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The Model for Improvement and PDSA

DHCF Nursing Facility Quality Improvement Collaborative March 2019

Selena Bolotin, LICSW

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So Many Choices…Where to Begin?

• Model For Improvement (MFI) and Plan-Do-Study-Act (PDSA)

• Baldrige

• ISO Quality Management Systems

• Lean

• Reliability Science

• Human Factors

• Situation-Background-Assessment-Recommendation (SBAR)

• Six Sigma

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Three Fundamental Questions for Improvement

• What are we trying to accomplish?

• How will we know that a change is an improvement?

• What changes can we make that will result in an improvement?

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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?

Model for Improvement

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What Are We Trying to Accomplish?Developing an Aim

• State the aim clearly• Use numerical goals• State the time frame and site of the work

Example: “By the end of 2019, our NH will decrease the percentage of LS residents with facility acquired pressure ulcers by 25% through the application of the SKIN bundle

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How Will We Know That a Change Is an Improvement?

Measurement Basics• Just enough!

• Qualitative vs. quantitative

• Should not take more time nor effort than the improvements or system

• Monthly measures should clarify your aim statement and make it realistic

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Measurement Basics (cont’d)

• Integrate measurement into the daily routine

• Plot measures monthly

• Use a balanced set of five to seven measures to assure that the system is improved

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Example: Annotated Run ChartGoal: 100.0 Median: 0.0

Annotations:a Inserviced all staff on interview techniqueb designated "interview specialists" c expanded "interview specialist" to cover all units and weekendsd prompted voiding added as option in standing orders for admissione turnover in designated interview specialists

a b

c

d

e

0.0

20.0

40.0

60.0

80.0

100.0

120.0

Apr-19 May-19 Jun-19 Jul-19 Aug-19 Sep-19 Oct-19 Nov-19 Dec-19 Jan-20 Feb-20 Mar-20

Rate

Date

Process Measure 1: Documented Pre-trial preference and motivation

Rate Goal Median

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What Change Can We Make that Will Result in Improvement?

Change Ideas• Everything goes!

• Think outside the box!

• Borrow from other disciplines, organizations, topics.

• Proven change packages (e.g., Vanderbilt, INTERACT, IHI’s Campaigns, literature, etc.)

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Accelerating Improvement:

PDSA Cycles Paired with the Model For Improvement

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Act Plan

Study Do

The PDSA CycleFour Steps: Plan, Do, Study, Act

Also known as:

• Shewhart Cycle

• Deming Cycle

• Learning and Improvement Cycle

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PDSA Cycle for Learning Improvement

Act Plan

Study Do

•Adopt, Adapt, or Abandon?•What changes are to be made?•Next cycle?

•Objective•Questions and predictions (Why)•Who, What, When, Where

•Complete the analysis of the data and compare to predictions

•Summarize learning

•Carry out the plan•Document problems, unexpected observations•Begin analysis

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Testing on a Small Scale• Pick the most likely helpers

• Use existing knowledge from co-workers

• Incorporate redundancy in the test– Side-by-side with the existing care system

– Try the change two different ways

• “Cycle of 1” - Conduct the test in one wing, with one person, with one subject, etc.

• Develop a plan to simulate the change in some way

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Decrease the Time Frame for a PDSA Test Cycle

• Years

• Quarters

• Months

• Weeks

• Days

• Hours

• Minutes

Drop next down two levels to plan test cycle!

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What are we trying toaccomplish?

How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

Model for Improvement

Act Plan

Study Do

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Repeated Use of the PDSA Cycle

Proposals, Theories,

Ideas

Changes That Result in

Improvement

A P

S D

A P

S D

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How will we know that achange is an improvement?

What change can we make thatwill result in improvement?

accomplish?What are we trying to

Model for Improvement

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Change Concepts, Theories, Ideas

Concept B

Concept C

Concept A

Concept D

Goal

Aligning all the Pieces to Reach the Goal

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Current Situation Resistant Indifferent Ready

Low ConfidenceThat change idea will lead to improvement

LargeCost of failure

Very, very Small Test

Very, very Small Test

Very, very Small Test

SmallCost of failure

Very Small Test Very Small Test Small Test

High ConfidenceThat change idea will lead to improvement

Large Cost of failure

Very Small Test Small Test Large Test

SmallCost of failure

Small Test Large Test Implement

Do you always need to test? It depends…..

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Games for Teaching Quality Improvement to Staff

Airplane game

Tabletop football game

Tennis ball game

Nut-and-bolt game

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Worksheets

• Project planning

• PDSA planning

• Run charts

• Others

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References• 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.

• “Eleven Worthy Aims for Clinical Leadership of Health System Reform,” Don M. Berwick, JAMA, September 14, 1994, Vol. 272, #10, p. 797-802.

• “The Foundation of Improvement.” Langley, G. J., Nolan, K. M., Nolan, T. W., 1994. Quality Progress, ASQC, June,1994, pp. 81-86.

• “A Primer on Leading the Improvement of Systems,” Don M. Berwick, BMJ, 312: pp 619-622, 1996.

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• Quality Improvement Through Planned Experimentation. 2nd Edition R. Moen, T. Nolan, L. Provost, McGraw-Hill, NY, 1998.

• “Accelerating the Pace of Improvement - An Interview with Thomas Nolan,” Journal of Quality Improvement, Volume 23, No. 4, The Joint Commission, April, 1997.

• “Understanding Variation”, Quality Progress, Vol. 13, No. 5, T. W. Nolan and L. P. Provost, May, 1990.

References (cont.)

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Questions and Answers

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Prepared with assistance from Lloyd Provost, Associates in Process Improvement, and the Institute for Healthcare Improvement