Quality Improvement
The Model for Improvement,
PDSA Cycles, and
Accelerating Improvement
Heather Maciejewski
BEACON Quality Improvement Coordinator
Ohio 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 Series
•
•
•
•
•
•
•
Select a Quality
Improvement
Topic
Conduct
Expert Meeting
Planning
Group
(Experts)
Develop
Framework
and Changes
Spread and
Dissemination
Participants
(YOU!)
Learning
Session
Supports:
Experts
Learning Session
Action Period Calls
Telephone
Email
Monthly Reports
Monthly Data
Action Period
Calls
Holding the
Gains
Approach is Based on
The Model for Improvement
Model 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?
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
Key Driver Diagram
Medical Directors: Sarah Denny, MD and Michael Gittelman, MD
Principal Investigator: Jamie Macklin, MD
Updated: April 3, 2014
INTERVENTIONS
SMART 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 on
random weekly audits.
A “safe sleep” position
includes:
• Sleeping in his/her own crib
• Alone in the crib
• Laying on his/her back
KEY DRIVERS
Nursing Education
Multi-Disciplinary
(PCA, OT/PT) Education
CHEX Quality Board Tips
Nurse champions/RN care partners
Scripting for – and with – parents
Safe Sleep “Cheat Sheet”
• Grand Rounds
• Hospital pediatricians web module
Physician Education
Parent/Caregiver Education
GLOBAL AIM
•
•
•
•
Management of Environment
Provide children with the
opportunity to grow up to reach
their fullest potential by
eliminating death or injury due to
unsafe sleep habits.
Key Driver Diagram adapted from Nationwide Children’s Hospital
• Safety Videos/Edutainment System
(Franklin County/CPSC/NICHD)
• Take-home magnets
• Brochures
• Safe Sleep posters
• 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
THE MODEL FOR
IMPROVEMENT
The Model for Improvement
Model for Improvement
Part 1:
Answers
these three
questions
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?
Part 2:
Guides
change to
see if there
is an
improvement
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
The Model for Improvement
Model for Improvement
Part 1:
Answers
these three
questions
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?
Part 2:
Guides
change to
see if there
is an
improvement
The Improvement Guide
Associates in Process Improvement
Act
Set Aims
Establish
Measures
Select
Changes
Plan
Test the
Changes
Study
Do
The Model for Improvement
Model 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?
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
Aim
Aim Statements
• Provides a focused rationale and vision for
what your team plans to accomplish
• Are SMART
S: Specific
M: Measurable
A: Action-Oriented
R: Relevant/Realistic
T: Timely
Key Driver Diagram
Medical Directors: Sarah Denny, MD and Michael Gittelman, MD
Principal Investigator: Jamie Macklin, MD
Updated: April 3, 2014
INTERVENTIONS
SMART 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 on
random weekly audits.
A “safe sleep” position
includes:
• Sleeping in his/her own crib
• Alone in the crib
• Laying on his/her back
KEY DRIVERS
Nursing Education
Multi-Disciplinary
(PCA, OT/PT) Education
CHEX Quality Board Tips
Nurse champions/RN care partners
Scripting for – and with – parents
Safe Sleep “Cheat Sheet”
• Grand Rounds
• Hospital pediatricians web module
Physician Education
Parent/Caregiver Education
GLOBAL AIM
•
•
•
•
Management of Environment
Provide children with the
opportunity to grow up to reach
their fullest potential by
eliminating death or injury due to
unsafe sleep habits.
Key Driver Diagram adapted from Nationwide Children’s Hospital
• Safety Videos/Edutainment System
(Franklin County/CPSC/NICHD)
• Take-home magnets
• Brochures
• Safe Sleep posters
• 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
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 Improvement
Model 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?
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
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 Measures
EASE 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 Improvement
Model 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?
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
Ideas/
Changes
The Model for Improvement
Model 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?
The Improvement Guide
Associates in Process Improvement
Act
Plan
Study
Do
P-D-S-A
Cycle
PLAN – DO – STUDY – ACT
CYCLES
The PDSA Cycle
Four Steps: Plan, Do, Study, Act
Also known as:
• Shewhart Cycle
Act
Plan
Study
Do
• Deming Cycle
• Learning and
Improvement Cycle
The Improvement Guide
Associates 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 Guide
Associates 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
Key Points for PDSA Cycles
• 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
• Do initial cycles on smallest scale and
within shortest timeframe possible
- Think baby steps…a “cycle of one” usually
best
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





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
Do
• Complete the
• Carry out the plan
analysis of the data
• Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what
was learned
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
Plan
• Objective (tie to
AIM or Key Driver)
• Questions and
predictions (why)
• Plan to carry out
the cycle (who,
what, where, when)
Do
• Complete the
• Carry out the plan
analysis of the data
• Document problems
• Compare data to
and unexpected
predictions
observations
• Summarize what
was learned
Common PDSA Pitfalls
1. Testing changes where link to overall aim or
key driver is unclear
2. 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 Pitfalls
4. Not learning from “failures”
5. Lack of detailed execution plan
6. Failure to think ahead a few cycles
Plan
Do
Act
Study
PDSA WORKSHEET
Team Name: Best Pizza Delivery Team
Overall team/project aim:
Date of test: January 2nd
Test Completion Date: January 5th
Deliver pizzas within 30 minutes
What is the objective of the test? Reduce the number of late deliveries due to drivers getting lost
PLAN:
DO: Test the changes.
Briefly describe the test:
Provide maps for the delivery drivers to ensure they know the delivery
location, and can make it on time
Was the cycle carried out as planned?
X Yes  No
Record data and observations. 100% of deliveries were made without drivers getting
lost
How will you know that the change is an improvement?
Drivers will deliver pizzas on time without getting lost
What did you observe that was not part of our plan?
Day drivers ran into more traffic than expected.
What driver does the change impact?
Getting to delivery location efficiently
STUDY:
Did the results match your predictions?
What do you predict will happen?
The maps will help get drivers to their destination efficiently
XYes  No
Compare the result of your test to your previous performance:
Less drivers were lost because of the maps.
PLAN
List the tasks necessary to complete
this test (what)
1. Customer calls in order; person
answering phone confirms address
2. Address is given to Manager Joe
Person
responsible
(who)
Order Taker
When
Jan. 2nd
Order Taker
Jan.
3. Map is created for delivery address
Manager Joe
Jan. 2nd
4. Map is given to delivery driver
Manager Joe
Jan. 2nd
Delivery Driver
Jan. 2nd
Delivery Driver
Jan. 2nd
5. Delivery driver follows map to
address
6. Delivery driver reports back on
getting lost/not getting lost, and time
it takes for pizza to be delivered
Plan for collection of data:
2nd
Where
Clifton
Location
Clifton
Location
Clifton
Location
Clifton
Location
Clifton
Location
Clifton
Location
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.
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
PDSA Cycle Ramps:
Sequential Building of Knowledge
Successive tests of a change
build knowledge AND create
a ramp to improvement
A P
Changes That
Result in
Improvement
S D
Implementation
of Change
Best Practice
A P
Evidence
S D
Hunches
Theories
Testable
Very Small
Ideas
Scale Test
Follow-up
Tests
Wide-Scale Tests
of Change
The Improvement Guide
Associates in Process Improvement
Example of Accelerating
Improvement
Plan
Act
Plan
Act
Plan
Act
Plan
Act
TEST 1
What: Provide maps
Who (population): Day
drivers
Where: Clifton location
When: From 1/2 to 1/5
Who Executes: Mgr. Joe
Results: Nobody got lost
Stud
y
Study
Study
TEST 2
What: Provide maps
Who (population): all shifts
Where: Clifton location
When: From 1/6 to 1/13
Who Executes: Mgr. Joe
Results: Nobody got lost
but deliveries took longer &
some drivers had difficulty
using the map
Stud
y
Do
Do
Do
Do
TEST 3
What: Mapquest Directions
Who (population): Day
drivers
Where: Clifton location
When: From 1/14 to 1/17
Who Executes: Mgr. Joe
Results: Nobody got lost,
directions easier than map
but printing out & sorting
directions takes time
TEST 4
What: Mapquest Directions
Who (population): all shifts
Where: Clifton location
When: From 1/17 to 1/24
Who Executes: Mgr. Joe
Results: 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
“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=SCYgh
xtioIY
• PDSA Cycles:
http://www.youtube.com/watch?v=_ceS9Ta820&feature=youtu.be
References
Fuller, 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. JosseyBass 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