An Introduction to Quality Improvement Principles and the PDSA Cycle

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An Introduction to Quality Improvement Principles
and the PDSA Cycle

ConnectHIV Conference May 28th, 2009 Meera
Vohra, MPH
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Agenda

• 1000- 1010am Welcome, Introduction, Agenda
  Review
• 1010-1030am Satisfaction Continuum
• 10-30-1100am Slides- Quality Improvement
  Principles and the PDSA Cycle
• 1100-1120 am Small Group Exercise- PDSA Cycle
• 1120-1130am Debrief Aha Moments

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IOM - Definition of Quality
Quality of care is the degree to which health
services for individuals and populations increase
the likelihood of desired health outcomes and are
consistent with current professional knowledge.
Institute of Medicine. Medicare A Strategy
for Quality Assurance. Vol. 1. (1990)
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Overall Goal

• The best care we know how to give,
• for every patient,
• at every site,
• every day.

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QI is not QA
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QI vs. Accreditation and Clinical Research
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Balance between Performance Measurement and QI
Activities
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What We Want to Avoid..
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Principles on the Quality Improvement Journey
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Success is achieved through meeting the needs of
those we serve.
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Most problems are found in processes, not in
people. 
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Do not reinvent the wheel Learn from best
practices.
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Achieve continual improvement through small,
incremental changes.
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Actions are based upon accurate and measured data.
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Infrastructure enhances systematic implementation
of improvement activities.
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Set Priorities and Communicate clearly
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Introduction of Quality Improvement Model PDSA
Cycle

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Model for Improvement

• Improvement is about learning
• trial and error (scientific method)
• improvements require change, however not all
  changes are an improvement
• Measure your progress
• only data can tell you whether improvements are
  made
• integrate measurement into the daily routine
• Improvements thru continuous cycles of changes
• Plan-Do-Study-Act approach
• changes are initiated on a small scale to test
  them before implementation

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In 1601, James Lancaster successfully conducted
an experiment to illustrate the effectiveness of
lemon juice to prevent scurvy. When did the
British Navy adopt this treatment?

• 1602
• 1689
• 1757
• 1796

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In 1601, James Lancaster successfully conducted
an experiment to illustrate the effectiveness of
lemon juice to prevent scurvy. When did the
British Navy adopt this treatment?

• 1602
• 1689
• 1757
• 1796 (195 years later)

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Treatment of Scurvy

• Stephen J. Bown - Scurvy How a Surgeon, a
  Mariner, and a Gentleman Solved the Greatest
  Medical Mystery of the Age of Sail St. Martin's
  Press, 2004
• In 1601 lemon juice, as a protective against
  scurvy, is recorded by James Lancaster.
• In 1612, Woodall recommended citrus fruit for
  protection against scurvy on sea voyages.
• In 1753 James Lind published A Treatise on the
  Scurvy which portrays his experiment on-board the
  ship Salisbury in 1747.
• From 1772 to 1775 sailors on historic voyages
  with Captain James Cook remained free from
  scurvy.
• In 1796 lemon juice was officially introduced in
  the British Navy as a prophylactic against
  scurvy.
• In 1865 British Board of Trade adopted the policy
  for the merchant marine.

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How long did the NIH take to recommend the
treatment of ulcer as suggested by Dr. Marshall
in his 1984 Lancet Article?

• 2 years
• 5 years
• 10 years
• 20 years

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How long did the NIH take to recommend the
treatment of ulcer as suggested by Dr. Marshall
in his 1984 Lancet Article?

• 2 years
• 5 years
• 10 years
• 20 years

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Treatment of Ulcer Dr Marshall
Timetable 1979 Dr. Robin Warren, pathologist at
Royal Perth Hospital, Australia found bacteria in
stomach of patients 1981 Dr. Barry Marshall
starts residency 1982 Marshall cultivates
bacteria Helicobacter pylori, 100 in Duodenal
Ulcer and 77 in Gastric Ulcer 1984 first
publication in Lancet presents treatment of
ulcer with common antibioticum 1994 National
Institute of Health recommends treatment of ulcer
as suggested by Dr. Marshall
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In a recent article in the Journal of Quality
Improvement 92 QI projects were compared. What
was the timeframe from problem identification to
completion of first pilot?

• 23 days
• 60 days
• 397 days
• 504 days

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In a recent article in the Journal of Quality
Improvement 92 QI projects were compared. What
was the timeframe from problem identification to
completion of first pilot?

• 23 days
• 60 days
• 397 days
• 504 days

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Survey of 92 Quality Improvement Projects in
Journal of Quality Improvement

• Alemi F, Safaie F, Neuhauser D. A Survey of 92
  Quality Improvement Projects. Journal of
  Quality Improvement 2001, 27(11) 619-632
• 504 days from problem identification to
  completion of first pilot
• 397 days from first team meeting to the end of
  first cycle
• 75 days to describe current situation in
  flowchart
• 62 days for data collection if change was
  improvement

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• How can we accelerate change and improvements in
  HIV programs?

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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
Model for Improvement
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Model for Improvement
What are we trying to accomplish?
How will we know that a change is an improvement?
What change can we make that will result in
improvement?
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Model for Improvement
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Model for Improvement
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The PDSA cycle for learning and improvement
Act
Plan
Objective Questions and predictions (why) Plan
to carry out 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
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Why Test?

• Increase your confidence that the change will
  result in improvement in your organization
• Learn how to adapt the change to conditions in
  the local environment
• Minimize resistance when you move to
  implementation

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How do tests lead to improvements?

• You learn something from each test.
• That knowledge gets incorporated into the next
  test.
• Over time, as you build knowledge and expertise,
  you design a change that will result in
  improvement.

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Start Small and Build
Small- scale test
Follow-up test
Wide-scale tests
Implementation
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Start Small and Build
Introduce new CM Intake/Assessment Form
Improve Access to HIV Primary Care
Cycle 1A Adapt new CM form and test with one of
Joannes patients on Monday
Cycle 1B Revise tool and test with 3 case
managers and document feedback
Cycle 1C Revise and test tool with all clients
for one week
Cycle 1E Implement new tool and monitor the
standards

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Tips for PDSA Cycles

• Volunteers at first
• Useful, not perfect, data
• Use huddles to report
• Learn from others (Steal shamelessly, Share
  senselessly)
• Just get started!

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Tips for PDSA Cycles

• What change could you implement by next
  Tuesday?
• Use the Rule of 1
• 1 facility
• 1 office
• 1 provider
• 1 patient

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PDSA Large Group Case Study

• What PDSA do you suggest for the following
  scenario?
• An agency wants to initiate a QI project to
  remind clients of their upcoming appointment.

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PDSA Case Study

• Does your PDSA have the following three
  qualities?
• Can you do the PDSA by next Tuesday?
• Can you collect just enough data to know that
  this change will result in improvement?
• Do you have a hypothesis?

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References

• http//www.IHI.org/IHI/Improvement/
  ImprovementMethods provides information on
  improvement methods, strategies, and changes.
• Moen, Ronald, Thomas Nolan Process Improvement
  Quality Progress, 1987, p62.
• Langley, Gerald, Kevin Nolan and Thomas Nolan
  The Foundation of Improvement, Quality
  Progress, June 1994, p. 81.
• Langley, Gerald, Kevin Nolan, Thomas Nolan, Cliff
  Norman, and Lloyd Provost The Improvement Guide.
  San Francisco, CA Jossey-Bass, 1996.
• Nolan, Kevin ASQs Accelerating Change
  Collaborative Series A Challenge for Industry,
  Quality Progress, Jan 1999, p55.

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Key QI Resources

• NQC Website www.NationalQualityCenter.org
• Online Quality Academy
• Monthly TA Calls
• On-site TA for Ryan White grantees
• Training of Trainers (TOT)
• Training for Quality Leaders (TQL)
• Quality Link
• Regional Trainings

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National Quality Center (NQC)NYSDOH AIDS
Institute90 Church Street13th FloorNew York,
NY 10007-2919888-NQC-QI-TAInfo_at_NationalQualityCe
nter.orgNationalQualityCenter.org