The Improvement Model and The Improvement Model and PDSAsPDSAs

Aims of this session

To understand how change is related to systems

• To understand the purpose, application and structure of The Model for Improvement

• To appreciate the importance of measurement in improvement

• To understand how this methodology could be applied to practice

Learning Loop Game

RULES• 25 minutes to complete max 5 test runs (60 seconds each)• 1 final timed run• record how you approached the task for each test run• record your data – what happened each time you ran the

test• reflect on what happened - did it work? Could it be

improved?• what will you do differently next time

REQUIRED• facilitator to ensure team abides by the rules• timekeeper for the 60 second practice rounds• note-keeper/scorer for keeping record of your learning• one team member to represent you in the final round

Why Systems?

We all work with and within systems• Systems of communication

• Systems for submitting papers to committees

• Systems for distributing information

• Systems for complaints

• Reporting systems

Why change?

Because:

“If you always do what you have always done, you will always get what you have always got!”

Don Berwick

• Change is threatening

“Its always been done this way”• Change is time-consuming

“what’s the point it will only disrupt the system”

• Change means testing out things in your own setting

“some people are never happy, no matter what you do, so what’s the point”

Changing Systems/Changing people

What is the best way to approach change that results in improvement?What is the best way to approach change that results in improvement?

Trial & Error?Trial & Error?

ChaosChaos

Too much action,Too much action,not enough thinkingnot enough thinking

““Something must be done,Something must be done,this is something,this is something,

therefore we must do it…”therefore we must do it…”

Detailed prior study?Detailed prior study?

ParalysisParalysis

Too much thinking,Too much thinking,not enough actionnot enough action

““We can’t do anythingWe can’t do anythinguntil we know until we know exactlyexactly

what to do…”what to do…”

““Trial and Learning” ApproachTrial and Learning” Approach

How it has been done so far…

• Setting challenging aims- is it worth doing? Not “change for change sake”

• Identifying principles/change ideas- what has worked for someone? What might work for us?

• Measuring progress- knowing what’s happening

• Testing changes- starting small; reducing risk

• Implementing and sustaining change- change in systems and routines; developing skills and abilities

‘Trial and Learning’ Component Parts

Always speak tosomeone different

Didn’t specify what

I wanted properly

Getting Getting InformationInformation

Set impossibletimescales

Am I dealing withreally urgent

work?

Other deadlinesOther deadlines

Haven’t plannedtime available well

Not sharing workload

Didn’t check often

enough

Waiting for lineWaiting for linemanagers approvalmanagers approval

Not got an accurate

brief

Didn’t give manager

enough time

Defining the Problem

Change Methodology for

Improvement

The Thinking Part

Three fundamental questions for improvement( Nolan Questions )

The fundamental improvement questions

• What are we trying to achieve?– Know exactly what you are trying to do – have clear

aims and objectives

• How will we know that change is an improvement?– Measuring processes and outcomes

• What changes can we make that will result in an improvement?– What have others done? What hunches do we have?

What can we learn as we go along?

PDSA

The Doing Part of the Improvement Model

What is a PDSA?

• A structured approach for making small incremental changes to systems

• A full cycle for planning, implementing, testing and identifying further changes

• A common sense, easy to understand tool for bringing about change

• A tool which can reduce anxiety to change

Why use PDSAs?

• PDSA cycles have a long pedigree

• They are ‘natural’ to Health Care

• PDSAs are small in scope and build incrementally – small rapid cycles lead to improvement

• They have methodological validity

• They have been used and developed by Collaborative participants in the UK for 6 years and even longer across Scandinavia and America

What are we trying toaccomplish?

How will we know that achange is an improvement?What changes can we make

that will result in the improvements that we

seek ?

Model for improvement

Act Plan

Study Do

aims

measurements

change ideas

testing ideas before Implementing changes

Langley et al 1996

What do we mean by testing on a small scale?

• Use interviews or calculations to test feasibility

• Use volunteers or team members to do the tests

• Use a small sub-population• Use one location• Conduct the test for a short period

of time. Ideally over one week.

Source: D. Berwick

Plan, Do, Study, Act

Act Plan

Study Do

What changes are we going to make based on our findings

When and how did we do it?

What exactly are we going to do?

What were the results?

Objective (future tense)

• Define the problem

• What exactly are you trying to achieve

• Refer to the Nolan questions (think)

Plan (future tense)

• Who?

• What?

• Where?

• When?

• How?

• What are you going to measure?

Do (past tense)

• Just do it!

Note any variation from the plan, such as a change from the plan due to complexity, lack of staff etc.

Study (past tense - outcome)

• Study the outcome of your measures

What worked? Do you need to carry out another PDSA? Do you need to involve more people?

Do you need to generate more ideas?

• What didn’t work and why?

Do you need to change the plan? Do you need to tweak

the original pdsa?

Act (present / future tense)

• What changes are you going to make based on your findings?

• This will inform your next PDSA cycle

• Document the change you are going to make and identify future plans

Advantages of a PDSA approach

• Makes processes and learning explicit• Enables testing of ideas to:

– Customise change for/to local conditions– Evaluate ‘side-effects’– Improve the idea based on learning– Reduce risks to individuals and the system

• Minimise problems with getting started– Persuading the reluctant– Longest journey / first step stuff

The principles of PDSAs• Breaks down change into manageable,

bite-sized time-limited chunksNot audits – snap shots in time

• A PDSA cannot be too small!!!!!!It can be too big

• Small changes can be tested without causing upheaval to the whole systemTell others what you are doing

• If it doesn’t work, try something different based on your learningDocument what did/didn’t work

Why test?

• To learn whether the change will result in an improvement

• To predict the amount of improvement possible

• To learn how to adapt the change to different environments

• To understand the costs and impact of change

• To reduce resistance

What can we learn from testing changes...

• Taking action as a result of learning from the last tests

• Planning multiple tests around each change

• Thinking a couple of tests ahead

• Really scaling down the size

• Making sure there is agreement before testing

Source: Berwick

Repeated use of the PDSA cycle

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

Accumulating in

formatio

n, data and knowledge

Testing andrefining ideas

Implementing newprocedures & systems- sustaining change

Brightidea!

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

PLANPLAN

DODO

STUDY

STUDY

ACTACT

Create Multiple PDSA Ramps

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receptionist porters Nurses

Scottish Primary Care CollaborativeBorders GP Practice

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% of Diabetes Patients with a BP<140/80

Diabetes (blood pressure) Improvements with PDSAs

PDSAs to improve shared diabetes information with Secondary Care

PDSA to contact all Patients who have not had a BP check in the

last year

PDSAsPDSAs PDSAs

PDSAs to improve current patient recall system

PDSAs to Validate Diabetes Register

SCENARIO

• What are we trying to achieve?– know exactly what you are trying to do– have clear aims and objectives

• What changes can we make that will result in an improvement?– What have others done?– What hunches do we have? – What can we learn as we go along?

Measurement for Improvement

Measurement for Improvement

• What is measurement for improvement

• Why measure anything?

• What should you measure?

• How do you collect your data?

• How do you present and share your data?

What is measurement for improvement?

IMPROVEMENT ACCOUNTABILITY RESEARCH

Purpose Understanding of Process

Evaluation of change

To discover new knowledge

Comparison

Reassurance

To bring new knowledge into daily practice

Data Gather just enough data to learn and complete another cycle

Large amounts of data Gather as much data as possible ‘just in case’

Duration ‘Small tests of significant change’ accelerates the rate of improvement

Short & current

Long periods of time

Long & past

Can take long periods of time to obtain results

Long & past

Why measure?

• Critical part of testing and implementing change.

• Allows us to know if change resulted in an improvement.

• Allows us to determine further impact of the change.

• To evidence improvements.

What should you measure?

• Develop aims before measures.

• Design measures around aims.

• Make measures easy to collect by staff.

• Should not take longer than one week

• How will we know that change is an improvement?– Measuring processes and outcomes

How do you collect your data?

• Define starting point [ BASELINE]

• Collecting data:

Tick box sheets, Excel spreadsheet

Existing information.

Patient & Staff Questionnaires

• Build measurement into work

• RIGHT person to capture the RIGHT data at the RIGHT time

How do you present and share your data?

• Define Improvements in raw numbers and as % improvement.

• Use newsletters, intranet, posters, patient and professional groups, journals etc.,

• fundamental questions for improvement

• results from using the PDSA cycle

• effective use of data

• testing changes

Source: D. Berwick

The elevator to success is out of order.

You’ll have to use the stairs ……

One step at a time

Useful links

• Institute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.uk

• Improvement & Support Team Toolkit

http://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gp

• Improvement Leaders Guideswww.modern.nhs.uk/improvementguides