Run charts Science of improvement Developing changes that are new, by definition, requires a creative effort = the art of improvement Studying the changes and their resulting impact (beneficial or not beneficial) forces us to consider the science of improvement Today I’m presenting a short primer on PDSA Cycles because many people are familiar with the term but it is widely misunderstood and misused. To me, it is probably the most vital part we glass over or rush through with any QI effort. So I encourage you to refine this skill within your own team and throughout your organization. Though the PDSA cycle is meant to promote rapid cycle testing, sometimes the cycle takes longer than we anticipated. Diane Liu, MD Director, UPIQ Utah Pediatric Partnership to Improve healthcare quality

Principles of improvement Knowing why you need to improve Having a feedback mechanism to tell you if the improvement is happening Developing an effective change that will result in improvement Testing a change before implementation Knowing when and how to implement change From The Improvement Guide Langley and Provost page 25 “Key Points from Chapter One)

Learning and Improvement Theories, hunches, and best practices What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in improvement? Model for Improvement Breakthrough Results A P S D Evidence & Data D S P A Wide-scale implementation of change A P S D This is how we use PDSAs in practice. We start with some hunch or theory (our predictions; the change ideas) and we test on a very small scale. We evaluate the data from that test and plan the next test; and so on. We don’t implement any change until we have done the sequential building of knowledge we get from running PDSA cycles. Learning and Improvement Test new conditions A P S D Sequential Building of Knowledge with multiple PDSA Test Cycles Figure 7.2 ‘The Improvement Guide’ Langley, et al. 2009 Follow-up tests Theories, hunches, and best practices Small Scale Testing

RUN Chart (a.k.a. time series or trend chart) Display key measures over time Determine if changes result in improvement Determine if gains are held Graphical display of data Plotted in order Simple to interpret Makes progress visible

Interpret run charts – “rules” of significance Shift – 6 or more consecutive points all above or all below the median Trend – 5 or more consecutive points all going up or all going down Number of Runs – nonrandom points; series of points in a row on either side of median

Sample run chart SHIFT ALMOST a TREND!

HPV RUN CHART – MISSED OPPORTUNITIES No median line but we were pretty much hugging the 40% - so if we believe the median is near there, there really aren’t any shifts or trends going on. Need more months of data to help us know if any of our changes are resulting in improvements for reducing missed opportunities.

Knowledge is gained sequentially REMEMBER Improvement is an outcome of the application of (appropriate) knowledge Knowledge is gained sequentially All improvement occur due to changes but not all changes lead to an improvement

QUESTIONS? Diane.Liu@hsc.utah.edu THANK YOU! QUESTIONS? Diane.Liu@hsc.utah.edu Diane Liu, MD Director of The Utah Pediatric Partnership to Improve Healthcare Quality