This work is supported by a grant from the CDC
to the Academic Pediatric Association and
in-kind contributions from
Children’s Mercy Hospital in Kansas City, MO.
QUALITY
IMPROVEMENT
TRAINING:
Module #1
The Model for Improvement and
Deming’s Lens of Profound Knowledge
Module 1 Objectives
1. Describe 3 steps in the QI process you need
to take before making changes
2. Describe the 2 components of the Model for
Improvement
3. Describe the 4 interrelated components of
profound knowledge that Dr. Deming argued
should be understood in order to make
changes that result in improvement
Importance of a Thoughtful QI Approach
If you want to improve your clinical setting,
what are your options?
1. Keep doing what you are doing & hope for
different results
2. Just do something new & hope for the best
 Unexpected consequences?
 Sustainability?
 Isn’t this approach the root of a lot of our
cynicism?
3. A thoughtful QI approach
1. Steps you need
to take before
making changes
Don’t “Just Do It”
Before you start making changes,
key steps include:
1.
2.
3.
Develop a general mission or goal
Understand the problem
Generate and prioritize possible change
ideas or interventions
1) A general mission statement
What you are trying to accomplish –
in a general way (e.g., “We want to increase
our adolescent immunization rates.”)
 At this phase, you probably do not know the
specifics (e.g., For which vaccines are your
rates low? Are they only low for a subset of
patients?)

Development of a more specific
Aim Statement is covered in a later module.
2) Understand the problem
 Objective methods – observations,
process flow maps, data collection
 Subjective methods – cause & effect
diagrams, 5 whys, opinion sessions
These tools will be introduced in
later modules, too.
3) Generate and prioritize
possible changes
It is important to consider all
potential options and then
determine how to move forward.
Tools to help you with this are in
a later module, too.
2. The Model for
Improvement
The Model for Improvement

Answering 3
fundamental
questions for
improvement

Testing changes
through iterative
rapid cycle
improvement trials
(aka PDSA Cycles)
Three Fundamental
Questions for Improvement
Rapid Cycle Improvement Trials
(aka PDSA Cycles)
Plan a change
Do it in a small test
Study the results
Quantitative data (run charts)
Qualitative data (front-line worker experience)
Act
Adopt: Accept and deploy results, or
Adapt: Modify change, or
Abandon: Stop testing this change and try
another one
3. Four
interrelated
components of
Profound Knowledge
The System
The parts of the process and how they
interact with one another.
 Example: “Frankly, the doctors don’t know
what the nurses have already told the
parents about adolescent vaccines, nor do
the nurses know what the doctors plan to
say.”

Understanding Variation
How do results vary from time to time, even
when we aren’t changing the system?
Example: Drive time to work
 As the “manager” of my commute, I’ve
designed the route, same each day
 Average: 15 minutes
 Really 12-18 minutes
Common cause variation
Variation:
How do results vary from time to time?
Common cause variation



Due to factors inherent in the system
(the noise in the system)
Accounts for most of the variation
Predictable
Variation:
How do results vary from time to time?
Common cause variation



Due to factors inherent in the system
(the noise in the system)
Accounts for most of the variation
Predictable
Variation (continued)
Special cause variation



Due to unexpected factors outside the system
Accounts for little of the variation
Unpredictable
Variation (continued)
Special cause variation



Due to unexpected factors outside the system
Accounts for little of the variation
Unpredictable
Why do we care about differentiating
between these causes of variation?

Understand the pattern before making
changes in order to address the problems
inherent to the system.

Analyze the data to be sure that the change
resulted in improvement and is part of the
(new) system
Psychology of Change
What will motivate the individuals to change?
 People are motivated for different reasons.
 Extrinsic motivation (rewards)
 Intrinsic motivation (reflects values,
passions, and beliefs

Self Determination Theory
People are intrinsically motivated
toward greater
 Autonomy,
 Competence, and
 Relatedness…
Theory of Knowledge
“Knowledge
comes from
theory.”
Theory of Knowledge
The more knowledge you have about the
system and what you are trying to
accomplish, the better able you are to predict
if a change will result in improvement.
 This component is enhanced when you’re
testing changes in PDSA cycles.
 Each cycle builds your
knowledge of the system
& helps your
decision-making

Questions that help clarify aspects of
the problem:




What are the potential beliefs about these
vaccines held by those within the system?
How could those beliefs affect the success of
the QI project?
What are barriers to change within the office?
(people / processes)
What are the attitudes towards change itself
that make change harder here?
(continued):

How could the barriers be overcome?

Recognizing that different things motivate
different people, what could we do to
motivate these people?

What additional information does the change
group need and how would we gather that
information?
Summary
1.
Before making changes, it is important to develop
a mission or goal statement, understand the
problem, and prioritize possible changes.
2.
The Model for Improvement includes 3
fundamental questions and iterative, rapid PDSA
cycles.
3.
4 interrelated components of profound
knowledge you need to understand include the
system, variation, knowledge and psychology.
The End
of QI Module #1
Reference:
Langley, G., Moen, R., Nolan, K., Nolan, T., Norman, C., & Provost, L. (2009)
The Improvement Guide: A Practical Approach to Enhancing Organizational
Performance, 2nd Edition. San Francisco: Jossey-Bass.