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
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
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
Why change?
Because:
“If you always do what you have always done, you will always get what you have always got!”
Don Berwick
• 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”
Changing Systems/Changing people
What is the best way to approach change that results in improvement?What is the best way to approach change that results in improvement?
Trial & Error?Trial & Error?
ChaosChaos
Too much action,Too much action,not enough thinkingnot enough thinking
““Something must be done,Something must be done,this is something,this is something,
therefore we must do it…”therefore we must do it…”
Detailed prior study?Detailed prior study?
ParalysisParalysis
Too much thinking,Too much thinking,not enough actionnot enough action
““We can’t do anythingWe can’t do anythinguntil we know until we know exactlyexactly
what to do…”what to do…”
““Trial and Learning” ApproachTrial and Learning” Approach
How it has been done so far…
• 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
‘Trial and Learning’ Component Parts
Always speak tosomeone different
Didn’t specify what
I wanted properly
Getting Getting InformationInformation
Set impossibletimescales
Am I dealing withreally urgent
work?
Other deadlinesOther deadlines
Haven’t plannedtime available well
Not sharing workload
Didn’t check often
enough
Waiting for lineWaiting for linemanagers approvalmanagers approval
Not got an accurate
brief
Didn’t give manager
enough time
Defining the Problem
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?
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
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
What are we trying toaccomplish?
How will we know that achange 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
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.
Source: D. Berwick
Plan, Do, Study, Act
Act Plan
Study Do
What changes are we going to make based on our findings
When and how did we do it?
What exactly are we going to do?
What were the results?
Objective (future tense)
• Define the problem
• What exactly are you trying to achieve
• Refer to the Nolan questions (think)
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.
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?
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
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
The principles of PDSAs• Breaks down change into manageable,
bite-sized time-limited chunksNot 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 systemTell others what you are doing
• If it doesn’t work, try something different based on your learningDocument what did/didn’t work
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
Source: Berwick
Repeated use of the PDSA cycle
PLANPLAN
DODO
STUDY
STUDY
ACTACT
PLANPLAN
DODO
STUDY
STUDY
ACTACT
Accumulating in
formatio
n, data and knowledge
Testing andrefining ideas
Implementing newprocedures & systems- sustaining change
Brightidea!
PLANPLAN
DODO
STUDY
STUDY
ACTACT
PLANPLAN
DODO
STUDY
STUDY
ACTACT
PLANPLAN
DODO
STUDY
STUDY
ACTACT
PLANPLAN
DODO
STUDY
STUDY
ACTACT
Create Multiple PDSA Ramps
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receptionist porters Nurses
Scottish Primary Care CollaborativeBorders GP Practice
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% of Diabetes Patients with a BP<140/80
Diabetes (blood pressure) Improvements with PDSAs
PDSAs to improve shared diabetes information with Secondary Care
PDSA to contact all Patients who have not had a BP check in the
last year
PDSAsPDSAs PDSAs
PDSAs to improve current patient recall system
PDSAs to Validate Diabetes Register
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
• 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?
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
Long & past
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.
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 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
Source: D. Berwick
Useful links
• Institute of Healthcare Improvementwww.ihi.orgA Guide to Service Improvementwww.scotland.gov.uk
• Improvement & Support Team Toolkit
http://member.goodpractice.net/ContinuousImprovementToolkit/Welcome.gp
• Improvement Leaders Guideswww.modern.nhs.uk/improvementguides
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