#QualityImprovement and #PDSA cycles - how to decide what to DO

Plan Do Study Act (PDSA) cycles are a quality improvement tool used to test process change. Not all change leads to improvement. In order to evaluate the change for its impact on your patients and the care you provide them, you need to test the change.

The Institute for Healthcare Improvement (IHI) uses the Model for Improvement developed by Associates in Process Improvement. Both sites provide resources for using this method, including this worksheet from IHI.

To summarize briefly, the process requires you to develop a PLAN for how you will test the change including how you will measure the change. Then you will DO the change in a small scale or pilot, measuring the outcome before and after implementing the change. After completing the pilot, you will STUDY the results of your test by carefully examining the before and after measurement. Finally, you ACT on what you learned, generally through modifying and re-testing the new change in a new PDSA cycle. You repeat until you are convinced that the change consistently creates more benefit than harm, which constitutes improvement.

There are many great resources on many different websites to help guide you in the PDSA process.

But the biggest challenge for you will be deciding WHAT to do.

STEP 1 - Know your organization’s most pressing problems. Hint - start with your data. Data includes your performance metrics, but it also includes your survey data from patients and staff.

STEP 2 - Prioritize - No organization has enough resources to change everything at once. Besides exhausting your staff, you’ll also contaminate your tests of change. When you change everything at once, you can’t determine which change produced the improvement, if there was improvement. And changing everything at once may produce no overall improvement, hiding real improvement that could be generated from one of the changes.

STEP 3 - Find evidence based innovations to address your priority problems. If you use innovations that have already been tested and found to work, you will have a head start. You will waste less time with more PDSA cycles and you are more likely to reduce unintended harm to your patients and staff from the change.

All this is necessary for successful PLANing of what to DO.

In the next post I’ll dig deeper into the process of how to decide what to do.

 ©TheEvidenceDoc 2018

Can't get no #patientsatisfaction while waiting for Godot

I have adult children. It's sometimes difficult staying out of their lives and decisions, especially in matters of health. So instead I ask a lot of questions. The last several weeks I've been asking quite a few of one child who is struggling, as so many patients do, with getting through the referral process into specialty care. She first saw her primary care doc for an unusual acute illness. He was easy enough to get in to see. He evaluated her, took blood for labs and said the office would call with results. After a week of no response I encouraged her to call and get the results. They were then promptly provided along with a scheduled next appointment for the following week. During the appointment, the doc said he would refer her to a specialist to follow up with the lab findings. She waited another week with no contact from the specialist so I prodded her to call the primary care again. They said they sent the referral and to wait for contact from the specialist. She did get the number of the specialist, but waited another week with no call from them. With more urging from me, she then called the specialist office who said yes, she was on the list to be called and would hear in a couple of days. Ten days later with no call, I urged her to call back...

Are you tired of reading this yet? Imagine being the patient, fearful with abnormal labs and wondering what's wrong and whether or not the delay in care will impact her long term health.

How often does this happen in the US? We have surprisingly little data to address. Merritt Hawkins conducted a survey by calling physician offices in 15 metropolitan areas to schedule an appointment with several specialties for non-emergent conditions. https://www.merritthawkins.com/2014-survey/patientwaittime.aspx  They found average wait to schedule a cardiology appointment in DC was 32 days ranging from as short as 4 to as long as 186 days! Average wait to see an ob-gyn in Boston was 46 days ranging from 5 to 103.

How long do patients wait to get to your care or the care of your specialty colleagues? Do you know? We cannot improve what we haven't measured.

  1. Do you know how long your patients wait to get an appointment to see you?
  2. Do you know how long your patients wait to get an appointment when you refer them for specialty care?
  3. Do you know how smooth the process is for patients to navigate?
  4. Do you provide your patients with information they can use while waiting for their next appointment?
  5.  Have you ever thought about what it's like for patients trying to get access to your care?

I know we were trained to provide the best care to our patients when we interact with them. But the patient interaction begins long before you see them in your office.

How can you improve scheduling for your patients? You can start by asking your patients about their wait experience (gather data). Then you can read this free resource from the National Academies of Science, Engineering and Medicine for some ideas on what to do about it. https://www.nap.edu/catalog/20220/transforming-health-care-scheduling-and-access-getting-to-now

Make sure your patients don't compare their wait to see you to Waiting for Godot.





Healthcare #qualityimprovement is doing the right things right

 We can improve the quality and safety of the healthcare we deliver to patients.

That’s the premise behind quality improvement and patient safety programs, initiatives and interventions. The study of quality improvement interventions, called improvement science, is relatively new. Improvement science is just beginning to evaluate the performance of the tools and techniques. Many of the techniques such as Plan-Do-Study-Act (PDSA) cycle, Lean, and Six Sigma come from manufacturing and seek to improve efficiency. They seek to improve efficiency by doing things right. 

While it is important to get better at delivering the right care,

it is essential to first know what is the right care to deliver.

The assumption behind many of the manufacturing improvement processes is that we just need to get better at delivering the right care.  But all too often, we honestly don’t know what the right care is.

The right care should provide each person with care that is effective - that is care that improves their life compared to what would have happened had they not sought care.

What may surprise many people, even some working in health care is that many of the clinical actions we consider standard have not been shown to be more effective than other care options or even no care.

Evidence-based care seeks to fill this gap in knowing by:

First, using data to identify what we know

Then, develop and test solutions for what we don’t.

We identify what we know using data. We call the end result of the rigorous collection and critical analysis of all relevant data “evidence–based”. Good evidence–based analysis tells us how much confidence to have in a particular clinical action. Is there enough evidence to be reasonably sure that the clinical action works? Or perhaps there is just enough evidence to make a reasonable guess today that may change when we accumulate more and better data? Or is there simply not enough evidence to make any reasonable guess?

We use the science of evidence-based methods to help us determine which are the right clinical actions to deliver. We use manufacturing improvement processes to help us get better at doing the right things.

If your quality improvement toolbox only includes one or the other set of tools, you aren’t maximizing your effectiveness and efficiency. The incorporation of evidence-based methods can improve the quality of the care you deliver and encourage innovation while managing risk. Infusing your quality improvement innovations with evidence-based methods means you can begin to take more calculated risk. You can put evidence-based methods to work in your organization to identify the right things to do so that your manufacturing improvement tools can help you then standardize and systematize the best care.

 © TheEvidenceDoc 2016