Implementing Quality Improvement Introduction to PDSA cycles
Implementing Quality Improvement
Introduction to PDSA cycles
Objectives
After this session participants will:• Understand how to do a gap analysis• Understand the main steps in
implementing a change to improve quality
• Understand the concepts of PDSA
You’ve done the measurement.
What should you do with all that data?
Your data shows: Only 70% of eligible patients are routinely screened for TB.
How can you improve this?
How do we improve a problem?Some general principles
• Need to ensure there is an atmosphere of improvement
• The discussion is not accusatory or seeking to blame
• The problem is in the process not the individual– Clinic procedures, information, materials/supplies,
equipment
6
QI methods
• Many approaches, some overlaps, but all with the same goal: Improve a gap
• Some basic questions that the team must ask– Why does the gap exist?– How can we close the gap?– Did we succeed?
Introduction to PDSAA process that helps us to organize how we
will improve a gap
• Plan• Do• Study• Act
Remember the link between measurement and QI
Measure quality
Work to address the gap: QI
Identify a gap
Understand why gap exists
PDSA cycles focuses on the highlighted areas
Measure quality
Work to address the gap: QI
Identify a gap
Understand why gap exists
Adapted from JSI
PDSA cycles focuses on the highlighted areas
Measure quality
Work to address the gap: QI
Identify a gap
Understand why gap exists
Act Plan*
Study Do
Act
Does the intervention need to be modified?
ORIs the change ready to expand and integrate?
Plan*Understand why gap
existsMake a plan to fix the gapDecide how to implement
plan (who, what, where, when)
StudyDid the measurement
show the expected difference?
Were other changes seen?
Share with team
DoCarry out the plan on small scaleDocument problemsBegin analysis
The PDSA cycle
*Plan as response to identified gap
Adapted from IHI, HIVQUALJSI and others
Expand and integrateIdentify a gap
So how do you plan what your change (QI project) will be?
Step 1: Planning to improve a quality gap
1. Understand where in the system things are not working:1. Make a Flow chart2. Brainstorm - Where do we think problems are?3. Cause and Effect (Fishbone)
2. Develop the solution3. Make a plan to fix the gap4. Decide how the plan will be implemented
(discussed in next talk)
Make a flow chart• A map of what should happen• Work with the QI team and others as needed• Draw out each of the detailed steps required
to have the desired outcome– An eligible patient is started on ART
• Start with patient registering to clinic, end with patient started on ART.
– Patient receives Cotrimoxazole prophylaxis• Start with patient comes into clinic and end with
patient leaving clinic with CTX pills
Flow chart 1: TB screening , diagnosis and referral for treatment at the OPC
Patient
Document in the registration book & patients chart:- Check pt’s ID card- Stamp TB screening (if used)
- Physical examination- TB screening: check questions
Lab: smear or culture
Get result
Three sputum:- 1: on-site- 2: morning after- 3: on-site
BK positive
Giving to the registration nurse for documentation
Refer to TB unit for treatment
Any suspected symptom
2 days
1-5 days
Doctor
Registration nurse
Lab: taking specimens
Brainstorming• Refer to the flow chart as a guide• List all potential causes of the quality gap• Work as a team and continue until you have
exhausted all ideas• Categorize into potential groups
– Human resources– Patient factors– System/protocols– Guidelines– Infrastructure– Resources– Other factors
Flow chart 2: List all the possible gaps
Patient
Document in the registration book & patients chart:- Check pt’s ID card- Weight, temperature, BP- Stamp TB screening (if used)
- Physical examination- TB screening: check questions- Baseline tests: CBC, CD4, LFT, HBV, HCV, VDRL
Lab: smear or culture
Get result
Three sputum:- 1: on-site- 2: morning after- 3: on-site
BK positive
Giving to the registration nurse for documentation
Refer to TB unit for treatment
Any suspected symptom
2 days
1-5 days
1Stamp not available Forget to stamp chart
2Forget to ask about symptomsForget to document
Doctor
Registration nurse
Lab: taking specimens3
Do not take sputum
4 Lost or poor specimens
5 No resultResult not documented
Cause and effect/Fishbone
• Developed by Ishikawa• Helps to categorize the potential causes of the
gap – Ex. those developed by brainstorming
• Guides where you might try to improve
Systems and guidelines Resources
Other factors
Physical InfrastructureStaff
Gap
Patients
Guidelines and systemsScreening guidelines not clearCharts not well organized
ResourcesStamp lost Other factors
Physical Infrastructure: Inadequate space, Too crowded
StaffToo fewNot trainedMDs get called away
Patient not screened for TB
PatientsCome late to appointment
Step 1 Plan - Some tips• Work as a team. Every voice counts.• Start with a flow chart, then brainstorm
possible gaps in each step of the process.– The “change” or first QI project may be found
after this step.• Categorizing into systems will help to further
organize and guide where the change can be focused.
• Ask representative from leadership to join and develop the detailed plan
Step 1: Example of a plan to improve TB screening from 70% to 90% of patients
• After discussion of the possible causes, the clinic decides the biggest problem is that nurses and doctors forget to ask about symptoms and a reminder is needed.
• Solution: Place signs on the desk and use a stamp that had been provided, but not regularly used.
Step 2: Do
The PDSA Cycle
Do• Carry out the plan• Document
problems• Begin analysis
Do: Principles• Is there something easy that another clinic has
already done?• Start small and simple
– What can we change by next week?
• Test it out – don’t be afraid to just try something small to see if it works
• Document what happens, both good and bad.– Do a mini chart review– Note any affects on resources or other systems
The PDSA CycleRef. National Quality Center
Example simple solution
Step 3: Study
The PDSA Cycle
StudyDid the measurement
show the expected difference?
Were other changes seen?
Share with team
Did the stamp improve TB screening?
13% 70%
TB screening stamp with symptom put on doctor’s desk
• Quick review of 10 charts: 9 screened for TB• Minimal work for nurses
Step 3: Study
The PDSA Cycle
StudyDid the measurement
show the expected difference?
Were other changes seen?
Share with team
Yes! This plan worked
No effects on resources
Step 4: Act
The PDSA Cycle
ActDid the plan work?
Yes: How will you expand or sustain it?
No: What will you try next?
Act: What Will We Do (Based on What We Learned)?
In our example:1) we will continue to use the stamp2) make sure that it has a secure place to stay3) add signs to remind staff and patients about
TB screening4) continue to monitor.
The PDSA Cycle
Example: TB screening
13% 70% 90%
- Remind staff about TB screening in staff meeting- Make a paper reminder put on the desk in front of the doctor
TB screening stamp with symptom put on doctor’s desk
Goal: 90%
Another example
• Clinic ABC found that many patients were missing clinic visits.
• After writing out a flow chart and brainstorming potential causes they decided the core cause was many patients had barriers to keeping appointments
Plan: Tool to improve on time visits.
• Objective: screen HIV patients for issues that might affect their ability to come to clinic on time.
• Prediction: adding a screening tool will add time to the patient visit, but we can keep this to a minimum
• Steps: Nurse Thuy and Counselor Ngoc researched and identified possible tools that were reviewed by Ngoc and Dr. Phuong. They selected one tool for Dr. Phuong to use with at least three patients in the clinic on Thursday
• Necessary tasks: 1. Identify tool. 2. Copy tool and place in patients' charts. 3. Dr. Phuong reviews instructions for using tool. 4. Explain tool to patient. 5. Use tool
Adapted from the National Quality Center
Do: Implementing the adherence tool
• Dr. Phuong used the tool on one patient the next day
The PDSA Cycle
Study: What happened with the tool?
• The tool was 5 pages long• Added 35 minutes to the patient’s visit• The next patient waiting for the doctor was
late for work so had to leave his appointment
• We made things worse!
The PDSA Cycle
Act: What happened with the tool?
• The clinic team sat down again to come up with a new plan to screen patients for barriers.
Emphasis point
All improvements require change, however, all changes don’t lead to
improvement
Summary
• Goal of QI is to improve• Requires team approach• Many approaches exist – most use
incremental and continuous change• Start small• Measure before, during and after to make
sure there is improvement• Make sure the change is institutionalized so
the change is sustained.
Summary slides - Quality Improvement: first step
Guidelines and standards
Performance goal
Actual performance
Quality Indicators
Performance gap
Quality Improvement Intervention
Adapted from JSI and EGPAF
95%
80%
Actual performance
Performance gap
Performance goal
Second QI Intervention
Quality Indicators
Guidelines and standards
Quality Improvement: second intervention
Adapted from JSI and EGPAF
95%
85%
90%
Resources
• NationalQualityCenter.org• HIVQUAL• John Snow International• Institute for Healthcare Improvement• Partners in Health
Resources