PI ModelPI ModelPI ModelPI Model

Mike Davies, MD FACPMike Davies, MD FACP

““Improving our work Improving our work IS our workIS our work, not a , not a distraction from distraction from

work!”work!”

““Improving our work Improving our work IS our workIS our work, not a , not a distraction from distraction from

work!”work!”““All teach all learn”All teach all learn”

““Healthcare is a team sport”Healthcare is a team sport”

Discussion• Think of a “big change” that was

not implemented very well….• What Went Wrong?

Why change strategies often don’t

work

• Lots of planning then lots of implementing– Analysis paralysis– Lack of consensus on problem and

solution– Risky change process

Why change strategies often don’t work

• Pushing one solution/idea– One person’s perspective– How do we know it works?– Lack of agreement– Ignores all of the

context/circumstances

Improvement Involves “Experimentation”

• Setting aims/goals• Generating ideas • Testing • Measuring progress• Reflection

Lots of activity doesn’t necessarily mean lots of

improvement!• Focus changes on aims and goals• Are the changes we’re making really an

improvement (according to the aims and goals)?– Avoid the “my idea” trap– Take the emotion out – Measure!

-“It is not enough to be busy, so are the ants. The question is, what are you so busy about?”

Thoreau

3 Questions• 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?

Nolan

A Model for Improvement

PLAN

DOSTUDY

ACT

Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA. 1996

What is our aim? How will we know a change is an improvement?What changes can we make to make an improvement?

Plan the test: the experiment

Execute itAssess the results

Act differentlythe next time

The ‘unofficial version’!• Hunch

– What could be happening here?• Test

– Let’s try something different• Reflect

– How did it work?• Change

– Should we keep doing it?

From Sarah Frasier

“Kinds” of Data• Judgment

– Research– Performance appraisal – “do something TO you”

• Improvement– Process improvement efforts– “do something WITH you”

Average Cycle Time Run Chart

29

39

49

59

69

79

89

99

109

119

129

11/15

/2004

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11/24

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11/25

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11/26

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11/27

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11/28

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11/29

/2004

Min

utes

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in

Improvement

A P

S D

APS

D

A P

S D

D SP A

DATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

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

PDSA Cycles• Are Not Plans!• Are small in scale

– Thinking months – think weeks; thinking weeks – think days; thinking days – think hours

– Thinking facility – think unit; thinking unit – think teams; thinking teams, think ONE team

– Thinking all patients – think a type of patient; thinking a type of patient, think a sample; thinking sample then 3-5 may be enough

Exercise

• AIM- find the rule underlying a series of numbers

• Measure - feedback from the instructor• Changes - are new ideas suggested by

the team

PDSA Test ResultsT eam Cycle Sequence to T est Correct Incorrect

1

2

3

4

5

6

7

8

9

10

11

12

13

14

PA

S A

P

DS

A

P

DS

A

P

DS

A

Small Scale Test

Follow-up Tests

Wider Tests

ImplementationDATA

HunchTheoryIdea

ChangesRepeat PDSA

How to Implement a Change

Belief thatchange willresult inimprovement

High

Low

SuccessfulChange

Unsuccessful Change

Still Needs Further Testing

Developing Testing Implementing

From Lloyd Provost

PA

S A

P

DS

A

P

DS

A

P

DS

A

PA

S A

P

DS

A

P

DS

A

P

DS

A

PA

S A

P

DS

A

P

DS

A

P

DS

A

BalanceDemandAnd Supply

DecreaseAppt. Types Decrease

Demand

Readiness for ChangeCurrent State Resistant Neutral Ready

LowConfidence

th a t ch a n g e willle a d to

imp ro ve me n t

Largecos t offailure

Ve ry SmallScale Te st

Ve ry SmallScale Te st

Ve ry SmallScale Te st

Smallco st o ffailu re

Ve ry SmallScale Te st

Ve ry SmallScale Te st

Small ScaleT est

HighConfidence

th a t ch a n g e willle a d to

imp ro ve me n t

Larg eco st o ffailu re

Ve ry SmallScale Te st

Small ScaleT est

Large ScaleTest

Smallco st o ffailu re

Small ScaleT est

Large ScaleTest Implement

From Lloyd Provost

Successful PDSA• Think multiple tests over wide

range of conditions• Think a couple of PDSA’s ahead• Scale down the size• Learn from the last experience

3 Questions• 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?

Nolan

Change Thinking

• It is NECESSARY to be successful– So….. get started!

• It may not be SUFFICIENT to be successful only a few times– So……keep going!

• Build up data, experience and evidence over time! – This is true learning!

Summary• Keep focused on Aim – Measure –

Change• Changes are “small experiments”• Experiment wisely – PSDA• Learn from small changes over wide

conditions before implementing widely• Get started and keep going