Quality Improvement Methods
a. Definition: In order to assure a successful change, an organized and reliable implementation approach must be used. Quality improvement changes, such as those that result from research findings, seem to succeed best when repeated small incremental steps are used. PDSA cycles consist of planning the change (Plan), carrying out the change (Do), observing and analyzing the results of the change (Study) and then deciding what additional changes should be made (Act). This is a cycle, done repeatedly until the results meet the objectives. It is best to start out with a small change or test and to learn from that before full implementation where problems might occur on a larger scale.
b. Literature: Lean method literature provides descriptions and how to implement PDSA. Various publications and organizations provide guidelines, templates and examples. There is literature on examples of PDSA use, such as:
- Van Tiel, F. H., et al. "Plan-do-study-act cycles as an instrument for improvement of compliance with infection control measures in care of patients after cardiothoracic surgery." The Journal of Hospital Infection 62.1 (2006): 64-70.
- Guinane, C. S., J. I. Sikes, and R. K. Wilson. "Using the PDSA cycle to standardize a quality assurance program in a quality improvement-driven environment." The Joint Commission journal on Quality Improvement 20.12 (1994): 696.
- Walley, Paul, and Ben Gowland. "Completing the circle: from PD to PDSA." International Journal of Health Care Quality Assurance 17.6 (2004): 349-358.
The PDSA approach is generally credited Dr W. Edwards Deming to See: Deming, W. Edwards (1986). Out of the Crisis. MIT Center for Advanced Engineering Study.
c. Example: A healthcare system decided to change its outpatient screening process based on results from a recent research project that determined some screening steps were unnecessary and should be dropped. The healthcare system decided on a PDSA approach. The steps followed were:
- Plan: The object was defined explicitly: to reduce the total time for patient screening by 20% by dropping certain questions. As a temporary test, they planned to change screening at one of their clinics as of a certain date, to follow up with the clinic after a month to determine the impact on the process and to track patient outcomes to see if the change had any adverse effects.
- Do: The change test was carried out in one clinic and related data was gathered on an ongoing basis to understand the results of the change.
- Study: Results from the test clinic were compared to performance objectives, and conclusions were reached.
- Act: This step consisted of determining if any further changes were needed to the new process based on the results from the clinic. This may involve further or expanded tests or deciding whether the change should become permanent. The lessons from the each PDSA cycle were used to expand the change to more of the clinics in the system.
PDSA is a cycle and often shown as a graphic such as:
d. Steps: The idea of PDSA is a cycle of steps, generally implementing a small change, learning from the results and repeating the cycle until the desired change is fully complete and sustaining. A PDSA worksheet is available from a number of sources and some healthcare organizations have developed their own PDSA worksheet. These record for each step:
- Plan - Describe the problem, the objective of the test and a description of who, what, when and where changes are involved. Define the baseline or initial descriptive data to determine if the change is as intended.
- Do - Carry out the test, document results and any problems.
- Study - Analyze the results, compare them to the objectives and decide on next steps or if the planned changes should be revised or, if necessary, abandoned.
- Act - Modify or refine the change and plan for the next cycle.
Repeat this cycle as necessary.