pdsa examples in healthcare
Model for Improvement: Plan-Do-Study-Act (PDSA) Cycles Once a team has set an aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the real work setting. How you might use this catalog We have labeled most of the cycles with the component of the Care Model addressed by the documentation. Registry reviewed and only minor field to be added. This process did not work well. The checkout area can get busy and backed up at times. Ask: Who needs to be involved? The general consensus was that the form which required them to simply check off their goals was preferable to the one which actually made them write them down. Here you will record how well it worked, if you meet your goal. We identified several translation errors when we compared the form to the English language version. Going through the prescribed four steps guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again. Key principles of the model for improvement. The provider and nurse will make the decision at the FX facility after reviewing the forms. Krafcik, J. F. (1988). The DMAIC methodology is used to improve existing processes and procedures. Institute for Healthcare Improvement. All of the examples are real. 1 did it on 1 patient. Each intervention goes through a PDSA cycle to test its validity and to adapt it to the specific context. way to write management's goals and objectives. Agency for Healthcare Research and Quality. An official website of the Department of Health and Human Services, Latest available findings on quality of and access to health care. I plan to: see if the signs put up in the exam rooms help physicians remember to do teach-back and increased its utilization. We are testing this form on the next five (5) diabetic patients we see. 7/22/02 to 7/25/02 Where are we testing? Dr. Deming found that the focus on Check is more about the implementation of a change, with success or failure. Original objective completed. After implementation,study the results. It provides you with a log of your improvement process, your reflections, and a transferable plan for other teams . Some of these patients may have eventually come in for a Diabetic Planned Visit, but many of our patients are acute care-oriented, and are very unlikely to come in for a dedicated visit for diabetes. An example would be " In PDSA cycle 1, we found that by reallocating existing human resources (0.25 FTE) to the accessioning station in the afternoon, our weekly average success rate of meeting the TAT target improved from 51% to 69%. Before you select an intervention, you need to discover the cause of your problem. The observations of patients, provider and nursing staff about whether the patients perceived the forms to be useful as well as how they felt about taking the time to go over them and fill them out. This was causing the charts of some patients (especially frequent fliers) to become very thick. For the 1 who was not sure how to integrate it, we will look for other teach-back resources to help address this. PDSA - Plan, Do, Study, ACT Goals & Targets: Develop a process to administer PRAPARE surveys and identify possible responses to determinants. We are looking for a form that is easy to follow, is inclusive of all selected measures, and that will provide medical staff with pertinent medical information when assessing asthma patients. We need to do the same thing for QI projects. The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change by planning it, trying it, observing the results, and acting on what is . We added information about how to find EKG, Colon CA screening, LEAP scoring, and lab test descriptions and locations to the existing information on the cheat sheet. We need to approach them at a different point in their visit when they are still with usmaybe at a point where they are waiting for the doctor and have nothing to do. Senior Leader report: We tested two different self-management goal sheets with two patients. Remember: The PDSA is an iterative process. Does your team have easy access to relevant data to quickly assess progress (or regression)? Plan-Do-Study-Act (PDSA) is a structured, straightforward approach to implementing quality improvement projects/initiatives in practices. ___________________________________________________________ End of Example 4 Example 5: Decision Support: Use of Screening Tool (test of change involves provider only) July 2002 Purpose of Cycle: Train medical providers to administer PHQ-9 PLAN What are we testing? The plan was attempted Time was set aside to analyze the data and study the results Action was rationally based on what was learned. The study found Lean principles enabled Toyota to overtake the top car manufacturers of the time, such as Ford and General Motors 3, 14, 16. Maybe the goals of '3 out of 6 patient encounters should contain teach-back' is unrealistic. Tool: Teach-backStep: MDs continuing performing Teach-backCycle: 3rd Try. Are we ready to implement the change we tested? We tested two different forms. Once you have your list of stakeholders, you need to determine how often to engage in each person. Here you will write down observations you have during your implementation. We will ask physicians if they notice the signs and if they reminded them to perform teach-back. 4 out of 5 physicians did teach-back on 3 patients Wednesday afternoon. (3 weeks have gone by since initial introduction.). The idea of self-management was explained to them and they were asked to fill out the form setting goals for their active participation in their care. The Center for Disease Control and Prevention defines quality improvement asa continuous and ongoing effort to achieve measurable improvements in the efficiency, effectiveness, performance, accountability, outcomes, and other indicators of quality in services or processes which achieve equity and improve the health of the community.13, The U. S. Department of Health and Human Servicesdefines quality improvement assystematic and continuous actions that lead to measurable improvement in health care services and the health status of targeted patient groups.15, The Agency for Healthcare Research and Quality defines quality improvement asthe framework we use to systematically improve the ways care is delivered to patients.1. ?g\@gcd d6;B!~fa$ C S{D(F6tTnad%`u2C?aSHt* Screening tool will be easy to administer and score. The Phrase Health team often adopts the Plan-Do-Study-Act (PDSA) framework given its simplicity. Particularly at the beginning of your work with the Care Model, if you are developing a test of change in a particular component, you might start with a look at the example(s) in that component to help you create your plans. It is anticipated that with the regular dietician needing translation, we should not increase our bookings with Spanish-only patients. An example of an outcome measureis CLABSIrates. In addition, the team would like tocreate a laminated handout for quick reference, which describes the timing ofvarious labs, screening, and specialty referrals (for example, annual eyeexam, quarterly HgbA1c measurements, etc. Going through the prescribed four steps guides the thinking process into breaking down the task into steps and then evaluating the outcome, improving on it, and testing again. >^J XMl@aPK&1 Content developed by Associates in Process Improvement Layout modified by Harrington Family Health Center 2002 Excellent documentation of a cycle, clearly planned. When it comes to the overarching plan, health IT and informatics professionals agree that although the PDSA model may seem simple, it can often be implemented incorrectly. Providers quickly became proficient in using the PHQ. S site using Ms laptop with current PECS database (M is our Clinical Expert FNP who has been spearheading the implementation of PECS) Predictions What do we expect to happen? These results were consistent with those of some studies on TBI published in the 1980s . The most commonly used QI models - Model for Improvement, Lean, and Six Sigma - were initially developed for use in the manufacturing industry. Feedback from medical providers Who will collect the data? The form does not provide enough space for notes or questions. Management Review, 70(11), 3536. Exploring 25 years of lean literature. Your team can choose to look at just one key metric, say handwashing compliance rates, oryour team can choose to look at a couple metrics, say handwashing compliance rates and CLABSI rates. Registry has been placed on network server. Does the project align with other efforts? Goals must be within your capacity to reach. ThePlan-Do-Study-Act (PDSA)cycle is the engine that drives QI projects. > % bjbj%% " G G A I l 0 0 0 0 ( ( ( D D D 8 D t >E O fF G H H H X * \ L +^ $ Q q ( ^ T X ^ ^ d 0 0 H H d d d ^ 0 H ( H d ^ d \ d e :z PDSA (plan-do-study-act) worksheet. We only had 8 surveys returned at the end of the week. The nursing informatics team constructed and implemented the alert. When will the data be collected? <>>> We are going to initially test these on one patient each at their next visit. Each of its nine steps stand for the following actions: 3) There may be middle ground you havent identified yet. 'D!DgSfu#/ Model for Improvement & PDSA cycles Improvement methodologies are used nationally and internationally, to improve processes of care or patient outcomes. There are a dozens of Lean tools to help you identify and eliminate waste in processes and procedures. Whiteboard Control Charts 1. Tool: Teach-backStep: MDs initially performing Teach-backCycle: 1st Try. The Armstrong Institute also offers a range of training opportunities, including Lean and Six Sigma certification, that are available to health care professionals everywhere. This may include how the patients react, how the doctors react, how the nurses react, how it fit in with your system or flow of the patient visit. A decision will be made as to exactly where in the chart the form should be kept. Act: The Team determined we needed to return to our original system, which we did, with a minor concession to appease the Medical Records staff. B(id4{dS?"0\7I( #;e*"p+PG3oO`tAoZ =]Bb!I,wJ"xaA9{\mem!F~RIe8)FwJ4 ydv4L*t~{xiT;,{R0E;1kTvj~. This will help us track ourprogress as a group, and will help us focus on the areas where we arelagging. Who are we testing the change on? If goals are set too far out of your reach, you will not be successful. Updated 31 Jan 2023, Published 23 Sep 2022. Take a look at your results: Waste, or Muda in Japanese, is any step or action in which the user does not gain any value 16. In this text box is a summary version of the PDSA cycle, a short version of the longer documentation. The original was placed in the patients chart and they were given a copy to take with them. Where will the data be collected? What changes should we make before the next cycle? They would actively participate in discussions about various goals and would try to set realistic goals for themselves. everyone The PDSA approach facilitates individual, team and . We will ask the physicians if they still feel: We will put signs reading "Teach it Back" taped on the exam room desk/work area to remind physicians to use the technique. z '#e2a*N^@ZoSVPjx\a|QGWbW](8qIqDE-|/dG^@oPr!lU+sjA|ba>X(Hs| What is the plan, do, study, act cycle, and why do we use it in quality improvement projects? The Six Sigma model was developed by Bill Smith, an engineer at Motorola, after the company received too many warranty claims 3, 11. Model for Improvement (Plan-Do-Study-Act [PDSA] cycles): The Institute for Healthcare Improvement's Model for Improvement combines two popular QI models: Total Quality Management (TQM) and. We employed the forms with the first two diabetic patients that we saw. Who needs to be involved and what sort of participation do you need? Using PDSA cycles can help clinicians deliver improvements in patient care through a structured experimental approach to learning and tests of change. Without a time limit, there's no urgency to start taking action now. Exploring the clinical outcomes of patients sustaining severe traumatic brain injury (TBI) at our trauma centre from 1994-97 we found that the outcomes were marginal at best: 43% of our patients expired and 30% suffered severe disability. https://edhub.ama-assn.org/steps-forward/module/2702507 Category: Health Show Health Interprofessional collaboration: effects of practicebased interventions on professional practice and healthcare outcomes. There are fourtypes of QI metrics: structure, process, outcome, and balance. We noticed that the patient had other papers to manage at this time as well. 1 did not perform it at all (same one as before). The next step will involve how the information will be placed in the chart so as to be useful and readily reviewed. The PDSA cycle is an iterative, four step model for improving a process. The IHIoffers professional development programs including conferences, seminars, and audio and web-based programs to inform every level of the workforce, from executive leaders to point-of-care staff. People often find it easier to relate to examples from a familiar setting, so show them what a test cycle or two look like in their own health center. As you work though a strategy for implementation, you will often go back and adjust something and want to test whether the change you made is better or not. Goals should be relevant. If not, do you need to reiterate the plan and collect new data? No real problems were encountered during this test. One of these forms is a check off form with the ten (10) top goals listed, while the other requires the patient to actually choose and write down their own goals. Here you will write what you came away with for this implementation, whether it worked or not. Analyze the data; what does it show? The AHRQ Health Bildungsniveau Universal Accommodations Toolkit, 2nd edition, can help core care practices mitigate the complexity of health mind, increase patient understanding of health information, and enhance support for care of all health literacy levels. Complete analysis of data, summarize what was LEARNED, compare data to predictions We found that patients were very receptive to the idea of self-management goal setting after the concept was explained to them. A: Keep the brochure as is since student was able to understand it. Antony, J., Snee, R., & Hoerl, R. (2017). Counselor had to get English translation in order to understand concept and reword interview question in Spanish. The cheat sheet increased Rs comfort with the process. Six sigma has 2 major methodologies:define-measure-analyze-design-verify (DMADV) and define-measure-analyze-improve-control (DMAIC). Patients did not want to stay to fill out the survey once their visit was over. Immediately after the second patient visit the provider and nurse will discuss the two different forms and give their conclusions. Finally, you will act on what you learned. Public Health Laboratory: Influenza Process Improvement Kaizen. It reduces risk by starting small. All physicians found the teach-back video informative and seemed eager to try this new tool. Data: What data do we need to collect? Module 4. (Remember, programs are ongoing, long-term, and proactive initiatives that span the organization.) steroids), does not have enough space, and does not address other medications that the patient may be taking concurrently. M initially helped the PIA extract data, then the PIA worked independently with the cheat sheet. What happened? Once the patient steps out of the building, they will likely not remember to do the survey. This session takes a look how to test whether a change idea leads to improvement in quality of healthcare through the Plan, Do, Study, Act (PDSA) cycle, a co. We will run the July 10th clinic with one outreach worker but wont increase number of Spanish-only patients. Is there enough of that data to be meaningful? Who will collect the data? Plan: In this first Step, you should: Define the Problem or the Goal you want to achieve. In particular, we would like to stress the importance of a prediction as a key ingredient in your planning. Plan: In order to prevent this problem of thick charts we decided to generate a Diabetes Encounter sheet only for dedicated Diabetes Visits. No Diabetes Encounter sheet would be generated for those patients coming in for non-diabetes-related care, unless the patients diabetes was dealt with and then the provider would have the nurse run a Diabetes Encounter sheet before the visit was completed. (919) 843-0981, 2023 Institute for Healthcare Quality Improvement, Institute for Healthcare Quality Improvement, PDSA Tracker (example by IHQI Project Manager), A primer on PDSA: executing plan-do-study-act cycles in practice, not just in name, How to Collect Data While Eating Your Wings During the Super Bowl, Fundamentals of Health Care Improvement: A Guide to Improving Your Patients Care, Surprise Billing and Good Faith Estimate Notices, Avisos de facturas mdicas sorpresas y avisos de presupuestos de buena fe. I hope this produces: confirmation that each of the physicians will have performed teach-back on at least 3 of their afternoon patients. The Associates for Process Improvement, an Institute for Healthcare Improvement (IHI) partner organization,expanded on the PDSA cycle to create the Model for Improvement 10. Having them written down often helps people focus and learn more. Our provider champion and the nursing member of the team. R., MSW When will the data be collected? Institute for Healthcare Improvement. Due to the pressure from Records to change things, we let the change run for a full week and a half. At our FX facility. In the subsequent cycle, the team planned to tweak the alert to fire more appropriately based on their workflow analysis and user feedback. When will the data be collected? Keep the following in mind when using the PDSA cycles to implement the health literacy tools: Tool: Fill in the tool name you are implementing.Step: Fill in the smaller step within that tool you are trying to implement.Cycle: Fill in the cycle number of this PDSA. q ; P Q R S n o p q D E F _ ` a b |n jq UmH nH u &j >*B*UmH nH ph u j{ UmH nH u j UmH nH umH nH u &j >*B*UmH nH ph u mH nH u0J mH nH uj 0J UmH nH u 56\] j 56U\] 5>* \5\ 6]+ l m ] N Q Q 6 7 | Itis a leading innovator in health and health care improvement worldwide. Below can 2 examples of as to fill out the PDSA worksheet for 2 different tools, Tool 17: Get Patient Feedback also Tool 5: Getting the Teach-Back Method. We will encourage them to fill it out when they get home and offer a stamped envelope to mail the survey back to us. In your monthly Senior Leader reports, you will be asked to give a brief summary of your test cycles. We learned that translation didnt increase time and our bilingual staff could handle the mix. Identify ways in which we can assure both accessibility to the data while assuring accuracy and privileged nature of information. Ask: What are you trying to accomplish? Based on what you learned, what will you do next? The same data can be used in different ways, depending on what we want to know or . An explicit prediction increases the likelihood that you will really learn from your cycleeither from the success of a prediction that matches actual outcomes or from your failure to predict correctly. We will be testing during the week of 7/22/02 7/26/02 on the first five (5) diabetic patients seen. The second phase involves testing the intervention in real world settings using the PDSA cycle. PREDICTION: What do we expect to happen? Lean Six Sigma: yesterday, today and tomorrow. I hope this produces: Here you can put a measurement or an outcome that you hope to achieve. It is now the most commonly used QI approach in healthcare 1. Problems uncovered in the careful study section worth further reflection! Quality Improvement Examples: Organization-Wide, Ongoing Programs In this section, we provide four examples of quality improvement in healthcare that are specifically related to programs. Ask: How does the current process perform? Each contain 3 PDSA cycles. We will be utilizing the selected form with the next five (5) diabetic patients from our registry. What resources and support do you need? Problems? Download and use a PDSA template in your organization's problem-solving processes and quality improvement efforts. All team members have been provided with the comments and suggestions made about the form, and have been charged with redesigning the current form. For more information on the PDSA, go to the IHI (Institute for Healthcare Improvement) Web site. ''@p9*&+ lcNCMs_LAJ:`qwOX71v b Where are we testing? After implementation you will study the results. We uncovered issues of confidentiality and risks to data integrity. It is a powerful tool for learning. It is more effective to treat the underlying problem than the symptoms. Agency for Healthcare Research and Quality, Rockville, MD. The resources below are designed to assist with: Design and execute a PDSA Understand when to use a PDSA and when not to use a PDSA. Once you have identified what you want to change, the Plan-Do-Study-Act (PDSA) Cycle is a useful frame to help your team plan your intervention, test it on a small scale, and reflect before adjusting it or spreading it more widely. Observations? Analyze the process and determine the root causes of defects. STUDY: This form will need to be revised for future use with our patients. DO: On 8/21/01 M., a nurse case manager and team member used the Hill Health Center form to evaluate an asthma patient. (use back of form to elaborate) Notes 7 October 2003 PAGE 3 Catalog of PDSA Examples PLAN: STUDY: ACT: PLAN: STUDY: ACT: PLAN: STUDY: ACT: Senior Leader Report: We tested a Spanish version of PHQ tool on one patient on 20 July. Observations? The AHRQ Your Literacy Universal Precautions Toolkit, 2nd edition, can help primitive care practices reduce the complexity of health concern, increase patient understanding on heath information, and enhance support with patients of all health literacy levels. In addition, the Institute for Healthcare Improvement (IHI) recommends every team include members that represent three different kinds of expertise: system leadership, technical expertise, and day-to-day leadership7. ACT PLAN STUDY DO Senior Leader Report We tested use of PHQ by two providers. Senior Leader Report: We tested an orientation to the collaborative with 2 providers. To test this orientation format on 1-2clinicians and make modifications as needed.DO: The orientation format was developed and tested on onenew clinician, and one clinician who has worked with the collaborative team,but is not a full member of the team.STUDY: The orientation format we developed was very thorough and a usefultool to guide the orientation. 4 out of 5 felt comfortable with it and said they would continue using it. They re-ran the experiment with the changes in place. Some of the more commontools are A3Report, 5S, Bottleneck Analysis, Value Stream Mappin (VSM), Jidoka, Kaizen, Kanban, and Poka-Yoke. M and R When will the data be collected? What changes can you make that will result in improvement? <> All five patients understood the form and reacted positively to the self-management approach. It is based on scientific methods for measuring chances of success. A: Will keep the brochure as is as the DPH recommended no changes. (2011). You need not type up every cycleneatly written hand notes stored in a 3-ring binder provide most of the team benefit (except for archiving or back-up! 10-12-01 P: To test the brochure with the department of public health. Senior Leader Report: We tested how to use the clinic information network to give team members access to the registry tool, on 8/21. PREDICTION: What do we expect to happen? Shewhart and Deming used the steps of the scientific method as the foundation for the cycle 4, 12. We need to give patients a way to fill out the survey when they have time. S: DPH comments were positive. xioF{(. Testing is being conducted at the FX facility. We had them fill out both forms and then asked them which they preferred. It provides a structure for iterative testing of changes to improve quality of systems, and this method is now widely accepted in health care improvement ( Taylor et al., 2014 ). !bmd$|\AA5~Wk{$%q{. The name, PDSA, is an acronym for the steps in a circular process of iteration. 2. Senior Leader Report: We tested an assessment form from Hill Health Center on one patient seen 8/21. McCarty, T., Daniels, L., Bremer, M., & Gupta, P. (2005). Care Model: This model creates a system in which patients and healthcare providers have more productive interactions with each other during the care process. 3 out of 5 physicians said they did perform teach-back on 3 of their patients. ACTWhat adjustments to the change or method of test should we make before the next cycle? Intentional use of PDSA cycles accelerate teams' learning. We repaired the translation and tested with 1 patient on 27 July. The treatment at visit section could be modified by deleting the current information and having the provider simply fill in what treatment, if any, was provided. Ourinformal systems have worked fine with our small group, but doing theorientation highlighted the need for more clear descriptions of theseservices and clear ways clinicians can access these services for theirpatients. Brochure was distributed to the schools. Problems? Some patients did not want to be bothered at this point in the visit; they were more interested in getting checked out and on their way. ACT: What adjustments to the change or the method of test should we make before the next test cycle? I hope this produces: physicians will perform teach-back 3 out of 6 times. A six sigma process is one in which 99.99966% of all products are expected to be free of errors11. They transformed the troubled implementation into a PDSA test cycle. Dates were sometimes missing on encounter notes, and usually missing on vaccine records STUDY: Complete analysis of data, summarize what was learned, compare data to predictions We found that the cheat sheet made the process easier, and was a useful tool when modified. Changes can be focused at the operational level around a team's needs. S site, 2nd floor office DO: Carry out the change/test; collect data and begin analysis What was actually tested? The objective of this project is to reduce the long wait times and delays for outpatient diagnostic services since it creates the patients' dissatisfaction with the treatment and it could also "pose an important threat to healthcare quality and safety in outpatient settings" (Singh, Meyer, & Thomas, 2014, p. 727). Some physicians could not find appropriate situations for teach-back. Example: Based on the example above, the team determines from data analysis, that providers and nurses are unavailable most of the time due to 2 reasons: 1) Too many interruptions from Pharmacy representatives, and 2) Attendance at mandatory meetings. Act: Adjust the process based on the results found in the Study phase. 2nd floor conference room DO What was actually tested? (Tool 5: Use the Teach-Back Method). Chapel Hill, NC 27599 We will display the surveys at the checkout desk. Keep the following in mind when use the PDSA cycles to implement the health literacy tools: . Next, build your project team. Tool: Teach-backStep: MDs continuing to perform Teach-backCycle: modified 2nd try, I plan to: see if the physicians in Wednesday PM clinic are still performing teach-back by asking them after their last patient leaves. Understanding and acting on special causes of variation (fixing the current system). The Six Sigma modelis sometimes referred to as Zero Defects because it aims to eliminate defects and errors in processes and procedures. We agreed to flip the Diabetes Encounter sheet so the graph side was down, allowing for easier documentation of phone calls, etc. The Plan-Do-Study-Act (PDSA) method is a way to test a change that is implemented. Giving the PHQ raised several questions for providers about Indicating time frame of any given PHQ (initial, 6 week, 6 month); and Indicating disposition. What will the next test be? &. Student was then able to explain what he learned from the brochure. What can be accomplished within that time frame? We will revise access levels and identify ways to prevent data corruption. Lean defines 8 types of waste, or Muda: transportation, inventory, motion, waiting, overproduction, over processing, defects, and skills16. Define the Plan-Do-Study-Act Stage 1: Plan: Identify an opportunity, and plan for improvement Assemble the team Create an aim Statement Examine the current approach Identify Potential Solutions. JB}Owo>r)TtQ"PO H ! The afternoon of 8/7/03 Where will the data be collected?