The Improvement Model and
PDSAs
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
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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
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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
Changing Systems/Changing people
• 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”
How it has been done so far…
What is the best way to approach change that results in improvement?
Trial & Error?
Detailed prior study?
Chaos
Paralysis
Too much action,
not enough thinking
“Something must be done,
this is something,
therefore we must do it…”
Too much thinking,
not enough action
“We can’t do anything
until we know exactly
what to do…”
“Trial and Learning” Approach
‘Trial and Learning’ Component Parts
• 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
Defining the Problem
Always speak to
someone different
Didn’t specify
what
I wanted properly
Getting
Information
Didn’t
check
often
enough
Set impossible
timescales
Am I dealing with
really urgent
work?
Haven’t planned
time available well
Not got an
accurate
brief
Didn’t give
manager
enough time
Waiting for line
managers approval
Other deadlines
Not sharing
workload
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?
The Doing Part of the Improvement Model
PDSA
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
Model for improvement
What are we trying to
accomplish?
aims
How will we know that a
change is an improvement?
What changes can we make
that will result in the
improvements that we seek ?
Act
Plan
Study
Do
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
What changes
are we going to
make based on
our findings
What exactly are
we going to do?
Act
Study
What were
the results?
Plan
Do
When and how
did we do it?
Objective (future tense)
• Define the problem
• What exactly are you trying to achieve
• Refer to the Nolan questions (think)
Plan (future tense)
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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:
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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 chunks
Not 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 system
Tell others what you are doing
• If it doesn’t work, try something different
based on your learning
Document 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
Testing and
refining ideas
Bright
idea!
Implementing new
procedures & systems
- sustaining change
Create Multiple PDSA Ramps
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receptionist
porters
Nurses
Diabetes (blood pressure)
Improvements with PDSAs
Scottish Primary Care Collaborative
Borders GP Practice
PDSAs
% of Diabetes Patients with a BP<140/80
PDSAs
90
80
50
PDSAs to
Validate
Diabetes
Register
PDSAs to improve
shared diabetes
information with
Secondary Care
PDSAs to improve
current patient
recall system
40
30
20
10
0
PDSA to contact all
Patients who have not
had a BP check in the
last year
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% of People with Diabetes
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PDSAs
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
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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
Purpose
Data
Duration
Understanding of
Process
Evaluation of change
To discover new
knowledge
ACCOUNTABILITY
Comparison
Reassurance
RESEARCH
To bring new
knowledge into daily
practice
Gather just enough data
to learn and complete
another cycle
Large amounts of data
Gather as much data
as possible ‘just in
case’
‘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 Improvement
www.ihi.org
A Guide to Service Improvement
www.scotland.gov.uk
• Improvement & Support Team Toolkit
http://member.goodpractice.net/ContinuousImpr
ovementToolkit/Welcome.gp
• Improvement Leaders Guides
www.modern.nhs.uk/improvementguides