welcome to the quality improvement basics course the model for improvement and plan do study act PDS a tool module our topics in this module will be to learn about the broader set of quality improvement models and methodologies and then to focus in on the model for improvement and how the plan do study Act tool can be used to help your quality improvement team focus on specific processes set a goal and conduct multiple rapid cycle tests to achieve the intended goal also before we start please open the related documents for this module tools templates and any samples which are available on the webpage where you found this module link it will help you to have those ready for quick reference as screenshots of the documents may not be legible on your screen quality improvement methodologies there are a variety of quality improvement methodologies currently in use five are highlighted here as you'll learn here the model for improvement is accompanied in the world of quality improvement by many options and you may want to branch out and explore other models and methodologies once you get some expertise using the model for improvement fade there are four broad steps to the fade quality improvement model the letters of the fade acronym stand for focus defined the process to be improved analyze collect and analyze data develop create action plans for improvement execute implement the action plans and evaluate measures and monitor the system to ensure success Six Sigma Six Sigma is a measurement based strategy for process improvement and problem reduction it is completed through the application of the quality improvement project and accomplished with the use of two Six Sigma models the first being DMAIC define measure analyze improve and control which is designed to examine existing processes and the second is diem a DV define measure analyze design and verify which is used to develop new processes lean model this model defines value by what a customer a patient wants and seeks to eliminate waste and processes that are intended to deliver value to customers or patients it maps out how value flows to the patient the healthcare consumer and ensures that processes deliver care in a manner that is cost effective and time efficient the model originated in the manufacturing field and has been adapted to other industries including healthcare root-cause analysis is an approach or methodology which is used to determine why an unexpected or unintended outcome or event occurred and what can be done to prevent it from happening again that is the goal of root cause analysis the root cause analysis methodology bares many resemblances to the model for improvement approach and there are some tools from the methodology such as the five wise and fishbone diagrams which help to get at the underlying reasons a negative event or a near-miss occurred will touch on this methodology briefly before diving into the model for improvement while we will focus on and learn about the model for improvement these methodologies need to stand alone or be siloed if you have had previous training use or exposure to another methodology or see unique applications by combining the best practices or tools between two or more methodologies for your organization there are certainly no reasons not to do so for example as you learned the model for improvement you could expand the process mapping component of your work which we'll cover in another module to take that same process and look at it from a value perspective and do value mapping which is part of the lean model you might achieve the desired improvements with the model for improvement but need or would like to achieve cost reductions and increase value for example for your patients by applying the value mapping approach as well the prior slide outlines some of the most popular methodologies that are used in quality improvement work and they contains some common themes leadership probably the most important factor in successful implementation and is highlighted in all methodologies based on the scope and focus of your work leadership may denote the formal leadership roles of CEO CEO or perhaps a less formal role or subject matter experts or professional credentials such as an experienced RN may feel leadership positions in your organization measurement is included as a basis in each of the methodologies reviewed you can't improve what you can't measure this may be one of the more difficult aspects of the methodologies to implement depending on your organization staffing and expertise with the topic to quote null indicates who oversees the Bill and Melinda Gates Foundation where their husband quote data leads to better decisions and better policies it helps us create goals and measure progress it enables advocacy and accountability unquote staff involvement and team approach quality improvement cannot really be done well without involving staff ideally improvement work includes the active involvement from individuals closest to the work involvement setting aims and measures in understanding current processes and in identifying and testing changes to improve the process lastly focusing on the customer patient is embedded in each of the methodologies focusing on what is best for the customer the patient in healthcare incorporates patient centric objectives of safe effective efficient patient-centered timely and equitable CAIR root cause analysis root-cause analysis also called RCA is an approach or methodology which is used to determine wine unexpected or unintended outcome an event occurred and what can be done to prevent it from happening again the root cause analysis method can be used as a stand-alone approach but will take some pieces from the methodology that can be used in general quality improvement work such as the five why's technique to drill down beyond the initial suspected cause that may not be the true core of the problem some situations can be managed and resolved quickly they are unlikely to recur based on unique circumstances and negative consequences may be minor or non-existent or there is no pattern of previous similar events or trends root cause analysis takes time and requires resources to be done well events that are chronic recurring involving communication breakdown and are systemic in nature are best for this type of in-depth problem-solving brew cause analysis is a different process than manage an incident and implementing immediate action to correct the situation root cause analysis occurs after the immediate situation is resolved involved individuals and staff are safe immediate communication to individuals families and staff is concluded and any external and internal reporting requirements are completed the root cause analysis process is then performed by a team to identify breakdowns and process and systems that contributed to the event and creates solutions to prevent them from recurring root cause analysis is not intended to find who is at fault rather it is focused on these systems at play and how they may have led individuals to make the choices they did the improvement process resulting from an RCA focuses on changing systems in order to change behavior the value of undertaking a root cause analysis investigation are very similar to those used in the model for improvement the RCA methodology avoids choosing a quick fix engages staff and analyzing why events occur promotes changing culture through encouraging a non-punitive approach guides teams to measure the impact of changes made as a result of the root cause analysis and improves safety additionally root cause analysis is most frequently used when unexpected events with serious outcomes occur repeating incidents are observed or detected in our systems in process near-misses happen and an incident is avoided root cause analysis helps to drill down and avoid these near misses in the future along with correcting processes where failure may have happened but a good catch avoided an incident we can't and shouldn't rely on good catches rather we need to correct the underlying issues that led to them the root cause analysis process uses a similar approach and relies on some of the same tools as you've been learning about miss qi basics course the seven steps of the RC a process are one identify the event to form a team three describe the event where did breakdowns occur four identify all factors five identify root causes and contributing factors six create change by designing and implementing process and system changes seven measure to determine results as you learned in the Qi basics module the elements of systems and process thinking are embedded in quality improvement and that is no different for root cause analysis a process provides certain steps to follow and those steps are either designed or highly influenced by the policies and procedures in place when we use root cause analysis to get at the core of the issue we can make changes to the process by properly modifying the policies and procedures to create more reliable safer more predictable process outcomes or results the result of improved processes has the effect of creating improved systems which produce the intended results or outcomes our systems are made up of processes people environmental factors equipment and technology and influenced by our organizational culture root cause analysis helps us to determine which of these factors led to an event or undesired outcome the five why's root cause tool starts with a problem statement and ask the question why in repeated succession to identify the root cause include team members with direct knowledge of the processes and systems involved in the problem being discussed this technique works well if the problem is not overly complex if after asking why several times and the answer does not seem clearer correct further analysis may be needed the more complex the problem the more likely it will take further analysis to reach the root cause let's step through the five why's process number one develop a clear and specific problem statement to the team facilitator asks why the problem happened and records the team response ask the team to consider if the most recent team answered to the question why or corrected is that likely the problem would recur if the answer is yes this is a contributing factor not a root cause three if the answer provided is a contributing factor to the problem the team keeps asking why until there is agreement from the team that the root cause has been identified and if corrected the problem would not recur for it often takes three to five times of asking why but it can take more than five keep going until the team agrees the root cause has been identified here's a screenshot of the five wise tool which is available on the webpage where you launch this module like the other tools available as part of this course their instructions on how to use it similar to those we just step through on the prior slide the model for improvement step by step the model for improvement draws its success from the application of the following concepts it encourages learning by testing and change on a small scale for example you use the model and tools to pilot the change in one department with one nurse one shift etc testing on a small scale is then scaled up through expanded application and further testing of the changes you are making it eliminates studying the problem to death and moves the team from contemplation to action and it's easier to do this based on a small scale initial focus it also minimizes data collection and/or data overload you'll learn in the using data module that it's best to collect just enough data to avoid suffering from analysis paralysis the model for improvement is elegant in its simplicity by asking three questions to drive three key steps number one what are we trying to accomplish this sets the aim or goal along with the focus or scope of our work - how will we know that change is an improvement this demands we employ measures to quantify progress in success you can't improve what you can't measure 3 what change can we make that will result in an improvement we need to create a hypothesis and test it out once we have asked the three questions and provided answers the plan do study act PDS a rapid cycle testing tool translates our answer to the third question into action steps to test out our proposed changes as you conduct each cycle or test using your PDS a tool the answers to questions 1 & 2 will remain the same however you may discover that a different change or approach is needed so your answer to Question 3 would require running a new PDS a test cycle question 1 is to ask what the team is trying to accomplish improvement begins with setting aims stay fit and clearly and gain agreement from the team make the a measurable use a percentage goal the next will define how to set a SMART goal make your aim achievable your aim should be realistic and it can be expanded through subsequent PDSA cycles as you scale up the change when your team is setting a goal or aim for your PDSA cycle you want to make sure that your goals are smart ones SMA RT the goals that you set in your quality work should meet the test of the smart acronym each aspect of your goal should meet this set of criteria is your goal specific measurable achievable relevant and time-based specific what are we trying to accomplish near the description of your work to focus on the specifics measurable as quality improvement is a data-driven undertaking how can you quantify and measure this goal and the change you are seeking achievable can we envision ourselves actually accomplishing the goal is the goal within our means within the given time frame resources and budget a hand relevant achievement of the goal should fit into your organization's mission and strategy time based you want to put a date on the calendar and set a deadline for achieving the goals you can also set major milestones as part of your goal rather than a single end date an example of answering the first question what are we trying to accomplish is done by setting a SMART goal we will reduce the occurrence of facility acquired MRSA infections by 25% within six months of implementing our proposed changes this goal statement meets the smart criteria think through each one is it specific measurable achievable relevant and time-based here are a few more examples increase the number of our long term nursing home residents with a vaccination against both influenza and pneumococcal disease documented in their medical record from 61 percent to 90 percent by December 31st 2019 another might be by December 31st 2020 the average time a patient will spend at our clinic will be reduced by 10 percent from sixty five to fifty eight point five minutes question two asks how will we know that change is an improvement this question underscores the measurable portion of the SMART goal criteria we need to determine a measure and set a goal that we expect to achieve by the change we are implementing your team will need to ensure that data exists or that you have some ability to collect data which will provide measurement of your proposed change as you determine what your measure will be also think about whether you are measuring the process itself or a specific outcome what is the change in health for the group of patients you are measuring we will cover the difference between process and outcome measures in the using data module an example of a process measure using our mersa infection example from the prior slide might be measuring average additional amount of time spent in the hospital for patients that acquire a MRSA infection this would measure the average time needed to address the Mersenne infection compared to patients with similar treatments or procedures without that complication an outcome measure would be focused for example on the percent of patients that are readmitted to a hospital within 30 days after discharge this tells us something about quality of care provided to patients for a particular facility another example would be to count the number of mersa infections over a given time period is this documented in your EHR can you get at the data with the reporting tools or applications you have to someone on your team know how to do that what other data might you collect or already have documented on this by units for patient demographics types of treatments or procedures performed where the patient subsequently contracted MRSA etc by collecting this type of data and slicing and dicing it we can determine if the steps we will take to reduce the Mercer rate will be an improvement as we can indeed set a baseline and measure what the current infection rate is and then compare it to the new set of data we'll collect after our proposed improvements are implemented question three what changes can we make that will result in an improvement this prompts us to formulate a plan to implement and test the change that we hypothesize will achieve our goal to do this we need to clarify with the actual current process the series of tasks to carry out the work looks like in the process mapping module in this course we'll learn the basics of doing just that it's helpful to draw a simple diagram of the process that the team agrees accurately represents how the work is carried out as you diagram what is currently happening in your process keep an eye out for this checklist of typical process issues redundant or duplicate tasks forgotten tasks unnecessary steps that do not add value delays inconsistency with standards and lack of continuity of care across units or between clinicians as you start to dissect your process this will generate conversations about what the root cause of the issues are that may be at the basis of poor performance for your chosen measure or spark ideas about forming even better if you're doing just average or below an optimal level an additional technique was introduced in the prior section on root cause analysis the five why's by continually asking the why question and stepping down into more detail you'll unearth more information about the process and what might be at the core of the issues you're addressing and needing to change lastly you should consider reviewing literature studies and guidelines that provide best practice recommendations in our example with Merce infections the Qi team has decided to ask questions about the process to better understand what's happening why are we seeing the MRSA infection rate going up is there a pattern of infections that may be linked with a time of day certain environmental triggers or perhaps some sort of correlation with staffing patterns at the root cause of the issue these hypotheses can be discussed by the Qi team and staff that carries out the process you are analyzing ultimately the goal is to arrive at a proposed set of changes or a single change that you believe will result in the desired improvement answering the third question in the model for improvement moves your Qi team into the next step using your PDS a tool as you construct your plan do study act tests for improvement consider the tips to help confirm your proposed changes be clear about the problem you're trying to solve if you start to make changes without being clear about the problem you tend to implement changes that don't really fix the problem or get to the core of the issue if your process is overly complex think about ways to limit the variation and simplify the process look outside of your organization and learn what works at comparable facilities copy copy copy but be sure to give credit as the saying goes imitation is the sincerest form of flattery and why try and reinvent the wheel there are very likely other organizations that have run into similar challenges and have implemented solutions that you can adapt to your facility use your network of professional relationships as well as researching using the internet to seek out what solutions may already exist and are proven and effective and lastly don't let perfect get in the way of good the PDSA tool will help your Qi team achieve success as it is designed for repeated cycles of small-scale change to determine what change works best don't expect perfection on first attempt reven after a few repeated attempts to improve your process rather the PDSA tool is meant to help implement and test incremental change toward your stated goal during the planned stage first refer back to how you answer the three key questions what are we trying to accomplish how will we know that change is an improvement what change can we make that will result in an improvement you can then start asking some additional nuanced questions that will lead you to define the details of your planning step what change are you testing with each PDSA cycle what do you predict will happen and why predictions are important because you are really testing a hypothesis with each PDS a test cycle if we do X we expect that it will result in y teams will also address who will be involved in this PDSA for example one staff member or customer or patient one time or for one shift or one day the key is to start with small tests you'll also want to determine when and where will the change be tested how long will the change take to implement what resources will be needed and what data will need to be collected do you have an existing baseline set of data for your measure are you measuring a process or an outcome during your planning portion of the PDSA you are answering what when who why where and how long types of questions to formulate your plan the next step is do carrying out your tests as you defined in your plan you'll collect data to set your baseline as well as to determine the impact of changes to your process having the two sets enables the comparison you'll make to evaluate if the changes resulted in the expected improvements document observations including any problems and unexpected findings it's important to collect both quantitative and qualitative data staff feedback about feasibility of workflow is essential to take into account when considering scaling improvements the qualitative feedback is also important when considering culture change and how your organization is adapting to the change study is the evaluation step of the PDSA test cycle you'll analyze the data you have collected compare data to your benchmarks and the expected or predicted outcome or goal what did you learn by analyzing the quantity data and combining that with qualitative observations or notes gathered during your test period did you encounter problems what success stories did you have to report did any surprises occur and are you satisfied with the results in the study step you are assimilating analyzing and making sense of the test you just conducted in preparation for the next step act the last step in the PDSA rapid improvement cycle is act based on what was learned from the test what changes should be made before the next cycle what will the next test be will you implement or change your approach are you ready to implement more broadly especially if you had notable success and don't see a need for additional testing cycles how will you maintain gains if you did indeed achieve your goals this is one of the area's you want to confirm and be certain of one of the challenges in quality improvement is that once the focus is taken off a process or some change that you implemented it is easy and indeed normal to fall back into the previous way we worked consider how you will continue to monitor and hold those gains over time lastly if you didn't achieve your goal in the first cycle it's time to establish a new plan and repeat the PDSA cycle this doesn't necessarily mean establishing an entirely new plan just identify how you could have done better and what needs to be improved for the second cycle or third or subsequent cycle of your PDS a testing as you work your way through these considerations and determine what the next action steps will be once again review your responses to the three key questions what are we trying to accomplish how will we know that change is an improvement and what change can we make that will result in an improvement based on what you learn from your PDS a test you'll categorize your actions as adapt adopt or abandon with regard to the changes improvements you tested adapt modify the changes and repeat the PDSA cycle adopt consider expanding the changes to additional staff patients departments or units abandon change your approach entirely and repeat the PDSA cycle in a different manner a brief note on one of your options for the act step if you and your team are ready to adopt the changes as you have experienced success try using the rule of five to further spread the successful changes for example if you change the process in one department or unit try spreading it to five other departments or units this allows for further testing and confirmation without going too broad immediately if those additional five units are successful then repeat the process if you started with one person or role then increased that to five and so on five doesn't have to be the absolute number four or six could work as well but pick a number that makes sense and attempt an incremental spread of your success the rule of five helps restrain spread that may be too quick and too broad for the organization to adjust to and also allows for more gradual confirmation before we truly scale up and spread change once you've filled out your PDSA form and completed all four steps one complete test cycle you can check your work by asking the four questions here that will confirm if you are actually using the tool as intended the test or observation was planned including a plan for collecting data and a prediction about results the plan was attempted did you carry out your test and collect your data time was set aside to analyze the data and study the results action was rationally based on what was learned what are you going to do next based on the results keep in mind that using the PDSA rapid cycle small-scale testing method is an iterative process meaning the process of implementing PDSA requires multiple cycles of testing and implementation and learning from each test cycle to inform the next one it's very normal and expected that you don't get it right on the first or even second cycle as you repeat each cycle you are modifying your answer to the third question of the model for improvement the answers to the first and second don't change as you attempt different changes for improvement number one what are we trying to accomplish the answer remains the same number two how will we know that change is an improvement this answer also remains the same what change can we make that will result in an improvement the answer varies with each cycle as you test out different answers to this question by repeating the PDSA cycle your interventions become more refined and your data learning modifications and new approaches will be integrated with each subsequent cycle this way you will increase your knowledge about the process with each cycle and are able to make the needed refinements through observations study and data collection to meet or exceed your defined goals additionally if there are any initial missteps those can be corrected on a small scale where the impact is minimal before spreading the change more broadly you can learn how to adapt the change to conditions in the local environment during your initial PDSA attempts you can evaluate costs and side-effects or unintended consequences and you can start to build buy-in with small-scale success and minimize resistance when you are ready to scale and spread the successful changes to keep your quality improvement efforts organized be sure to document your PD sa test cycles as you progress through each step here's a screenshot of the PDSA form available to you on the same webpage where you found the link for this module as you implement the model for improvement and use the PD sa tool keep in mind these tips when testing changes test the changes you are making on a small scale until you are confident and ready to scale them up and spread them beyond your initial test unit Department facility etc involve care teams that have a strong interest in improving care take advantage of your champions and advocates study the results after each change all changes are not improvements so discontinue testing of anything that doesn't work if help is needed involve others who do the work even if they're not on the improvement team some additional input and often a fresh perspective from outside your Qi team can be very useful ensure overall performance is improving changes in one part of a complex system may adversely affect another let's go over a few ideas of how you can best utilize the PDSA tool within your quality improvement team if you have any team members that aren't familiar with the PDSA tool be sure to teach it to them as you've learned here it's not complex and that is one of the significant strengths of the tool the three questions should be discussed and answered as a group what are we trying to accomplish how will we know that change is an improvement and what change can we make that will result in an improvement by having a group conversation you gain buy-in trigger some brainstorming and new idea for process improvement and concurrently keep your team on the same page another benefit of this approach is creating a shared mental model among your team members a concept covered in the teams and facilitation module when it comes to the plan do study act steps you'll continue the planning portion as a team but you may need to break out into some sidebar or subgroup conversations to go over particulars when you proceed to the do step implementing the changes it is the people who carry out the work that will need to be engaged along with anyone that is responsible for data collection as part of that step the study step may start with your data analytics expert or someone well-versed in data collection and analysis once you're convinced that your Qi team has study the results of your do step you are now ready to proceed to the next step you'll need to decide whether to adapt adopt or abandoned the changes you tested will you attempt a second cycle or proceed to solidify your gains and spread or scale the successes to other units force or departments thank you for taking time to learn about the model for improvement and the plan do study act tool as part of the quality improvement basics course please join me in the next module of the course process mapping