How Mr. Potato Head Can Help PDSAs … Sandy Perkins, MS, RD/LD

Change Method The Model for Improvement is a method to help accelerate change …and increase the odds that the changes we make are an improvement .

Use the Model for Improvement to guide Team work, including: Aim Use the Model for Improvement to guide Team work, including: Identify a Quality Improvement Aim. (Plan) Identify Ideas team members believe will lead to the greatest amount of change. (Plan) Identify process and outcome measures based on chosen Ideas. (Plan) Implement Ideas to “test” change. (Do) Measure progress (outcomes and processes). (Study) Adjust ideas as needed. (Act) Measures Ideas Evaluate the Aim Test the Idea

Challenges in applying to state-level public health work State level public health practitioners do not usually have the power to actually make changes – but have to work through other people. Processes for policy changes are complicated, lengthy, and involve working with diverse groups of stakeholders. Resources for collecting data for the STUDY phase are usually very limited. May be difficult to conceptually integrate with other, more common public health planning approaches. PDSA cycle not looking at the forest – just want to look at one tree.

Ways that PDSA thinking can be helpful Its about process Its about improving systems Its about small steps that build on each other It gives you permission to fail One cycle sets you up for the next cycle Its a team thing – it gives a common language for planning and evaluation Its something that you can do with small numbers/samples and get ongoing feedback as you progress (as opposed to setting up a big change with a lot of people and then measuring if it works with a large randomized trial).

Why Test ? Increase your confidence that the change will result in improvement in your organization Learn to adapt the change to conditions in the local environment Minimize resistance and provide justification when you move to implementation Help identify champions for the change Since knowledge is based on testing rather than brainstorming / planning increase confidence the change will result in actual improvement

“Negative results on the fish… Let’s try rubbing two sticks together.” Fundamental and part of our every day lives… “Negative results on the fish… Let’s try rubbing two sticks together.”

The PDSA Cycle Act Plan Study Do Adapt? Adopt ? Abandon? Next cycle? Objective Questions and Predictions(why) Plan to carry out the cycle (who, what, where, when) Adapt? Adopt ? Abandon? Next cycle? Study Do Complete the analysis of the data Compare data to predictions Summarize what was learned Carry out the plan (on a small scale) Document problems and unexpected observations Begin analysis Rapid testing. Plan – Questions and predictions (why). What few behaviors will lead to the greatest amount of change? How will you motivate and enable change? Do – Try it – don’t think just try something. RAPID Study – Analyze results – give feed back. Act – Adopt – every thing is good Adapt – small changes to improve Abandon – Begin again

Learning and Improving Changes that result in improvement D S P A Learning from predictions and data Implementation of change: Tests of Implementation A P S D D D S P A A P S D Wide-scale tests of change – When does it fail? A P S D Follow-up tests – What works and when? Hunches Theories Ideas As you move up the cycle – you adapt the test either in scale or scope. Scale: Time span or number of events included in a cycle. When scale up test of change, think about more. Scope : Variety of conditions under which tests occur. When change the scope of test, think about difference . Point out the Very small scale test Repeated use of PDSA Cycles Very small scale test – What did we learn? Attributed to Institute for Healthcare Improvement

How Small is Small Enough? Biggest problem is too big. Opportunity for “failures” without impacting performance Learn how to adapt the change to conditions in the local environment Identify how much improvement can be expected from the change Evaluate costs and side-effects of the change Minimize resistance upon implementation Increase belief that change will result in improvement The question is How Small is Small Enough?

Consequences of Failed Test Depends Disaster Zone Major Consequences of Failed Test Minor Stay out of the disaster zone: Consequences of a failed test are rarely minor: Impact on patients Resource Utilization Morale Momentum Small Large Size of your Test

PDSA Test Size Current Situation Resistant Indifferent Ready Low Confidence that current change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Small Scale Test High Confidence that current change idea will lead to Improvement Large Scale Test Implement Objective: Matrix of size of test to implementation Explanation: This slide is a matrix of the size of the test of change as it relates to readiness for, cost of failure and confidence in the change. For example, if the current situation contains high resistance to a change and there is very low confidence in or evidence of success related to the change and the cost of failure is high, then the test should be very small. Only in high readiness, low cost of failure and high confidence should the team move to implementation. Cost of failure includes Money Reputation Cultural – feeling changes is helpful or resistance. Attributed to Lloyd Provost, BS MS Associates in Process Improvement API

PDSA TIPS......

Volunteers at first; move to others Start with the Willing! Volunteers at first; move to others Facilities “Ready” or “indifferent” to make the change. LA – willing already had policies Not resistant. OH – wanted to start with the hard to reach. They were hard to reach. Only 2 followed through. Willing is about motivation not resources and comes in all sorts, willing is not better resourced. Willing is who volunteer. -

Proximity and relationship helpful for follow up. Think Local! Proximity and relationship helpful for follow up.

Rule of 1! 1 meal 1 day 1 facility 1 provider 1 business 1 person 1 afternoon 30 minutes Small then grow 5 people 3 days / week …..

Dealing with “Failure” Grasp the opportunity to learn. Possible reasons for failed tests:  Change was not executed well Support processes were inadequate Hypothesis of your “good change idea” was just wrong

Key Points Knowledge is gained through testing (versus planning or brainstorming). Tests should be small, rapid, and sequential. Developing a theory and prediction before each test and reviewing them in comparison to the test results afterwards is essential. Learning from other teams can accelerate learning and understanding. Measurement does not have to be hard and aids learning.

How Can Mr. Potato Head help teach about PDSAs? They can’t, but Mr. Potato Head can help you with PDSA’s.

Assemble Mr. Potato Head quickly and accurately. They can’t, but Mr. Potato Head can help you with PDSA’s.

Split into Teams of Four

Designate a team roles Tester Documenter Time Tracker Accuracy Score Inspector Groups of 4 can mix up. Tester – Mr Potato Head Recorder - Print - PDSA Tracker Form Timer - Print - Run Chart Time Inspector- Print - Run Chart Accuracy – write time and accuracy score on paper and give to me.

Round One / Base Line Data Team - Predict of the time and accuracy score they expect to achieve. Tester - assemble Mr. Potato Head to look like the picture as fast and accurate as possible Documenter - capture observations in the Do section of the PDSA tracker form. Time Tracker – time the assembly and document the time score on the run charts Accuracy Score Inspector – review the assembled product and document the accuracy score on the run chart STOP – Put down Mr. Potato Head. Study results by comparing actual time and accuracy score with their predictions. Additionally, discuss any observations.

Testing cycles 2, 3, 4… Identify one theory for rapid and accurate assembly to test. Write change idea and questions in Plan section of tracker Predict of the time and accuracy score they expect to achieve. Conduct their test. Capture observations in the Do section of the PDSA tracker form. Document the time and accuracy score on the run charts. STOP Do not do any more tests. Study results by comparing actual time and accuracy score with their predictions. Additionally, discuss any observations. Decide to adapt the change idea for another test, adopt it, or abandon it.

Discussion

Questions

Six Sources of Influence MOTIVATION ABILITY PERSONAL 1. What might people find painful, frightening, boring, or uncomfortable about the vital behaviors? 2. What skill gaps get in the way of doing the vital behaviors? SOCIAL 3 & 4. What social influence challenges are you up against? How are vital behaviors discouraged? How are vital behaviors enabled. STRUCTURAL 5. Are there costs or penalties for doing the vital behaviors? Are there rewards for doing the wrong behavior? 6. What environmental factors could enable the wrong behaviors? Motivation = Is it worth it? Ability = Can I do it? Diagnose : Identify the barriers that are currently keeping from engaging in the vital behaviors. Identify Strategies to influence people to engage in the vital behavior for EACH strategy.

All Washed Up! What does it take to get people to change. https://www.youtube.com/watch?v=osUwukXSd0k&index=9&list=PLq6xHLjpckwe3xY4sNpJTEac8Pq_wrDR9