Quality Improvement Models: PDSARebecca S. (Suzie) Miltner, PhD, RNAssociate Professor, School of Nursing

UAB MissionTo improve the health and well-being of society, particularly the citizens of Alabama, by providing innovative health services of exceptional value that are patient- and family-centered, a superior environment for the education of health professionals, and support for research that advances medical science.

UAB MissionTo improve the health and well-being of society, particularly the citizens of Alabama, by providing innovative health services of exceptional value that are patient- and family-centered, a superior environment for the education of health professionals, and support for research that advances medical science.

And we have opportunities for improvement…

Opportunities for improvement…Admission process/Bed assignmentEquipment availabilityTraining and competencyPrioritizationSupervision/Oversight

In the “past”… People were disciplined (maybe terminated)

New rules came down from managers/leaders

Everyone had to sign the inservice sheet as a record that they knew the new policy.

No changes within system…just waiting for the next incident.

What do you do to change a process to make it

better?

The Quality FoundationAvedis Donabedian, MD, MPH (1919-2000) Father of quality assessment Structure-process-outcome framework for QI and health

services research Famous quotes:

“People have a big problem understanding the relationship between quality and systems. System management doesn’t get taught in medical school or nursing school.’’

‘‘There’s lip service to quality and, goodness knows, propaganda, but real commitment is in short supply.’’

‘‘Systems awareness and systems design are important for health professionals, but are not enough. They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to love your profession, you have to love your God. If you have love, you can then work backward to monitor and improve the system.’’

What IS Quality Improvement?

-9-

What IS Quality Improvement?Quality Improvement is a data-driven, formal approach to the analysis of performance and the systematic efforts to improve it.

What IS Quality Improvement?The combined and unceasing efforts of everyone – health care professionals, patients and their families, researchers, payers, planners, administrators, educators – to make changes that will lead to

better patient outcomes, better system performance, and better professional development.

-11-

Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

Quality Improvement: Bridging the Implementation Gap

Implementation Gap

Scientific understanding

Patient care

Prog

ress

Time

QUALITYIMPROVEMENT

13

Rubenstein, L. & Pugh, E. 2006. Strategies for Promoting Organizational And Practice Change by Advancing Implementation Research. Journal of General Internal Medicine, 21, S58-64.

What is Quality Improvement?

Models for Improvement

14

Frameworks or Models?

Essentially, all models are wrong,but some are useful.

Box, George E. P.; Norman R. Draper (1987). Empirical Model-Building and Response Surfaces, p. 424, Wiley. ISBN 0471810339.

Why Use Frameworks or Models? System of rules, ideas or beliefs that is

used to plan or decide something A supporting structure around which

something can be built A way to operationalize abstract concepts Visually depict how something should

work Frame of reference and common language

when working in a group

Improvement ModelsPlan-Do-Study-Act (PDSA)Total Quality

Management/Continuous Quality Improvement

Model for ImprovementSix SigmaLean / Toyota Production SystemLean Six Sigma

17

The Quality Foundation Walter Shewhart (1891 – 1967)

Western Electric Co. Variation and statistical control Designed to assist Bell telephone in their

efforts to improve reliability and reduce frequency of repairs

Developed the Plan-Do-Check-Act (PDCA) cycle

19

SHEWHART CYCLE

Plan

DoCheck

Act

20

FOCUS-PDSA► Focus Find an opportunity► Organize A team► Clarify Understand process / problem► Understand Variation, root causes, barriers► Select Opportunity and strategy

► Plan Intervention► Do Intervention► Study Measure the results► Act To hold gains continue to improve

21MODEL FOR IMPROVEMENT

What is Lean?Goes by many names (e.g. Lean

manufacturing, Toyota Production SystemKey theory is removal of wasteEmphasis is on work flowKey steps

Identify which features create value Identify the sequence of activities called the

value stream Let the customer pull the product or service

through the process Perfect the process

22

Bevan et al, (2005). Lean Six Sigma: Some Basic Concepts. NHS Institute for Innovation and Improvement

Method developed in industry at Motorola in the 1980s under the leadership of Bob Galvin. Won the Baldrige Award in 1988.

Further popularized by General Electric under Jack Welch and became the company’s operating strategy in 1995.

Goal is to achieve defect-free performance at the level of 3 or fewer defects per million (6 sigma)

What is Six Sigma?

Sigma calculation is related to number of defects. 6 sigma = 3 defects per million (99.99966%) 5 sigma = 233 defects per million (99.98%) 4 sigma = 6210 defects per million (99.4%) 3 sigma = 66807 defects per million (93.3%) 2 sigma = 308537 defects per million

(69.1%) 1 sigma = 691462 defects per million

(30.85%)Goal for any individual measure is set

(specification limit) and this is used to determine if there is a defect or not.

Six Sigma Measure

Lean and Six Sigma

25

Specify Value

Understand Demand Flow Level Perfection

Improved efficiency and speed

Lean: Focuses on dramatically improving flow in the valuestream and eliminating waste.

Six Sigma: Focuses on eliminating defects and reducing variationsin processes.

Define Measure Analyse Improve ControlImproved

effectiveness

Bevan et al, (2005). Lean Six Sigma: Some Basic Concepts. NHS Institute for Innovation and Improvement

Lean Six Sigma Combines lean and six sigma conceptsDefine, measure, analyze, improve,

controlSigma yield decreases as complexity

increases, so first reduce complexity (steps in the process), then improve sigma per part or step

Comparison of different models

27

Quality ImprovementQuality Improvement is a data-driven, formal approach to the analysis of performance and the systematic efforts to improve it.

Plan

Do

Study

Act

Identify a problem

Organize a team

Define the process

Understand process performance - data

Choose a process change

• This framework serves as the basis for most improvement methodologies• QI tools are the enablers for

these components. They allow efficient, effective completion.

• QI is a team sport. All stakeholders are key to understanding the process and choosing rational interventions

30

CQI elementsKey features

systematic data guided activities

designing with local conditions in mind

iterative development

Rubenstein et. al. 2013. How can we recognize CQI?

Improvement Tools Team building Group decision making techniques

Brainstorming Affinity diagrams Multi-voting Nominal group technique

Process mapping Aim statements Developing measures (metrics) Analyzing (and displaying) data Tests of change (PDSA)

31

MODEL FOR IMPROVEMENT32

33

PDSA CYCLE

Plan

DoStudy

Act

34

PDSA CyclePlan

Define the aim, question, and predictions Plan your data collection to answer the questions

Do Try out the change idea and collect data

Study Analyze the data and compare to your predictions

Act Plan the next cycle Can you implement the change?

35

Stage Description Steps

PlanPlant the test or observation, including a plan for collecting data.

1) State the object of the test.2) Make predictions about what will happen and why.3) Develop a plan to baseline the current process and

test the change. (Who? What? When? Where? What data need to be collected?)

 

Do Try out the test on a small scale

1) Carry out the test.2) Document problems and unexpected observations.3) Begin analysis of the data. 

StudyAnalyze the data and study the results.

1) Complete analysis of the data.2) Compare the data to your predictions.3) Summarize and reflect on what was learned. Adapt, Adopt or Abandon? 

ActRefine the change based on what was learned from the test.

1) Determine what modifications should be made.2) Prepare a plan for the next test. 

PDSA Cycle

PDSA Cycle Example

Note:• Prediction• Measures• Responsible Persons

P D S A

P D S A

P D S A

P D S A

DATA

Ideas

Changes in the systemresulting in improvement

Modify the protocol and make it standard practice

Use the protocol with allthe patients

Modify the protocol and try with other patients

Create a protocol and try with a few patients

PDSA Cycles: Iterative Process

Tomolo A M et al. Qual Saf Health Care 2009;18:217-224

Revised conceptual model of rapid cycle change.

LEARNING BY DOINGAn improvement simulation exercise

*Thanks to my colleague, Brant Oliver, PhD, MS, MPH, at the Dartmouth Institute

Learning ObjectivesAfter completing this simulation exercise,

participants will be able to:

(1) describe the IHI Model for Improvement, including the Plan-Do-Study-Act Cycle;

(2) conduct simple PDSA cycles in a simulated environment;

(3) create simple data displays for performance measurement; and

(4) describe and interpret Run Charts.

In this exercise we will simulate the model for improvement…

IHI (2004)

42

PDSA CYCLE

Plan

DoStudy

Act

Simulation Exercise: Mr. Potato Head

A scene from “Toy Story” (Pixar Studios)

Credits:• Original program: Institute for Healthcare Improvement (IHI), Cambridge, MA (2004)

• Adapted by Steve Harrison, Sheffield MCA, Sheffield, UK (2013)

• Adapted for collaborative simulation with real time measurement dashboard and registry (B. Oliver, 2015, 2016) & playbook (M Godfrey (2015).

Imagine that building Mr. Potato Head is improving the quality of falls prevention in an academic medical center...

Ja Fe Ma Ap Ma JuJu

l-04 Au Se Oc No De Ja Fe Ma Ap

0

2

4

6

8

10

12

14

16

# Patients Meeting Criteria

# Me

etin

g Cr

iteria

Jan-

04 Fe Ma Ap MaJu

n-04

Jul-0

4 Au Se Oc No DeJa

n-05 Fe Ma Ap

20

30

40

50

60

70

80

% Of Patients Meeting Criteria

% M

eetin

g Cr

iteria

Your Evidence Based Practice Bundle of Care: Potato Head

46

What we aim to achieve…

• “Build it right” (adhere to the evidence based practice guideline)

• “Build it fast” (optimize access to care)

• “Do it consistently” (optimize reliability)

• “Continuously improve” (optimize value)

Facility Teams for the PDSA Simulation…• Unit Nurse Manager• Staff RN: Timer• Staff PCT: Recorder• PT/PharmD/MD: Observer(s)

Falls Prevention Program Components Hat = Risk Assessment Glasses = individual care plan Tongue = medication s Mustache = orthostatic HTN Nose = interprofessional team Right ear = mobility program Left ear = feet/footwear Eyes = vision Pants = hip protectors Left arm = environment Right arm = goal

setting/feedback

We have to pretend! We can’t do all these

interventions, so… Accuracy will

represent getting the right preventive measures to the right patient

Speed of putting the parts together will represent efficiency

How will we measure our success? Accuracy = score 0-3

How does the scoring work?

Let’s figure that out! 0 = xxx 3 = xxx

Speed = time measured with stopwatch on smart phone

We will simulate a facility level improvement collaborative…• 1 Baseline cycle and successive PDSA

cycles

• Simulate rapid cycle improvement in separate microsystems

• Track performance (building speed and accuracy score) using Run Charts and descriptive displays

• Cascade measures and simulate an improvement collaborative

P D S A

P D S A

P D S A

P D S A

DATA

Ideas

Changes in the systemresulting in improvement

Modify the protocol and make it standard practice

Once you are happy, try the set of interventions with all the patients

Modify the interventions and try with more patients

Try one set of interventions on 5 patients

PDSA Cycles: Iterative Process

Potato Head Simulation…

PDSA Plan Time Accuracy1 Baseline

234

0

20

40

60

80

100

120

140

Tim

e

0

0.5

1

1.5

2

2.5

3

Accu

racy

Common Cause

Variation caused by chance causes, by random variation in the system, resulting from many small factors.

Example: Variation in work commute due to traffic lights, pedestrian traffic, parking issues.

Special Cause

Variation caused by special circumstances or assignable cause not inherent to the system.

Example: Variation in work commute impacted by flat tyre, road closure, heavy frost/ice.

Types of Variation

Statistically significant

56

Common Cause Variation

Reduce Variation (Increase Precision): Make the process even more reliable.

Sub-Optimal Average Performance: Redesign process to get a better result.

Special Cause Variation

Identify the Cause: If Positive: “Maximize, optimize, replicate, or standardize.” If Negative: “Minimize or eliminate”

57

Application – Responding to Variation

Benchmarking helps to empower improvement collaboratives…

Potato Head “Best Practice” Flow Diagram to Standardize for Playbook

“Potato Head

Playbook”

The “light” side

I expect continuous

improvement!

The “dark” side

Final Thought:

Our job is not only to DO our work, but also to IMPROVE our work – ultimately to improve patient care quality.

-Paul Batalden