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

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

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
whats 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 whats 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, Too much thinking,
not enough thinking not enough action
Something must be done, We cant do anything
this is something, until we know exactly
therefore we must do it 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 whats 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 Didnt specify
someone different what
I wanted properly
Getting
Information

Set impossible Didnt Not got an

timescales check accurate
often brief
enough
Didnt give
Am I dealing with manager
really urgent Havent planned
enough time
work? time available well
Waiting for line
managers approval
Not sharing
Other deadlines 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? measurements
What changes can we make
that will result in the
improvements that we seek ? change ideas

Act Plan testing ideas

before
Implementing
Study Do
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 What exactly are
make based on we going to do?
our findings
Act Plan

Study Do
What were When and how
the results? 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)
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 didnt 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:
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 doesnt work, try something different
based on your learning
Document what did/didnt 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
 Implementing new
Repeated use of the procedures & systems
- sustaining change

PL
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PDSA cycle

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 Create Multiple PDSA Ramps

A P A P A P
S D S D S D
A P A P A P
S D S D S D

A P A P A P
S D S D S D

A P A P A P
S D S D S D

receptionist porters Nurses

 Diabetes (blood pressure)
Improvements with PDSAs
Scottish Primary Care Collaborative
Borders GP Practice
% of Diabetes Patients with a BP<140/80 PDSAs PDSAs
90 PDSAs

80
PDSAs to improve
70
shared diabetes
PDSAs to information with
Secondary Care PDSAs to improve
% of People with Diabetes

60
Validate
Diabetes current patient
50
Register recall system
40

30

20
PDSA to contact all
10 Patients who have not
had a BP check in the
0
1 2 3 4 5 6 7 8
last
9
year
l in
e
th th th th th th th
0 1
th
2 3
th 1 1 1 1 14 15 16 17 18 19 20 21 22 23 24
se h th th th th th th th th th th th th th th
a on on on on on on on on on ont o n o n o n o n o n o n o n o n o n o n o n o n o n o n
B M M M M M M M M M M M M M M M M M M M M M M M M
 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

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 ACCOUNTABILITY RESEARCH

Purpose Understanding of
Process Comparison To bring new
Evaluation of change Reassurance knowledge into daily
To discover new practice
knowledge

Data Gather just enough data

to learn and complete Large amounts of data Gather as much data
another cycle as possible just in
case

Duration Small tests of

significant change Long periods of time Can take long periods
accelerates the rate of of time to obtain
Long & past
improvement results
Short & current 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.
Youll 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