The Model for
Improvement
Presenter Name
Bright Futures Training Intervention
With Office Staff
Workshop I
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Session Objectives
 Gain understanding of the Model for
Improvement.
 Refine team Aim statement.
 Practice applying the Model for Improvement
and Plan-Do-Study-Act methods.
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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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Model for Improvement
What are we trying to accomplish?
How will we know that
changes are an improvement?
What changes can we
make that will result in
an improvement?
 Aim
 Measures
 Ideas
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Model for Improvement
Aim
What are we trying to accomplish?
MEASURES
How will we know that changes are an improvement?
IDEAS
What changes can we make that will result in an improvement?
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What Are We Trying to Accomplish?
Aim
Written statement of accomplishments
expected from improvement effort
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Team Aim Should Be
 A stretch, not business as usual
 Achievable, not impossible
 Understandable and clear to others
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Why Aim for the Moon?
 “If you aim for the moon, you might reach the
top of the telephone pole. If you aim for the
top of the telephone pole, you might never
leave the ground.”
- John Whalley, MD, Mountainview Pediatrics
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Aim Statements
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What will be different at the end?
Time frame.
System to be improved.
Setting or subpopulation of patients.
Goals.
Guidance on how and limitations.
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Sample Aim Statement
By [insert date], Happy Valley Pediatrics will improve the provision of
preventive and developmental services to patients younger than 5
years by implementing the Bright Futures framework in our practice.
Our office will focus on adopting strength-based counseling strategies
and tools, the routine use of structured developmental assessments,
forming links with resources in our community, and instituting a recall
and reminder system.
We will achieve this Aim by using the Bright Futures Implementation
and Training tools and materials so that:
1. One hundred percent of charts for children younger than 5 years
have preventive services documented on a preventive services
prompting sheet.
2. Ninety percent of children younger than 5 years have structured
developmental assessments documented in their charts.
3. More than 90% of families with children younger than 5 years have
parental strengths and needs assessed at well-child visits.
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Evaluating Your Practice Aim
Does the Aim
 Describe what will be improved?
 Seem like a stretch?
 Seem achievable?
 Have numeric goals?
 Describe the system being improved?
 Describe population of interest and setting?
 Does it provide guidance (how, limitations)?
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Model for Improvement
AIM: What are we trying to accomplish?
MEASURES:
How will we know that changes
are an improvement?
IDEAS: What changes can we make that will result in
an improvement?
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Types of Measures
 Outcome (Voice of the system)
 Process (Voice of the processes)
 Balancing (Voice of caution)
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Using Measures:
Annotated Run Charts
Clinician education
Reduced
appt
delays
Practice wide
guidelines
Reminder system
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Model for Improvement
AIM: What are we trying to accomplish?
MEASURES: How will we know that change is an
improvement?
IDEAS:
What changes can we make that will
result in an improvement?
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Model 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 improvement?
Act
Plan
Study
Do
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The Plan-Do-Study-Act Cycle
for Learning and Improvement
Act
Act
• What changes
are to be
made?
• Next cycle?
Study
Study
• Complete the
analysis of the data.
• Compare data to
predictions.
• Summarize what
was learned.
Plan
Plan
• Objective.
• Questions and
predictions.
• Plan to carry out
the cycle (Who, What,
Where, When?).
Do
Doout the plan.
• Carry
• Document problems
and unexpected
observations.
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Plan-Do-Study-Act Cycles
 Use Plan-Do-Study-Act cycles to adapt good
ideas to your specific situation.
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Force us to think small.
Force us to be methodical, make predictions.
Allow rapid adaptation and implementation of
changes to your setting.
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Key Points for Plan-Do-StudyAct Cycles
 Often the study is specific to the Plan-Do-StudyAct (PDSA) cycle.
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Linked to goals, but often “downstream”
Investigative
Usually ends with PDSA cycle
Can be qualitative, not just quantitative
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Key Points for Plan-Do-StudyAct Cycles
 Initial cycles on smallest scale possible.
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A “cycle of one” often appropriate
“Failed” cycles offer learning
 Later, test under many conditions.
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Breakdowns
Supports
Doubters
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Tests of Change
Changes that
result in
improvement
Ideas
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Change Principles
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Use substitution.
Match amount to need.
Conduct training.
Focus on core processes.
Work with suppliers.
Simplify.
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Reduce setup and
prep time.
Practice prevention.
Develop backup
plans for special
situations.
Use reminders.
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Looking for Good Ideas
 What factors do you face?
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Identifying children at risk
Connecting families with community services
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Barriers at Many Levels
 Patient
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Knowledge about development
Stigma
 Provider
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Time
Counseling resources and skills
 Practice
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Process for eliciting concerns
Organized materials and resources
Referral system
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Sample Plan-Do-Study-Act
 Objective: Test using Parents’ Evaluation of
Developmental Status with 4 to 5 patients
 Questions:
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Will it be hard to integrate into office flow?
Will parents like being asked for input?
Will length of visit increase?
 Predictions:
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Will be successful if front office clips form to patient
charts prior to check-in.
Will not increase visit length too much.
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Plan-Do-Study-Act Sample
 Plan for Test
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Front office will clip Parents’ Evaluation of Developmental Status
(PEDS) to 4 charts of patients younger than 5 years scheduled
for visit on Tues/Thurs.
Nurse Jayne will collect PEDS from patients prior to Dr Smith
conducting physical examination.
 Plan for Data
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Nurse will ask patients their opinion.
Front office will record visit time.
Dr Smith will report on types/number of questions.
Nurse will record number of PEDS completed prior to
examination.
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Plan-Do-Study-Act Sample
 Study
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One patient could not complete Parents’ Evaluation of Developmental
Status (PEDS) on own  3 of 4 prior to examination.
Did not significantly increase visit length.
Helped to have forms on chart (to remind nurse).
Dr Smith reported parents able to articulate chief concern at beginning
of visit (instead of at end per usual).
All 4 patients liked questions and being asked.
 Act
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Nurse will assist patients in completing PEDS in examination room prior
to Dr S.
Try again with all patients younger than 5 years for 1 week.
Continue to track visit length, patient feedback.
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Breakout
 Refine Aim.
 List measures (at least 1 outcome, 3 process,
1 balancing).
 Generate changes using “change concepts.”
 Plan first Plan-Do-Study-Act cycle.
 Report out.
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Model for Improvement
PDSA Planning Worksheet
Form for
Planning a
Plan-DoStudy-Act
Cycle
Team Name: _____ _____________________________
Cycle: ___________
Date:_________________
PLAN
Objective for this cycle:
Act
Study
Plan
Do
Questions:
Predictions:
Plan for change or test (Who, What, When, Where?):
Plan for collection of data (Who, What, When, Where?):
DO Carry out the change or test. Collect data and begin analysis. D escribe observations, problems encountered, and
special circumstances.
STUDY Complete analysis of data. Summarize what was learned.
ACT Are we ready to make a change? Plan for the next cycle.
Change Principles
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Use substitution.
Match amount to need.
Conduct training.
Focus on core processes.
Work with suppliers.
Simplify.



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Reduce setup and
prep time.
Optimize maintenance
and prevention.
Develop backup plans
for special situations.
Use reminders.
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Summary Improvement Principles
Miss Frizzle (Magic School Bus):
“Take chances, make mistakes,
get messy.”
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