More o n PDSAs

1. More on PDSAs Connie Sixta, RN, PhD MBA Patricia L. Bricker, MBA

2. Characteristics of the Improvement Model • Action-oriented – “What are you going to test next Tuesday?” • Rapid-cycle testing of changes • Evaluation and revision of all changes before implementation • Testing and implementing the changes in small populations, then spreading to the larger population • Evaluate impact using annotated run charts • Monthly reporting of tests and outcomes

3. Chronic Care Model Health System Community Health Care Organization Resources and Policies ClinicalInformationSystems Self-Management Support DeliverySystem Design Decision Support Prepared, Proactive Practice Team Informed, Activated Patient Productive Interactions Improved Outcomes

4. Act Plan Study Do Model for Improvement What are we trying to accomplish? How will we know that a change is an improvement? What changes can we make that will result in improvement?

5. Act Plan Plan Plan Study Plan Do Plan PDSA versus PPPP Action & Improvement No Action, no improvement

6. Why Test? • Increase the belief that the change will result in improvement • Predict how much improvement can be expected from the change • Learn how to adapt the change to conditions in the local environment • Evaluate costs and side effects of the change • Minimize resistance upon implementation

7. The PDSA Cycle Act Plan • Objective • Questions and • predictions (why) • Measure of success • Plan for the cycle (who, • what, where, when) • What changes • are to be made? • Next cycle? Study Do • Complete the • analysis of the data • Compare data to • predictions • Summarize what • was learned • Carry out the plan • Document problems • and unexpected • observations • Begin analysis • of the data

8. A A P P S S D D D S P A A P S D Repeated Use of the Cycle Changes that result in improvement DATA Hunches and Theories

9. Testing on a Small Scale • Conduct the test with one provider in the office, or with one patient • Conduct the test over a short time period • Test the change with the members of the team that helped develop the plan • Test the change on a small group of volunteers • Minimize confusion, frustration until bugs are worked out, then spread

10. Plan (P) for Organized Evidence-based Care PDSA 1: Test EMR alert system for patients with DM Objective: Implement DM alert system for staff/providers

11. The DSA Part of the PDSA DO: Test completed as planned and provider/staff provided feedback. DM patients on the schedule/seen Thursday counted. Provider and staff kept track of # DM patients identified with alert. STUDY: For 90% of DM patients, the alert activated. One patient with DM without an alert had problem list error. Both MA and MD felt the alert was very helpful in giving planned care at every visit and proactively addressing needs. ACT:Retest with another MA and MD on Monday.

12. Plan (P) for Organized Evidence-based Care PDSA 2: Test clinical guidelines/reminders for DM patients Objective: Implement DM guidelines/reminders

13. The DSA Part of the PDSA DO: Pam was ill on Wednesday, so Pat (MA) and Dr. Moore completed the test as planned and provided feedback. Counted default clinical guideline/reminder template for DM patients. Determined accuracy of reminders on the template. STUDY: For 100% of the DM patients, guideline/reminder template appeared as a default mechanism. DM reminder status incorrect for eye exam and vaccines (flu and pneumovax). Both MA & MD stated default clinical guideline/reminder template supported planned care at every visit. Easy to use. ACT:Revise DM eye exam and vaccine reminders and retest with MA and MD on Monday.

14. PDSA Cycle: Self-Management Plan Act • Use a SM tool • Tool supports SM • process, goal setting • Staff and patient • satisfaction, # goals • Select tool, teach staff, • use tool with 2 patients • Revise tool • Retest with 2 • more patients Study Do • Staff and patients liked tool and process, one goal set per patient • Want to revise tool • Successful test • Use SM tool with 2 pts • Document problems, • satisfaction, # of goals • Begin analysis • of the data

15. Plan (P) for Patient-centered interactions PDSA 3: Test the DM self-management tool with patients Objective: Set self-management goals with patients using atool

17. The DSA Part of the PDSA DO: Test completed as planned with 2 DM patients. Patients and staff asked for feedback. STUDY: One goal set per patient. Patients identified one behavior to work on and were confident (>7.0) they could achieve it. Susan slightly uncomfortable with process but wants to use the tool again to gain comfort with goal setting. ACT:Retest tool with two patients on Friday. Revise tool by end of next week, adding importance score, symptoms & management of hypoglycemia and retest.

18. To Be Considered a PDSA Cycle • The test or observation was planned (including a plan for collecting data). • The plan was attempted. • Time was set aside to analyze the data and study the results. • Action was rationally based on what was learned.

19. Do Study • Reasons for failed tests 1. Change not executed well –re-look at plan 2. Support processes inadequate 3. Hypothesis/hunch wrong • Collect data during the “Do” of the PDSA Cycle to help differentiate these situations • Follow improvement trend of measure graphs • Spread changes when they work well across providers, care teams, patient population

20. DM Outcome Measures PDSA 2

22. What changes do you plan to test by next Tuesday?

23. Some PDSA Ideas • Population alert on medical records • Template/Flow sheet with embedded guidelines • Pre-visit planning • Provider-care team (nurse, MA) huddles • Identifying patients not seen in past 6-12 months that need follow-up care • Standing orders • Planned care at every visit • Self-management tool • Risk assessment process, tool