Think about your activities over the past week, identify at least one time in which you have applied the PDSA Improvement Model

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 1/8

PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.

The PDSA Cycle

Walter Shewhart, at Bell Laboratories, was the first to introduce the Plan, Do, Study, Act

(PDSA) cycle, which was presented earlier in Figure 1–3. Although the PDSA cycle is often

attributed to Deming, he attributes it to Shewhart (Deming, 1986). It should also be noted

that over time, the abbreviation PDSA was changed by some to PDCA, the “S” for study being

changed to “C” for check, as in checking what impact an improvement has made on the

process being changed. Today the terms are used interchangeably, as we will do throughout

this book. Either way, Shewhart’s concept has become a very powerful and frequently used

quality improvement methodology that has withstood the test of time.

The two very successful and well-known applications of the PDSA cycle that have evolved in

health care are HCA’s FOCUS–PDCA model (Batalden and Stoltz, 1993) and the Model for

Improvement (Langley et al., 2009). In addition to these two major PDSA applications,

numerous other CQI initiatives have centered around this basic improvement cycle.

The broad applicability of the PDSA cycle in health care can be traced directly to its roots as

it was applied by Deming. One of Deming’s major premises (1993) was that management

needs to undergo a transformation. In order to respond successfully to challenges to

organizations and their environments, the way to accomplish that transformation, which

must be deliberately learned and incorporated into management, is by pursuing what he

called “profound knowledge.” The key elements of his system of profound knowledge are (1)

appreciation for a system, (2) knowledge about variation, (3) theory of knowledge, and (4)

psychology.

The Deming process is especially useful in health care because professionals already have

knowledge of the subject matter as well as a set of values and disciplines that fit the Deming

philosophy. Training in Deming methods adds knowledge of how to build a new theory

using insights about systems, variation, and psychology, and it focuses on the answers given

to the set of basic questions that center around knowing what is to be accomplished.

Furthermore, it applies a cyclical process of testing and learning from data whether the

change being made is an improvement and what improvements are needed in the future

(Batalden and Stoltz, 1993). A Deming approach, as adopted by the HCA, is illustrated in

Figure 1–7. It was referred to by the HCA as FOCUS–PDCA and provided the firm’s health

care workers with a common language and an orderly sequence for implementing the cycle

of

36

37

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 2/8

PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.

continuous improvement. It focuses on the answers given to the following basic questions

(Batalden and Stoltz, 1993):

37

38

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 3/8

FIGURE 1–7 The FOCUS–PDCA Cycle

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 4/8

1. What are we trying to accomplish?

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

3. What changes can we predict will make an improvement?

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 5/8

PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.

4. How shall we pilot test the predicted improvements?

5. What do we expect to learn from the test run?

6. As the data come in, what have we learned?

7. If we get positive results, how do we hold on to the gains?

8. If we get negative results, what needs to be done next?

9. When we review the experience, what can we learn about doing a better job in the

future?

38

39

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 6/8

FIGURE 1–8 Model for Improvement

Source: The “Model for Improvement”—a systematic approach to rapid improvement of health processes (Langley et al., 2009).

In parallel with the FOCUS–PDCA model was the introduction in 1992 of the Model for

Improvement by Langley et al. (2009). It includes a PDSA cycle as its core approach,

returning to the traditional “S,” emphasizing the importance of studying what has been

accomplished before making further changes (Figure 1–8). Careful study and reflection are

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 7/8

PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.

points of emphasis made by Berwick (1996), who describes this model as “inductive learning

—the growth of knowledge through making changes and then reflecting on the

consequences of those changes.” Central to this model are three key 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 an improvement?

The wide use of these approaches is due directly to the elegance and simplicity of the PDSA

cycle. Likewise, the range of applications ties directly to the generalizability of the PDSA

cycle. Recent applications have included public health (see Chapter 16), health care in

resource-poor countries (see Chapter 19) and traditional medical care in industrialized

settings, which are described throughout this book.

Quality Improvement Collaboratives

Quality improvement collaboratives (QICs) are another example of a broad-based approach

that exemplifies the evolution of CQI methods across geographic boundaries and areas of

health care, with applications that range from primary care to public health. Although some

authors feel that clear evidence of their effectiveness, in terms of improved outcomes, is

lacking, their widespread adoption is well documented (Schouten et al., 2008). Simply

defined, QICs consist of “multidisciplinary teams from various health care departments or

organizations that join forces for several months to work in a structured way to improve

their provision of care” (Schouten et al., 2008, p. 1491). They have been described as

temporary learning organizations (Ovretveit et al., 2002) and have also been described in

the context of diffusion of innovation; more specifically, in their comprehensive review of

the literature on diffusion of innovation in health service organizations (2005), Greenhalgh

et al. describe the goal of QICs as “spread of ideas.” These authors formally describe QICs as

multi-organizational structured improvement collaboratives and provide a succinct

description of how they work:

Participants in a quality collaborative work together over a number of months, sharing

ideas and knowledge, setting specific goals, measuring progress, sharing techniques for

organizational change and

39

40

6/3/2018 Bookshelf Ambassadored

https://ambassadored.vitalsource.com/#/books/9781449679606/cfi/6/18!/4/34/4/2/68/2/[email protected]:44.9 8/8

PRINTED BY: [email protected] Printing is for personal, private use only. No part of this book may be reproduced or transmitted without publisher's prior permission. Violators will be prosecuted.

40

41