Quality Improvement ProcessUsing Plan, Do, Study, Act(PDSA) – Planning for ActionKathy Hybarger, RN, MSNConnie Steigmeyer, RN, MSNBetsy Lee, RN, MSPHLinda Woolley, RN, MSM

Quality Improvement is not Rocket science Too complicated to attempt Just more to do More red tape

Quality Improvement is Finding the way to do it – Better– Faster– Easier Part of our everyday life

Quality Improvement Is used to make improvements to aprocess Focuses on making an entire system’soutcomes better by constantly adjustingand improving the system itself, instead ofsearching out and getting rid of “badapples”Think of ways you try to improve your ownprocesses everyday; whether it’s caring for yourfamily or doing your work

Linda’s Story

QI Principle Your systems are creating your outcomes. What you’re doing is getting you whatyou’re getting To GET something different, you have toDO something different.

Plan, Do, Study, Act (PDSA) Keys to SuccessCollaborationPilot-testingMeasurement 2003 Institute for Healthcare ImprovementQuality Partners of Rhode Island

The PDSA Cyclefor Learning and ImprovementStart withthis stepAct- What changesare to bemade?- Next cycle?Study- Complete the analysisof the data- Compare data topredictions- Summarize whatwas learnedPlan- Objective- Questions andpredictions (W hy?)- Plan to carry outthe cycle(who, what, where, when)Do- Carry out the plan- Document problemsand unexpectedobservations- Begin analysisof the data

First Question—What are wetrying to accomplish? Aim content:– Explicit over-arching description– Specific area of focus (population)– Goals Aim characteristics:– Time specific– Measurable– Define project unit

The “What” of Pressure UlcerPrevention: Six Key Interventions Conduct a pressure ulcer admission riskassessment for all patients. Reassess risk for all patients daily. For all patients identified as being at riskfor pressure ulcers:– Inspect skin daily.– Manage moisture: Keep the patient dry andmoisturize dry skin.

The “What” of Pressure UlcerPrevention: Six Key Interventions For all patients identified as being at riskfor pressure ulcers:– Optimize nutrition and hydration.– Minimize pressure: Ensure that patients areturned every two hours and use pressurerelieving surfaces.

PLAN: Select your Goals Write down all goals– Short-term goals– Long-term goals– Post-goals Write down the goals with a timeline– Example: By the end of 3 months, 100% of all newlyhired staff will have education on pressure ulcerprevention during their orientation Re-evaluate goals periodically

Redesign Your System Design “what to change” from findings ofthe baseline data Take one corrective step at a time Do not try to solve all the problems at once

Second Question—How will we knowthat a change is an improvement? Measure over time using run charts Make measurement intervals as short aspossible – weekly instead of monthly Monitor measurements and change asneeded

87654321Number of NosocomialPressure UlcersRun aryJanuaryDecemberNovemberMonth

Run Chart: Rules for IdentifyingStatistically Significant ChangeRule 1Rule 2MedianTrend: 5 points in rowheaded in same directionNote: Ties between two consecutivepoints don’t cancel or add to a trend

DO: Implement Change Carry out a testPilot test on one unitShort period of timeSmall number of residents/patientsCommunicate, educate, and inform allstaff about the plan Assign one person to be responsible

Why test? Increase belief that change will work Document how much improvement can beexpected from the change Learn to adapt change to other conditions/your environment Evaluate costs/side-effects of change Minimize resistance to implementation

Testing vs. Implementation Testing—Trying and adapting existingknowledge on small scale. Learning whatworks in your system. Implementation—Making this change apart of the day-to-day operation of thesystem– On the pilot unit with the pilot population– Not after just one test!

Testing vs. Implementation Spread—Taking the change beyond thepilot unit/population– Other parts of the organization (Imaging, ER,OR, clinics; to other populations medical,surgical, pediatrics)

Principles for Testing Test to evaluate if a new idea or innovationwill work– “Screening”: Adopt / Adapt / Abandon Test small – principle of “oneness”– One nurse, one shift, one patient/resident,one change-of-shift report Engage those interested in testing– “Nurse Friendly” or “Curious Team Member”

Principles for Testing Don’t wait for a committee approval, go tothe committee after you have tested andhave some data to support the newchanges Make a prediction before you test that is astatement of your expectation Compare result of test to prediction toincrease learning

Principles for Testing Collect some data that will provide abaseline and ongoing measurement Run multiple tests simultaneously– Test several things at once: Turn clock,pressure ulcer kits, standard risk assessmenttools It takes many tests to build innovation– Sequence of tests

Principles for Testing Involve other units and multiplestakeholders (emergency department,surgical suite, imaging)

Successful Cycles to TestChanges Plan multiple cycles for a test of a change Think a couple of cycles ahead Initially, scale down size of test (# ofpatients/ residents, location) Test in parallel rather than sequentially Test with volunteers

Successful Cycles to TestChanges Do not try to get buy-in or consensus fortest cycles Be innovative to make test feasible Collect useful data during each test In latter cycles, test over a wide range ofconditions

Repeated Use of CyclePDSA MeasuresAPS DChanges ThatResult inImprovementImplementation ofchangeWide-scale tests ofchangeHunchesTheoriesIdeasA PS DFollow-up testsVery small scale test

Heels being floated on all peopleat risk while in bedData for Measurement100%90%Number of people with heels floatedNumber of people at risk %80%70%60%50%40%30%20%10%0%Day1Day2Day3Day4Week 1Day5Day6Day7Day8Day9Day10Day11Week 2Day12Day13Day14

Repeated Use of CyclePDSA MeasuresA physicaltrigger “greenpillowcases”will besuccessful inensuring thatheels arefloated while inbed.A PS DHeels were beingfloated while personA P was in bed.SD

Common InterventionsThat Do Not Work “ALONE” New forms– Be form neutral—take one away if you addanother one Staff education Posting memos Revising policiesDo these things in combination!

Revise and Re-evaluate Remember the first interventions do notalways work Use another PDSA cycle until it works asexpected

PDSA Benefit: “It is a Test!” You can see “what worked” vs. “what didnot” Decide on “what should be kept” and“what should not” Use theories and ideas to create changesthat will result in improvement.

STUDY Re-collect the same data and compareagainst baseline findings Evaluate if the process improved asexpected Summarize lessons and barriers

Evaluate Change Was it simple? (Keeping it simple helpsensure that it will continue) Were the intervention(s) easily understoodand accessible? (Does it make sense and dostaff know the why, where, when, and how?) Were all the staff aware of the project?(Awareness and input will help in preventingsabotage)

ACT Review pilot test evaluation data Determine successes and failures—aremodifications needed? Expand the test to involve other staff Adapt, adopt, abandon– Adopt—keep the change as tested, make itpart of the process

ACTAdapt, adopt, abandon– Adapt—make the changes needed to make itworkable– Abandon—let it go, if it didn’t work, don’t try tokeep it (but we’ve always done it this way) Document and report results Finalize your system change—spread intoeach other area requires testing

Change ConceptAllimprovementrequireschange yetall changedoes not leadto improvement

Quality Improvement Process Using Plan, Do, Study, Act (PDSA) – Planning for Action Kathy Hybarger, RN, MSN . – Define project unit. The “What” of Pressure Ulcer Prevention: Six Key Interventions Conduct a p