How Do I Do? PDSA Cycles Accelerating Change Dannie Currie, RN, MN, DHSA Safety Improvement Advisor Atlantic Node Safer Healthcare Now!

Overview Change Concepts PDSA Example Exercise and Commitment

Change Control Over Personal Experiences

Change Concept A general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. Creatively combing these change concepts with knowledge about the specific work can help generate ideas for tests of change. PDSAs are used to test the specific ideas. Change concepts are usually at a high level of abstraction, but evoke multiple ideas for a specific process. –Examples: Reduce handoffs Consider all parties as part of the same system Improve work flow Eliminate waste Berwick, Boushon,& Roessner, 2007

Change Concepts Aim: Assure customers do not leave bank cards behind

Change Concepts Aim: Assure customers do not leave bank cards behind Idea: Beeping sound Concept: Use reminder s

Change Concepts Aim: Assure customers do not leave bank cards behind Idea: Beeping sound Concept: Use reminder s Electric shock Voice reminders Siren Based on Edward DeBono’s Concept Fan

Changes While all changes do not lead to improvement, all improvement requires change. Key Change-The list of essential process changes that will lead to breakthrough improvement. Berwick, Boushon,& Roessner, 2007

Rapid Cycle Change Cycle –A structured trial of a process change. Drawn from the Shewhart cycle, this effort includes: Plan- a specific planning phase Do- a time to try the change and observe what happens Study- an analysis of the results of the trial Act- devising next steps based on analysis This PDSA cycle will naturally lead to the Plan of a subsequent cycle. Berwick, Boushon,& Roessner, 2007

PDSAs Moving From Testing to Implementing AP SD AP SD AP SD AP SD Change Ideas Learning From Data Very Small test Follow up tests Wide Scale tests of change Implementation of Change Changes Result in Improvement

Huddles The idea of using huddles, as opposed to the standard one-hour meeting, arose from a need to speed up the work of improvement teams. Huddles enable teams to have frequent but short briefings so that they can stay informed, review work, make plans, and move ahead rapidly. Berwick, Boushon,& Roessner, 2007

Rapid Cycle Testing AIM: State your overall goal you would like to reach Example: By October 31, 2007 we will have reduced undocumented and unintentional discrepancies by 75% of baseline on Medical Unit #1. Describe your first (next) test of changePerson Responsible When to be done Where to be done Test a BPMH process and data collection form on the one person within 24 hours of admission John RN June 22/07 Med Unit #1

Plan: List the tasks needed to set up this test of change Person Responsible When to be done Where to be done 1.Understand components of a BPMH 2.Write a rough draft steps in a BPMH and select a current form for use 3.Select a Patient and time 4.Conduct a BPMH and use the information to compare with AMO 5.Arrange a huddle with 2 other team members 6.Complete the “testing” worksheet Mary RN Jane Team Lead Susan Unit Manager Mary RN Susan Unit Manager John RN Today June 21 June 22 June 22 before 12 noon June 1430 June 22 before 1500h Here Med Unit #1 Conference Rm Med Unit #1

Plan (Continued) Predict what will happen when the test is carried out Measures to determine if prediction succeeds 1.Guideline and form will be used 2.Guideline and form will need refinements 3.There will be at least 1 medication discrepancy 4.The huddle will identify new change ideas for testing 1.Self Report Y/N 2.Discussed and recorded in huddle 3.Recorded on form 4.Yes/No

Plan Planning should provide the following: –Clear description of your next test of change –List of tasks with who, when and where –Predictions for what will happen –Simple measures for the predictions

Completing Test of Change Do: Describe what actually happened when you ran the test –The protocol failed to account for poor historians so more collateral information was required. Study: Describe the measured results and how they compared to the predictions –Guideline and form need revisions based on RNs feedback, there were 2 undocumented intentional and 2 unintentional discrepancies. The team leader suggested improvements for the BPMH form Act: Describe what modifications to the plan will be made for next time. –The guideline and form will be modified, and another test planned for June 25 th involving 2 RNs and 2 patients on Med Unit #1

Ramping Up Your Cycles As you move thru cycles increase size of the test –1Patient, 1 RN, 1Pharmacist, 1 Physician –2 Patients, 2 RNs, 1Pharmacist, 1 Physician –5 Patients, 2 RNs, 1Pharmacist, 1 Physician –15 Patients, 5 RNs,1Pharmacist, 2 Physician –25 Patients, 10 RNs, 2Pharmacist, 3 Physician

Rapid Cycle Change Initiation of Rapid Cycle tests is dependent on getting the first test of change started Do Not try to Perfect the change then implement…consider your work a masterpiece in progress Failure is a great Opportunity to plan to do better next time… Frequency of Testing determines the speed of the process improvement ie daily testing = improvement in weeks; weekly = improvement in 3-4 months

Spread The intentional and methodical expansion of the number and type of people, units, or organizations using the improvements. The Theory comes from the literature on Diffusion of Innovation (Everrett Rogers 1995) Berwick, Boushon,& Roessner, 2007

Exercise and Commitment Commitment to Group Groups of 2-3 Plan for testing a change idea Do, Study, Act by next Tuesday….

Exercise and Commitment Plan 2 tests of change to be completed by Tuesday #2 Post your results on the QIM community of Practice by Wednesday Read each other’s PDSA postings and provide feedback. Repeat Steps for week #3, Plan 3 tests of change by Tuesday #3

Exercise and Commitment If in 3 weeks time you have not successfully run 6 small tests of change what would have prevented this from happening?

Exercise and Commitment Monthly Call x 3: – Dec 03/07, January 10/08 and Feb7/08 6 month call, May 2008 I year call December 2008

Acknowledgements Berwick, D.,Boushon, B., & Roessner, J.(2007). “The Improvement Model,: A Powerful Engine for Change” IHI Web Based Training at: htm?TabId=2 htm?TabId=2 Harris, B. (2007). Change Concepts. Murray, M (2006). “Small Steps, Big Changes” workshop. Reasear, R. (2007). Institute for Healthcare Improvement “Designing Reliability Into Healthcare Processes: Based on the work of the Institute for Healthcare Improvement Innovation”

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