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PDSA: Plan-Do-Study-Act

Also Called:  Rapid Cycle Improvement,  PDCA (Plan-Do-Check-Act)

What is PDSA? Stage 1: Plan Stage 2: Do Stage 3: Study Stage 4: Act Examples More Information

What is PDSA?

PDSA, or Plan-Do-Study-Act, is an iterative, four-stage problem-solving model used for improving a process or carrying out change.

When using the PDSA cycle, it's important to include internal and external customers; they can provide feedback about what works and what doesn't. The customer defines quality, so it would make sense to also involve them in the process when appropriate or feasible, to increase acceptance of the end result. (If you're unsure about, who your customers are, you may want to create a customer chain to assist in identification.)

In applying PDSA, ask yourself three questions:

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What changes can we make that will result in an improvement?

Stage 1: Plan

A. Recruit Team

Assemble a team that has knowledge of the problem or opportunity for improvement. Consider the strengths each team member brings—look for engaged, forward-thinking staff.

After recruiting team members, identify roles and responsibilities, set timelines, and establish a meeting schedule.

B. Draft an Aim Statement

Describe what you want to accomplish in an  aim statement . Try to answer those three fundamental questions:

1. What are we trying to accomplish?

2. How will we know that a change is an improvement?

3. What change can we make that will result in improvement?

C. Describe Current Context and Process

Brainstorm

Examine your current process. Start by asking the team these basic questions:

· What are we doing now?

· How do we do it?

· What are the major steps in the process?

· Who is involved?

· What do they do?

· What is done well?

· What could be done better?

You might have already answered the last two questions if you have performed a  SWOT analysis .

Try a Swim Lane Map

You may find it helpful to construct a  swim lane map  to visually describe your process.

Creating a process flow or at least depicting the current process can be very useful. If your team runs into road blocks, you might have found where the problem is occurring—or maybe the right person for identifying a missing step is not at the table.

Gather More Detail

Once the general structure is completed, these can be some more helpful questions to ask:

· How long does the process currently take? Each step?

· Is there variation in the way the process is currently completed?

D. Describe the Problem

Using the aim statement created in Step B, state your desired accomplishments, and use data and information to measure how your organization meets/does not meet those accomplishments.

For example: If your objective is to maximize your staff's quality of work life, you might find evidence by surveying employees on workplace stressors.

Write a Problem Statement

Write a problem statement to clearly summarize your team's consensus on the problem. You may find it helpful to prioritize problems, if your team has identified more than one, and/or include a justification of why you chose your problem(s).

E. Identify Causes and Alternatives

Analyze Causes

For the problem in your problem statement, work to identify causes of the problem using tools such as  control charts ,  fishbones , and work flow process maps (e.g.,  flowcharts ,  swim lane maps ). The end of the cause analysis should summarize the cause analysis by describing and justifying the root causes.

Examine your process, and ask:

· Is this process efficient? What is the cost (including money, time, or other resources)?

· Are we doing the right steps in the right way?

· Does someone else do this same process in a different way?

Develop Alternatives

Try to mitigate your root causes by completing the statement,

"If we do __________, then __________ will happen."

Choose an alternative (or a few alternatives) that you believe will best help you reach your objective and maximize your resources.

Develop an action plan, including necessary staff/resources and a timeline. Try to account for risks you might face as you implement your action plan.

Stage 2: Do

Start to implement your action plan. Be sure to collect data as you go, to help you evaluate your plan in  Stage 3: Study. Your team might find it helpful to use a  check sheet ,  flowchart ,  swim lane map , or  run chart  to capture data/occurrences as they happen or over time.

Your team should also document problems, unexpected effects, and general observations.

Stage 3: Study

Using the aim statement drafted in  Stage 1: Plan, and data gathered during  Stage 2: Do, determine:

· Did your plan result in an improvement? By how much/little?

· Was the action worth the investment?

· Do you see trends?

· Were there unintended side effects?

You can use a number of different tools to visually review and evaluate an improvement, like a  Pareto chart ,  control chart , or  run chart .

Stage 4: Act

Reflect on Plan and Outcomes

· If your team determined the plan resulted in success,  standardize the improvement and begin to use it regularly. After some time, return to  Stage 1: Plan and re-examine the process to learn where it can be further improved.

· If your team believes a different approach would be more successful, return to  Stage 1: Plan, and  develop a new and different plan that might result in success.

The PDSA cycle is ongoing, and organizations become more efficient as they intuitively adopt PDSA into their planning.

Celebrate Improvements and Lessons Learned

· Communicate accomplishments to internal and external customers

· Take steps to preserve your gains and sustain your accomplishments

· Make long-term plans for additional improvements

· Conduct iterative PDSA cycles when needed

More Information

The ABCs of PDCA  and  PDSA Flowchart (PDF) Public Health Foundation

Embracing Quality in Local Public Health (PDF) Michigan Local Public Health Accreditation Program

Baldrige Performance Excellence Program National Institute of Standards and Technology, US Dept. of Commerce

Balanced Scorecard Institute

PDSA  [Note: Video will autoplay] Institute for Healthcare Improvement

Whiteboard: The PDSA Cycle (Part 1)  [Note: Video will autoplay] Whiteboard: The PDSA Cycle (Part 2)  [Note: Video will autoplay] Institute for Healthcare Improvement

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Outline

Introduction

Definitions

Characteristics / Elements of CQI

Evolution of CQI in Health Care

Broad-Based Approaches to CQI

Introduction

Continuous quality improvement (CQI) has evolved over time and across countries

Substantial progress has been made in the diffusion of CQI in health, e.g., in public heath

The need for greater diffusion of CQI continues, particularly due to greater complexity in health care systems

Quality and safety problems persist in health care and new techniques are available to address these

Definition of Quality in Health

The WHO definition of quality of care is “the extent to which health care services provided to individuals and patient populations improve desired health outcomes. In order to achieve this, health care must be safe, effective, timely, efficient, equitable and people-centered.”

Components of Health (WHO)

Safe. Delivering health care that minimizes risks and harm to service users, including avoiding preventable injuries and reducing medical errors.

Effective. Providing services based on scientific knowledge and evidence-based guidelines.

Timely. Reducing delays in providing and receiving health care.

Efficient. Delivering health care in a manner that maximizes resource use and avoids waste.

Equitable. Delivering health care that does not differ in quality according to personal characteristics such as gender, race, ethnicity, geographical location or socioeconomic status.

People-centered. Providing care that takes into account the preferences and aspirations of individual service users and the culture of their community

Quality Assurance(QA)

QA focuses on conformance quality, which is defined as “conforming to specifications; having a product or service that meets predefined standards” (McLaughlin & Kaluzny, 2006, p. 37).

QA is sometimes the primary goal of accreditation processes.

Definition of CQI in Health Care

CQI is defined as a structured organizational process for involving personnel in planning and executing a continuous flow of improvements to provide quality health care that meets or exceeds expectations

Common Characteristics of CQI

• a link to key elements of the organization’s strategic plan;

• a quality council made up of the institution’s top leadership;

• training programs for personnel;

• mechanisms for selecting improvement opportunities;

formation of process improvement teams;

• staff support for process analysis and redesign;

• personnel policies that motivate and support staff participation in process improvement;

• application of the most current and rigorous techniques of the scientific method and statistical process control.

Societal Cost of Poor Quality

Crosby: Cost of quality (“Quality is free”, 1979)

Cost of (poor) quality = cost of nonconformance

Poor quality care has an impact on the patients directly affected, the services which provide that care, and society at large

unnecessary costs associated with waste and wasted effort when work is not done correctly the first time.

includes the costs of identifying errors, correcting them, and making up for the customer dissatisfaction that results.

This view leads naturally to a broadening of the definition of quality by introducing the concept of adding value, in addition to ensuring the highest quality of care.

Quality/Accountability/Value

Improving quality involves three aims (“The triple aim: Care, health, and cost”: Berwick et. al, 2008: 759):

Improving the experience of care

Improving the health of populations

Reducing the per capita costs of health care

At a more micro level, improving quality also involves professional responsibility and development

An example of the evolution continuing in the 21st Century

These concepts have evolved further in the second decade of the 21st century to include a fourth aim directed at ensuring the well being of health care providers

See Chapter 2 (Bodenheimer & Sinsky, 2014)

Rationale for Implementation of CQI in Health Care

Health care organizations embark on CQI for a variety of reasons, including:

Engagement in true process improvement

Give customers (patients) the quality care they deserve

AND / OR

Accreditation requirements,

Cost control,

Competition for customers, and

Pressure from employers and payers

Characteristics/Functions of Health Care CQI

(1) Understanding and adapting to the external environment;

(2) empowering clinicians and managers to analyze and improve processes;

(3) adopting a norm that the term customer includes both patients and providers and that customer preferences are important determinants of quality in the process;

(4) developing a multidisciplinary approach that goes beyond conventional departmental and professional lines;

Characteristics/Functions of Health Care CQI

(5) adopting a planned, articulated philosophy of ongoing change and adaptation;

(6) setting up mechanisms to ensure implementation of best practices through planned organizational learning;

(7) providing the motivation for a rational, data-based, cooperative approach to process analysis and change; and

(8) developing a culture that promotes all of the above.

CQI: Philosophy and Process

CQI is simultaneously two things: a management philosophy and a management method.

It is distinguished by the recognition that customer requirements are the key to customer quality and that customer requirements ultimately will change over time because of changes in evidence-based practices and associated changes in education, economics, technology, and culture.

In health care such changes, in turn, require continuous improvements in the administrative and clinical methods that affect the quality of patient care and population health.

Elements of CQI in Health Care

Philosophical Elements

Structural Elements

Health Care Elements

Philosophical Elements of CQI

Strategic Focus

Customer Focus.

Systems View

Data-driven (evidence-based) Analysis

Implementer Involvement

Multiple Causation

Solution Identification

Process Optimization

 Continuing Improvement.

Organizational Learning

Structural Elements of CQI

Use of process improvement teams

Use of CQI tools

Creation of parallel organization (Quality Council) to monitor CQI

Gain commitment from top management

Utilize statistical analysis

Develop and review customer satisfaction measures

Use benchmarking

Engage in redesign of processes

Examples of CQI Tools

Flow charts

Run charts

Control charts

Cause and effect diagrams

Frequency

charts

Checklists

Pareto charts

Healthcare Elements of CQI

Use of epidemiological and clinical studies (evidence based medicine)

Involvement of staff in governance and peer review

Use of risk-adjusted outcome measures

Use of cost-effectiveness analysis

Use of quality assurance and risk management data and techniques

Evolution of CQI

From Japan(post-WW II) to US (1960s) to the World (21st century)

Most recently: to low and middle income countries

From TQM to CQI

Pioneers

Deming (14 points)

Shewhart

Juran

Feigenbaum

Crosby

Donabedian

Continuing Evolution in Japan

Taguchi

Ishikawa

Deming’s 14 Points

Deming’s 14-Point Program

Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge, MA 02139. Copyright © 1993 by W. Edwards Demig.

Cross Disciplinary Thinking

Cross-Disciplinary Strategic Thinking

Industrial Versus Health Care Quality

Cons

Ignores complexities patient-practitioner relationship;

Downplays competencies and motivation of the practitioner;

Ignores quality-cost trade-offs;

Gives less to clinical activities than to supportive ones;

Limited perspective on mechanisms for influencing professional behavior such as “education, retraining, supervision, encouragement and censure”

Pros

Importance of health care quality traditions.

Greater attention to consumers

Greater attention to system designs and processes

Expansion of self-monitoring, self-governing tradition to all staff

Greater role by management in CQI

Development of appropriate applications for health care monitoring.

Greater education and training in CQI for all staff

Evolution of CQI in Health Care

From hospitals to all segments of healthcare

From doctors and managers to all staff

From specialized knowledge to generalized competencies

From localized activities to national and international regulatory and accrediation agencies

The Big Bang of CQI

Institute of Medicine

To Err is Human (2000)

Crossing The Quality Chasm (2001)

Data already know, but these report galvanized the press, the public, professional groups and regulators

Increased demands for accountability and professional responsibility

Transfer of concerns from managerial responses, to across the board responsibility

Revised Boynton & Victor Model for Health Care From Industrialization to Personalization

Revised Boynton and Victor Model for Health Care

Mass Personalization

Personalization must not be mixed up with customization. While customization relates to changing, assembling or modifying product or service components according to customers’ needs and desires, personalization involves intense communication and interaction between two parties namely customer and supplier. Personalization in general is about selecting or filtering information objects for an individual by using information about that individual (the customer profile) and then negotiating the selection with the individual….

(Tseng and Piller, 2003, p.7)

Examples of Personalization in Health Care

Increased accessibility of data and information leading to increased patient and family participation in decision making

Possibility of personalized medicine – right drug at the right dose at the right time

Focus on individual rather than (chronic) condition, including evidence based medicine and self management

Recent Evolutionary Trends in CQI

The integration of CQI into public health activities

The integration of CQI into nursing education (QSEN)

The expanding role of accreditation.

The global spread of CQI across countries and health services

Greater understanding and use of broad–based applications and methods

PDSA/PDCA

PDSA Plan-Do-Study-Act

Shewhart (PDSA) cycles “provide a structure for iterative testing of changes to improve quality of systems…The pragmatic principles of PDSA cycles promote the use of a small scale iterative approach to test interventions, as this enables rapid assessment and provides flexibility to adapt the change according to feedback to ensure fit-for-purpose solutions are developed” (Taylor et al. 2014, pp.290-291).

PDCA is an alternate definition of PDSA

Used interchangeably

C:Check is equivalent to S:Study

Shewhart (PDSA) Cycle

Shewhart (PDSA) Cycle

Reprinted from The New Economics for Industry, Government, Education by W. Edwards Deming by permission of MIT and W. Edwards Deming. Published by MIT, Center for Advanced Engineering Study, Cambridge,

MA 02139. Copyright © 1993 by W. Edwards Demig.

Key Features of PDSA

The use of repeated iterative cycles

Prediction-based test of change (developed in the plan stage)

Small-scale testing (build as confidence grows – adapting according to feedback and learning)

Use of data over time (to understand the impact of change)

Documentation (to support local learning and transferability to other settings)

Source: Taylor et al. 2014, p.293.

FOCUS-PDCA

The FOCUS–PDCA Cycle

FOCUS-PDCA

FOCUS-PDCA creates common language and an orderly sequence for implementing CQI. It focuses on the answers to 9 questions (Batalden and Stoltz, 1993):

1. What are we trying to accomplish?

2. How will

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