The Improvement Model and PDSAs

1. The Improvement Model and PDSAs

2. 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

3. 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

4. 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

5. Why change? Because: “If you always do what you have always done, you will always get what you have always got!” Don Berwick

6. 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”

7. 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…” “Trial and Learning” Approach

8. ‘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

9. 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 Waiting for line managers approval Not sharing workload Other deadlines

10. Change Methodology forImprovement

11. The Thinking PartThree fundamental questions for improvement( Nolan Questions )

12. 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?

13. The Doing Part of the Improvement Model PDSA

14. 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

15. 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

16. 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 ? Act Plan testing ideas before Implementing changes Study Do Langley et al 1996

17. 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

18. Plan, Do, Study, Act 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?

19. Objective (future tense) • Define the problem • What exactly are you trying to achieve • Refer to the Nolan questions (think)

20. Plan (future tense) • Who? • What? • Where? • When? • How? • What are you going to measure?

21. 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.

22. 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?

23. 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

24. 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

25. 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

26. 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

27. 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

28. Implementing new procedures & systems - sustaining change ACT ACT ACT ACT ACT ACT PLAN PLAN PLAN PLAN PLAN PLAN DO DO DO DO DO DO STUDY STUDY STUDY STUDY STUDY STUDY Testing and refining ideas Accumulating information, data and knowledge Bright idea! Repeated use of the PDSA cycle

29. 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 Nurses porters

30. Diabetes (blood pressure) Improvements with PDSAs PDSAs PDSAs PDSAs PDSAs to improve shared diabetes information with Secondary Care PDSAs to Validate Diabetes Register PDSAs to improve current patient recall system PDSA to contact all Patients who have not had a BP check in the last year

31. 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?

32. Measurement for Improvement

33. 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?

34. What is measurement for improvement?

35. 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.

36. 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

37. How will we know that change is an improvement? • Measuring processes and outcomes

38. 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

39. How do you present and share your data? • DefineImprovements in raw numbers and as % improvement. • Use newsletters, intranet, posters, patient and professional groups, journals etc.,

40. fundamental questions for improvement • results from using the PDSA cycle • effective use of data • testing changes Model for Improvement Source: D. Berwick

41. The elevator to success is out of order. You’ll have to use the stairs …… One step at a time

42. 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