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 This will all be covered in more detail later in the presentation

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 Explain that the learning loop game will introduce them to some ideas about change and improvement processes. It is a team working exercise where everyone should participate, there are no right or wrong answers, it is the process that matters, the meaning will be about change and improvement, learning and measurement and not the specifics of how the game is run. Using PDSA and the improvement model as a means of implementing improvement is an experimental method of learning. The best way to learn about the process is to experience it. The learning loop enables you groups to set off on a learning process where they discover the PDSA model The Learning loop – 25mins to do 5 tests, 5 mins to do final Debrief – be positive and praise the group on their efforts. Ask the questions in the manual? PDSA cycles to achieve their goals. Lower scores at start leading to higher scores the more cycles. Time – carrying out tests of change don’t require large samples. E.g. if team spent 45mins debating whether to implement one way to get beads on amt and scored only 280 – chance used. But this is so often what happens in regular change projects – too much time spent on trying to develop single solution that testing small ones, alternatives doesn’t happen. Change is a challenge for many project teams – particularly engaging in the process to keep them and others motivated and demonstrates improvement in a measurable way. PDS process enables this.

We all work with and within systems 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 In every workplace setting, there are systems. There are appointment systems, systems for issuing prescriptions or medication, systems for ordering stock, to name but a few. By analysing systems and using the Model for Improvement, small changes can be made that do not upset the whole system. Any changes made are tested and evaluated to help reduce the fear and anxiety to making change happen.

Why change? Because: “If you always do what you have always done, you will always get what you have always got!” Don Berwick Systems are designed for a purpose and that is what they will deliver. In order to get different results, we must make changes.

Changing Systems/Changing people Change is threatening “Its always been done this way” Change is time-consuming “what’s 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 what’s the point” The importance of understanding systems, their influence on our daily lives and how difficult and frightening it is to start making changes is the subject of the first part of this presentation. Understanding your systems is the first step on that journey.

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, not enough thinking Too much thinking, not enough action “Something must be done, this is something, therefore we must do it…” “We can’t do anything until we know exactly what to do…” Organisational change usually follows one of two routes, we either have wholesale change – the current system ceases and a new system put in place without first being tested, or there is a huge information gathering exercise and endless research with no change actually taking place. The Model for Improvement advocates and is ideal for the Trial and Learning approach to change “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 what’s happening Testing changes - starting small; reducing risk Implementing and sustaining change - change in systems and routines; developing skills and abilities These are the principles behind a trial and learning approach

Didn’t check often enough Defining the Problem Always speak to someone different Didn’t specify what I wanted properly Getting Information Set impossible timescales Didn’t check often enough Not got an accurate brief Didn’t give manager enough time Am I dealing with really urgent work? Haven’t planned time available well Trying to define a problem is difficult. Ask a manager, a clinician and a patient what the problem is and you will get three different answers to the same question - as the fish diagram shows. Before moving forward, it is essential to ensure that there is agreement from the main players as to what the problem is and that the aim of the exercise is clear to all. Waiting for line managers approval Not sharing workload Other deadlines

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 first part is the thinking part. As it says, it makes us think about what we want to do. Is there a need to change? The three fundamental questions for improvement (Nolan et al) make up this part of the methodology. Question one asks the user to define clear aims and objectives that are crucial to successful change. If you don’t know what you want to achieve, how can you make the appropriate changes? The second Nolan question “How will we know that change is an improvement?” focuses on the importance of measurement. If there is no clear baseline of how things are before the change has been made, how is it possible to identify whether the changes has made things better or worse? “If you can’t measure it, you can’t improve it” – Don Berwick The third question may require a little research into what others have done. What is the point of reinventing the wheel? If changes have been made to similar systems, these ideas can be adapted and tested in your own area. What do you think might work? What changes do the team think may be effective? Gathering and recording the above information takes the user onto the doing part of the methodology, the PDSA cycle.

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 PDSAs (Plan Do Study Act) are small, rapid change cycles which help you break down large pieces of work into small, manageable chunks. The PDSA methodology offers the user the opportunity to test changes safely in their own environment. The most challenging aspect of learning this methodology is its simplicity. Audit has been part of the Health Service for many years and this involves looking at a whole picture at once over a long period of time. When using PDSAs, it is necessary to break the big picture down into small pieces and look at each one individually. Fear that the improvements will take a great deal of time is the initial reaction to this statement but, a PDSA should take no longer than one week to complete, thus looking at the small parts and completing the picture over a short period of time.

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 The reasons for using the PDSAs

Act Plan Study Do Model for improvement aims measurements change ideas What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in the improvements that we seek ? Model for improvement Act Plan Study Do aims measurements change ideas testing ideas before Implementing changes MFI is one of the tools under the broad banner of Lean Principles. These are principles which originate in manufacturing – Toyota Production System – Principles were adapted and applied to healthcare more than 10 years ago – widely used Making changes to the things we do can be time consuming and can sometimes feel risky. The Model for Improvement is a tried and tested approach to achieving successful change. Benefits Simple approach that anyone can apply Reduces risk by starting small Used to help plan, develop and implement change Highly effective The model consists of two parts of equal importance Thinking part consists of the 3 fundamental questions that are essential for guiding improvement work and Doing part which is made up of Plan Do Study Act cycles that will help you make rapid change 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. The example I have just given you was only small scale and this is the approach to testing that we used as part of the project and have done in a number of improvement projects locally. It is often difficult for health professionals to get away from a research approach to improvement i.e.. having perfect samples which reflect the community in which you are working. But life is not like that and we need useful data to inform the improvement so small samples are ok - I found this out myself when conducting interviews with carers. I asked Sara to find me a number of carers who had been recently bereaved - she found me 3! Even for a small sample to find useful data I thought this was a little small - however I was mistaken and learnt a big lesson - all three interviewees were saying exactly the same things about the medication experiences and difficulties with eating and swallowing - it was sufficient data for us to move on. Source: D. Berwick

Plan, Do, Study, Act Act Plan Study Do What changes are we going to make based on our findings What exactly are we going to do? Act Plan Study Do When and how did we do it? What were the results? This slide demonstrates the repeated use of the PDSA cycle, in that you continue from the Act in one cycle to the Plan of the next. When embarking on PDSAs, a succinct plan should be written (remember the fundamental improvement questions and use PDSA templates), this includes the who, how, why, when and where it is going to happen, followed by when and how it happened (Do), what the results were (Study) and what changes are going to be made based on the results (Act). This will provide you with the Plan/s for the next cycle/s in the change process Remember that this is a snapshot in time. If you save only one appointment in a session, remember that this equates to two appointments per day, ten per week, 40 per month and 400 in a year – for one clinician!

Objective (future tense) Define the problem What exactly are you trying to achieve Refer to the Nolan questions (think) When writing up a PDSA it is often easier to set each section in the appropriate context. The Overall Objective will be in future tense as you will have identified where you are now, where you want to be and the overall objective will state what you want to achieve in the longer term. The specific objective for the cycle will set out the smaller, more manageable part that you will detail in your plan.

Plan (future tense) Who? What? Where? When? How? What are you going to measure? When the plan is written, this will be in future tense as the user is noting what exactly will be done.

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. The Do part of the PDSA will be written in past tense as the plan will have been carried out.

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 didn’t work and why? Do you need to change the plan? Do you need to tweak the original pdsa? The Study section will also be past tense as the results of the measures will have been collated and analysed. The importance of measurement should be emphasised here, as it is absolutely essential to be able to evidence the need to make a change that will result in an improvement.

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 The Act, however, can be present or future tense as it indicates an action. The action can simply be that the results have shown that the change is working as expected, therefore the new system will continue, such as an evaluation of telephone consultations showing that the service has evaluated favourably. The Act could, on the other hand, be the next steps and lead on to a new PDSA cycle, therefore describing something that will be done in the near future.

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 Because the changes are small and not a change to the whole system at one time, there is less fear and, should the change not produce the desired outcome, a lesson has been learned and amendments can be made based on this learning.

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 doesn’t work, try something different based on your learning Document what did/didn’t work It is important to emphasise that PDSAs cannot be too small but that they can be too large. If looking at a number of records, ensure that this is a manageable amount and that the entire cycle, including the study and the act can be completed over a short period, no longer than a week. A PDSA can be done in a few hours.

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 This slide summarises our approach to testing and I’ve given you a few examples I cant emphasise how important it is to think a few tests ahead and really scaling down the size of those tests - we are still learning and refining the process and could probably have taken even smaller tests that’s the process bit complete I will now hand you over to Sara who is going to tell us about the the outcomes and how progress is continuing - Sara Source: Berwick

Repeated use of the PDSA cycle Implementing new procedures & systems - sustaining change PLAN DO STUDY ACT PLAN DO STUDY ACT Accumulating information, data and knowledge Testing and refining ideas PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT PLAN DO STUDY ACT As the PDSA cycle is worked through, the first few cycles are concerned with testing new ideas, amending them if necessary, further testing leading to further cycles implementing the changes and ensuring their sustainability. It is imperative to involve all the relevant stakeholders in planning and implementing change as this ensures the appropriate sign up and ensures that the new system is sustainable. Bright idea!

Create Multiple PDSA Ramps receptionist porters Nurses

Diabetes (blood pressure) Improvements with PDSAs PDSAs to improve shared diabetes information with Secondary Care PDSAs to Validate Diabetes Register PDSAs to improve current patient recall system This slide shows how the use of PDSAs directly correlates with improvements in the system. This graph represents the improvements made in the number of people with diabetes having a blood pressure of less than 140/80 as measured monthly by a practice taking part in the Scottish Primary Care Collaborative improvement programme. PDSA to contact all Patients who have not had a BP check in the last year

What are we trying to achieve? 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? ACCOUNTABILITY RESEARCH Purpose Understanding of Process Evaluation of change To discover new knowledge Comparison Reassurance To bring new knowledge into daily practice Data Gather just enough data to learn and complete another cycle Large amounts of data Gather as much data as possible ‘just in case’ Duration ‘Small tests of significant change’ accelerates the rate of improvement Short & current Long periods of time Long & past Can take long periods of time to obtain results

Critical part of testing and implementing change. 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. Main aims of the session. This will all be covered in more detail later in the presentation 35

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 Model for Improvement Source: D. Berwick

The elevator to success is out of order. You’ll 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/ContinuousImprovementToolkit/Welcome.gp Improvement Leaders Guides www.modern.nhs.uk/improvementguides