More on PDSAs
Connie Sixta, RN, PhD MBA
Patricia L. Bricker, MBA
Characteristics of the
Improvement Model
• Action-oriented – “What are you going to test
next Tuesday?”
• Rapid-cycle testing of changes
• Evaluation and revision of all changes before
implementation
• Testing and implementing the changes in small
populations, then spreading to the larger
population
• Evaluate impact using annotated run charts
• Monthly reporting of tests and outcomes
Chronic Care Model
Health System
Community
Health Care Organization
Resources and
Policies
SelfManagement
Support
Informed,
Activated
Patient
Delivery
System
Design
Productive
Interactions
Decision
Support
Clinical
Information
Systems
Prepared,
Proactive
Practice Team
Improved Outcomes
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
PDSA versus PPPP
Act
Plan
Study
Do
Action & Improvement
Plan
Plan
Plan
Plan
No Action, no improvement
Why Test?
• Increase the belief that the change will result in
improvement
• Predict how much improvement can be expected
from the change
• Learn how to adapt the change to conditions in
the local environment
• Evaluate costs and side effects of the change
• Minimize resistance upon implementation
The PDSA Cycle
Act
• What changes
are to be made?
• Next cycle?
Study
• Complete the
analysis of the data
• Compare data to
predictions
• Summarize what
was learned
Plan
• Objective
• Questions and
predictions (why)
• Measure of success
• Plan for the cycle (who,
what, where, when)
Do
• Carry out the plan
• Document problems
and unexpected
observations
• Begin analysis
of the data
Repeated Use of the Cycle
A P
S D
A P
S D
Hunches
and
Theories
Changes that
result in
improvement
Testing on a Small Scale
• Conduct the test with one provider in the
office, or with one patient
• Conduct the test over a short time period
• Test the change with the members of the
team that helped develop the plan
• Test the change on a small group of
volunteers
• Minimize confusion, frustration until bugs
are worked out, then spread
Plan (P) for Organized Evidence-based Care
PDSA 1: Test EMR alert system for patients with DM
Objective: Implement DM alert system for staff/providers
PLAN:
Predictions: EMR alert system will help staff/providers in recognizing
patients with DM on schedule, during pre-visit, visit.
Who, what, when, where: Develop EMR alert. On Wednesday Jean
(MA) will use alert to identify DM patients on schedule next day and
measures not met and due. On Thursday Dr. Moore will identify
patients with DM when EMR page opened.
How will you measure success of the test: The success of the test
will be identification by MA of 100% of the patients with DM on the
schedule and 100% identification by MD when opening the EMR
page. Ease in recognition and accuracy.
The DSA Part of the PDSA
DO: Test completed as planned and
provider/staff provided feedback. DM patients
on the schedule/seen Thursday counted.
Provider and staff kept track of # DM patients
identified with alert.
STUDY: For 90% of DM patients, the alert
activated. One patient with DM without an
alert had problem list error. Both MA and MD
felt the alert was very helpful in giving
planned care at every visit and proactively
addressing needs.
ACT: Retest with another MA and MD on
Monday.
Plan (P) for Organized Evidence-based Care
PDSA 2: Test clinical guidelines/reminders for DM patients
Objective: Implement DM guidelines/reminders
PLAN:
Predictions: EMR clinical guidelines/reminders that default whenever
DM patients seen will support planned care at every visit.
Who, what, when, where: Develop clinical guideline/reminder EMR
template. On Wednesday morning session, Dr. Moore and Pam (MA)
will test the template with scheduled DM patients.
How will you measure success of the test: The success of the test
will be an immediate default to the clinical guideline/reminder
template for 100% of patients with DM seen. Ease in reminder
interpretation, accurate status regarding guideline completion, and
ease in guideline updating.
The DSA Part of the PDSA
DO: Pam was ill on Wednesday, so Pat (MA) and Dr.
Moore completed the test as planned and provided
feedback. Counted default clinical guideline/reminder
template for DM patients. Determined accuracy of
reminders on the template.
STUDY: For 100% of the DM patients,
guideline/reminder template appeared as a default
mechanism. DM reminder status incorrect for eye
exam and vaccines (flu and pneumovax). Both MA &
MD stated default clinical guideline/reminder template
supported planned care at every visit. Easy to use.
ACT: Revise DM eye exam and vaccine reminders and
retest with MA and MD on Monday.
PDSA Cycle: Self-Management
Act
• Revise tool
• Retest with 2
more patients
Plan
• Use a SM tool
• Tool supports SM
process, goal setting
• Staff and patient
satisfaction, # goals
• Select tool, teach staff,
use tool with 2 patients
Study
Do
• Staff and patients • Use SM tool with 2 pts
liked tool and
• Document problems,
process, one goal
satisfaction, # of goals
set per patient
• Begin analysis
• Want to revise tool
of the data
• Successful test
Plan (P) for Patient-centered interactions
PDSA 3: Test the DM self-management tool with patients
Objective: Set self-management goals with patients using a tool
PLAN:
Predictions: Patients with DM can improve self-care when they are
taught behaviors to improve DM management and can select a
behavior change they want to work on and are confident they can
achieve.
Who, what, when, where: Use the NYC DOH DM form for teaching
DM management; use it to set a goal, and to score confidence.
Susan will use the tool on Friday with 2 DM patients (Mather &
Thomas) to teach DM management, set one goal, score confidence.
How will you measure success of the test: The success of the test
will be the completion of the DM self-management tool with at least
one goal and stated patient satisfaction with the approach/tool.
The DSA Part of the PDSA
DO: Test completed as planned with 2 DM patients.
Patients and staff asked for feedback.
STUDY: One goal set per patient. Patients
identified one behavior to work on and were
confident (>7.0) they could achieve it. Susan
slightly uncomfortable with process but wants to
use the tool again to gain comfort with goal setting.
ACT: Retest tool with two patients on Friday.
Revise tool by end of next week, adding importance
score, symptoms & management of hypoglycemia
and retest.
To Be Considered a PDSA Cycle
• The test or observation was planned
(including a plan for collecting data).
• The plan was attempted.
• Time was set aside to analyze the data and
study the results.
• Action was rationally based on what was
learned.
Do
Study
• Reasons for failed tests
1. Change not executed well – re-look at plan
2. Support processes inadequate
3. Hypothesis/hunch wrong
• Collect data during the “Do” of the PDSA Cycle to
help differentiate these situations
• Follow improvement trend of measure graphs
• Spread changes when they work well across
providers, care teams, patient population
0
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Feb-11
Jan-11
Dec-10
Nov-10
Oct-10
Sep-10
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
80
Aug-10
Jul-10
Jun-10
May-10
Apr-10
Mar-10
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Apr-09
May-09
100
Feb-10
Jan-10
Dec-09
Nov-09
Oct-09
Sep-09
Aug-09
Jul-09
Jun-09
May-09
Apr-09
Mar-09
0
Mar-09
0
Mar-09
Pct of DM patients with latest A1C >9
DM Outcome Measures
PDSA 2
60
40
20
100
Pct of DM patients with latest BP <130/80
80
60
40
20
100
Pct of DM patients with latest LDL <100
80
60
40
20
What changes do you
plan to test by next
Tuesday?
Some PDSA Ideas
• Population alert on medical records
• Template/Flow sheet with embedded guidelines
• Pre-visit planning
• Provider-care team (nurse, MA) huddles
• Identifying patients not seen in past 6-12 months
that need follow-up care
• Standing orders
• Planned care at every visit
• Self-management tool
• Risk assessment process, tool