank Concept Map
– PDSA Form
• Advice and Direction:
– Staff and Faculty will be
circulating around the
room. Raise your hand if
questions or advice
needed.
1/6/2018
34
Theory of Change Concept Map
AIM
Process
Measurement
Strategy
Structure
Education
Policy
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 75
Theory of Change Concept Map
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 76
1/6/2018
35
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 77
MODEL FOR IMPROVEMENT
PDSA Planning Worksheet
Team Name:__________________
Cycle start date:_________ Cycle end date:__________
PLAN: Describe the change you are testing and state the question you want this test to answer:
What do you predict the result will be?
What measure will you use to learn if this test is successful or has promise?
Plan for change or test: who, what, when, where
Data collection plan: who, what, when, where
DO: Report what happened after you carried out the test. Describe observations, findings, problems
encountered, special circumstances.
STUDY: Compare results from this completed test to your predictions. What did you learn? Any surprises?
ACT: Modifications or refinements for the next cycle; what will you do next?
A P
S D
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC 78
PDSA TIPS......
• Start with the Willing!
• Rule of 1!
• Just Start (Low Fat Mayo)
• Measure
• Keep on Keepin’ on!
• Use PDSA Form
1/6/2018
36
Virginia Leigh Hamilton Crowe RN Ed.D
Principal, Hamilton Consulting, LLC
How small is small?
79
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