Quality Improvement
The Model for Improvement, PDSA Cycles, and
Accelerating ImprovementHeather Maciejewski
BEACON Quality Improvement CoordinatorOhio Chapter, AAP
Session Objectives• To describe the components of the
Model for Improvement• To identify measures and goals for your
participation in EASE• To develop a clear plan for your team
to test a change idea• To identify future tests of change
QUALITY IMPROVEMENT STRUCTURE, APPROACH AND ROADMAP
Structure is Based on Institute for Healthcare Improvement (IHI)
Breakthrough SeriesSelect a Quality Improvement
Topic
Conduct Expert Meeting
Planning Group
(Experts)
Participants (YOU!)
Learning Session
Action Period Calls
Develop Framework and Changes
Holding the Gains
Spread and Dissemination
Supports:• Experts • Learning Session• Action Period Calls• Telephone• Email• Monthly Reports• Monthly Data
Approach is Based on The Model for Improvement
Model for ImprovementWhat 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Key Driver Diagram
SMART AIMKEY DRIVERS
INTERVENTIONS
By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits.
A “safe sleep” position includes: • Sleeping in his/her own crib• Alone in the crib• Laying on his/her back
GLOBAL AIM
Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.
• Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)
• Take-home magnets • Brochures • Safe Sleep posters
Nursing Education
• CHEX Quality Board Tips • Nurse champions/RN care partners• Scripting for – and with – parents • Safe Sleep “Cheat Sheet”
• Sleep sacks • Safe Sleep Policy developed• Assess hospital policy on clothing allowed
for patients• Mattresses on beds need evaluated• Potentially use fitted sheets on beds
Multi-Disciplinary (PCA, OT/PT) Education
Physician Education
Parent/Caregiver Education
Management of Environment
• Grand Rounds• Hospital pediatricians web module
Medical Directors: Sarah Denny, MD and Michael Gittelman, MDPrincipal Investigator: Jamie Macklin, MD
Updated: April 3, 2014
Key Driver Diagram adapted from Nationwide Children’s Hospital
THE MODEL FOR IMPROVEMENT
Model for ImprovementWhat 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Part 1:Answers
these three questions
Part 2:Guides
change to see if there
is an improvemen
t
The Model for Improvement
Model for ImprovementWhat 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Part 1:Answers
these three questions
Part 2:Guides
change to see if there
is an improvemen
t
Set Aims
Establish Measures
Select Changes
Test the Changes
The Model for Improvement
The Model for ImprovementModel 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Aim
Aim Statements• Provides a focused rationale and
vision for what your team plans to accomplish
• Are SMARTS: Specific M: MeasurableA: Action-OrientedR: Relevant/Realistic T: Timely
Key Driver Diagram
SMART AIMKEY DRIVERS
INTERVENTIONS
By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position on random weekly audits.
A “safe sleep” position includes: • Sleeping in his/her own crib• Alone in the crib• Laying on his/her back
GLOBAL AIM
Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.
• Safety Videos/Edutainment System (Franklin County/CPSC/NICHD)
• Take-home magnets • Brochures • Safe Sleep posters
Nursing Education
• CHEX Quality Board Tips • Nurse champions/RN care partners• Scripting for – and with – parents • Safe Sleep “Cheat Sheet”
• Sleep sacks • Safe Sleep Policy developed• Assess hospital policy on clothing allowed
for patients• Mattresses on beds need evaluated• Potentially use fitted sheets on beds
Multi-Disciplinary (PCA, OT/PT) Education
Physician Education
Parent/Caregiver Education
Management of Environment
• Grand Rounds• Hospital pediatricians web module
Medical Directors: Sarah Denny, MD and Michael Gittelman, MDPrincipal Investigator: Jamie Macklin, MD
Updated: April 3, 2014
Key Driver Diagram adapted from Nationwide Children’s Hospital
Global vs. Specific Aim Statements
Education and Sleep Environment (EASE): The Injury Prevention Learning Collaborative with
Hospitalists
• Global Aim: Provide children with the opportunity to grow up to reach their fullest potential by eliminating death or injury due to unsafe sleep habits.
Global vs. Specific Aim Statements
• Specific Aim: By February 28, 2015, at least 90% of children less than 1 year of age who are sleeping at a participating Ohio Children’s Hospital, will be found in a “safe sleep” position during random weekly audits.– A “safe sleep” position includes a child who is:
• Sleeping in his/her own crib• Sleeping alone in the crib• Laying on his/her back
The Model for ImprovementModel 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Measures
Why do we measure?Measures facilitate learning and are not for judgment or comparison
– Recognize areas for improvement – define the gap between where we are and where we need to be
– Provide feedback as a means to evaluate– are the changes we’re making having the desired impact?
– Characterize the robustness of change – how does our system respond to the changes we’ve made?
Process vs. Outcome Measures
• Process measures: represents the workings of the system
• Proportion of patients with hemoglobin A1c levels measured at least twice within the past year
• Proportion of children with asthma who receive asthma management plan
• Outcome measures: represents the voice of the customer or patient
• Reduction in BMI percentile• Hospitalizations or ED visits due to asthma• Patient satisfaction with time to getting an
appointment
EASE MeasuresEASE process measures include:• > 90% of patients 1 year of age and
younger will leave the hospital with information on safe sleep practices
• Each hospital will show that > 90% of children ≤ 1 year of age will be in “safe sleep” position (own crib, nothing in crib and on back) on random weekly audits by the end of the 12-month project – This is a bundled measure of all three items
for a safe sleep position
The Model for ImprovementModel 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
Ideas/ Changes
The Model for ImprovementModel 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?
Plan
DoStudy
Act
The Improvement GuideAssociates in Process Improvement
P-D-S-A Cycle
PLAN – DO – STUDY – ACT CYCLES
The PDSA CycleFour Steps: Plan, Do, Study, Act
Also known as:• Shewhart Cycle• Deming Cycle• Learning and
Improvement Cycle
Act Plan
Study Do
The Improvement GuideAssociates in Process Improvement
Use PDSA Test Cycles for:• Testing or adapting a change
idea– May answer a question related to the
aim• Implementing a change• Spreading the changes to the
rest of the system
Why Test?• Force us to think small• Increases your belief that the change
will result in improvement• Opportunity for learning without
impacting performance• Help teams adapt good ideas to their
specific situation
The Improvement GuideAssociates in Process Improvement
The PDSA Cycle
Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
Study Do
• Do initial cycles on smallest scale possible– Think baby steps…a “cycle of one” usually
best• “Failures” are good learning
opportunities; can be better than “Successes”
• As move to implementation, test under as many conditions as possible– Think about factors that could lead to
breakdowns, supports needed, “naysayers”– Different providers; different days of the
week; different patient populations, etc.
Key Points for PDSA Cycles
Key Points for PDSA Cycles• Do initial cycles on smallest scale and
within shortest timeframe possible- Think baby steps…a “cycle of one” usually
best Years Quarters Months Weeks Days Hours Minutes
Drop down “two levels” to plan Test Cycle!
The PDSA Cycle
Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
Study Do• Carry out the plan• Document problems and unexpected observations
The PDSA Cycle
Act Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
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
The PDSA Cycle
Act• What changes are to be made?• Next cycle?
Plan• Objective (tie to AIM or Key Driver)• Questions and predictions (why)• Plan to carry out the cycle (who, what, where, when)
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
Common PDSA Pitfalls1. Testing changes where link to overall aim or
key driver is unclear2. Failing to make a prediction before testing
the change 3. Failing to execute the whole cycle
– Plan, Plan, Plan-D-S-A (too much planning, not enough doing)
– P-Do, Do, Do-S-A (too much doing, not enough studying)
Common PDSA Pitfalls4. Not learning from “failures”5. Lack of detailed execution plan6. Failure to think ahead a few cycles
PDSA WORKSHEET
PLAN: Briefly describe the test:
Provide maps for the delivery drivers to ensure they know the delivery location, and can make it on time How will you know that the change is an improvement?
Drivers will deliver pizzas on time without getting lost What driver does the change impact?
Getting to delivery location efficiently What do you predict will happen? The maps will help get drivers to their destination efficiently PLAN
List the tasks necessary to complete this test (what)
Person responsible
(who) When Where 1. Customer calls in order; person answering phone confirms address
Order Taker Jan. 2nd Clifton Location
2. Address is given to Manager Joe
Order Taker Jan. 2nd Clifton Location
3. Map is created for delivery address
Manager Joe Jan. 2nd Clifton Location
4. Map is given to delivery driver
Manager Joe Jan. 2nd Clifton Location
5. Delivery driver follows map to address
Delivery Driver Jan. 2nd Clifton Location
6. Delivery driver reports back on getting lost/not getting lost, and time it takes for pizza to be delivered
Delivery Driver
Jan. 2nd Clifton Location
Plan for collection of data: Delivery drivers will keep a log of time they leave the store to the time they arrive at the delivery address; this information will be sent to Manager Joe.
DO: Test the changes. Was the cycle carried out as planned? X Yes No Record data and observations. 100% of deliveries were made without drivers getting lost What did you observe that was not part of our plan? Day drivers ran into more traffic than expected. STUDY: Did the results match your predictions? XYes No Compare the result of your test to your previous performance: Less drivers were lost because of the maps. What did you learn? Maps are useful for delivery drivers ACT: Decide to Adopt, Adapt, or Abandon.
Adapt: Improve the change and continue testing plan. Plans/changes for next test: Provide maps for all shifts, not just day drivers Adopt: Select changes to implement on a larger scale and develop an implementation plan and plan for sustainability
Abandon: Discard this change idea and try a different one
Team Name: Best Pizza Delivery Team Date of test: January 2nd Test Completion Date: January 5th Overall team/project aim: Deliver pizzas within 30 minutes
What is the objective of the test? Reduce the number of late deliveries due to drivers getting lost
Do
Study Act
Plan
PDSA Cycle Ramps: Sequential Building of Knowledge
Best PracticeEvidenceHunchesTheoriesTestable Ideas
Changes That Result in
Improvement
A PS D
APS
D
A PS D
D SP ADATA
Very Small Scale Test
Follow-up Tests
Wide-Scale Tests of Change
Implementation of Change
The Improvement GuideAssociates in Process Improvement
Successive tests of a change build knowledge AND create
a ramp to improvement
Example of Accelerating Improvement
TEST 1What: Provide mapsWho (population): Day driversWhere: Clifton locationWhen: From 1/2 to 1/5Who Executes: Mgr. JoeResults: Nobody got lost
TEST 2What: Provide mapsWho (population): all shiftsWhere: Clifton locationWhen: From 1/6 to 1/13Who Executes: Mgr. JoeResults: Nobody got lost but deliveries took longer & some drivers had difficulty using the map
TEST 3What: Mapquest DirectionsWho (population): Day driversWhere: Clifton locationWhen: From 1/14 to 1/17Who Executes: Mgr. JoeResults: Nobody got lost, directions easier than map but printing out & sorting directions takes time
TEST 4What: Mapquest DirectionsWho (population): all shiftsWhere: Clifton locationWhen: From 1/17 to 1/24Who Executes: Mgr. JoeResults: Nobody got lost, directions easier than map, but printing and sorting directions still took time; suggested telephone answerer device plan for printing/sorting maps for drivers
Do
StudyAct
Plan
Do
Study
Act
Plan
Do
Study
Act
Plan
Do
StudyAct
Plan
“All improvements requires change, but not every change is improvement.”
The Improvement Guide, 2009
Quality Improvement Videos
• The Model for Improvement: http://www.youtube.com/watch?v=SCYghxtioIY
• PDSA Cycles: http://www.youtube.com/watch?v=_-ceS9Ta820&feature=youtu.be
ReferencesFuller, S. (2010). Model for Improvement. PowerPoint slides
Griffin, F. (2004). The PDSA Cycle Testing and Implementing Changes. Retrieved from: www.njha.com/qualityinstitute/pdf/628200432756PM63.ppt · PPT file
Langley, G., Moen, R., Nolan, K. , Nolan T., Norman, Provost, L. (2009). The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. 2nd edition. Jossey-Bass Publishers., San Francisco.
Moen, R. and Norman, C. (2010). Circling back clearing up myths about the Deming cycle and seeing how it keeps evolving. Retrieved from www.qualityprogress. com
NHS Institute for Innovation and Improvement. Quality and Service Improvement Tools: PDSA. Retrieved fromhttp://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_improvement_tools/plan_do_study_act.html
Provost, L., Murray, S. (2011). The Health Care Data Guide: Learning from data for Improvement. Jossey-Bass Publishers., San Francisco.
Society of Hospital Medicine. Plan-Do- Study- Act. Retrieved from: http://www.hospitalmedicine.org/ResourceRoomRedesign/CSSSIS/html/06Reliable/Plan_study.cfm
The Model for Improvement National Primary Care Development Team (2004). Retrieved from: www.npdt.org