Model For Improvement

Part 1: Definition & Process

The Model for Improvement is based on the sequential building of knowledge and is centred on three questions that are fundamental to all improvement activities, followed by testing using the Plan-Do-Study-Act (PDSA) cycle .

The questions and the PDSA cycle allow for application to be as simple or as sophisticated as needed, depending on the situation and the people involved.

Multiple PDSA cycles that can adapt changes to local settings allow for knowledge to be built while changes are being tested, thus reducing risk.

Part 2: Setting the Aims

• Improvement requires setting aims
• The aim should be time-specific and measurable
• The aim should define the specific population of patients that will be affected.
• Agreeing the aim is crucial; so is allocating the people and resources necessary to accomplish the aim

Set the aims clearly

• Achieving agreement on the aim is critical
• Teams make better progress when they are very specific about their aims
• Make sure the aim describes the system to be improved
• Ensure that the aim gives guidance on the approaches to improvement

Use numerical goals

• Teams are more successful when they have unambiguous, focused aims.
• Setting numerical goals helps clarify the aim, creates tension for change and directs measurement
• "Reduce operating room time" is not as effective as "Reduce operating room time by 50% within 12 months."

Set “Stretch Goals”

• A stretch goal is one to reach within a certain time.
• "Reduce operating room time by 50% within 12 months" communicates immediately and clearly that maintaining the status quo is not an option
• A stretch goal makes people look for ways to overcome barriers - tweaking the existing system is not enough

Avoid “Aim Drift”

• The stretch goal “Reduce operating room time by 50% within 12 months” can slip to “Reduce operating room time by 40%” or “by 20%”
• Start each team meeting with an explicit statement of aim, e.g. “Remember, we’re here to reduce operating room time by 50% within 12 months”
• Review progress quantitatively over time

Refocus the Aim

• Every team needs to recognise when to refocus its aim.
• If the overall aim is at a system level (e.g. "Reduce adverse drug events in critical care by 30% in 12 months"), refocusing for a time on a smaller part of the system (e.g. "Reduce adverse drug events for cardiac critical care patients by 30% in 12 months") will help achieve the desired system-level goal

Part 3: Forming the Team

• Including the right people on a process improvement team is critical to a successful improvement effort
• Teams vary in size and composition
• Each organisation builds teams to suit its own needs

Effective Teams

• Effective teams include members representing 3 different kinds of expertise: executive leadership, technical expertise, and local leadership
• There may be more than one individual on the team with each kind of expertise, or one individual may have expertise in more than one area, but all 3 areas should be represented
• Executive Leadership
  • The team needs a leader with authority to institute a change and to overcome barriers
  • The team needs a leader who understands the both local implications of the proposed change and the more remote consequences such a change might trigger
  • The team needs a leader who has authority to allocate the time and resources the team needs to achieve its aim(s)
• Technical Expertise
  • A technical expert is someone who knows the subject intimately and who understands the processes of care
  • The expert can provide additional support by helping the team determine what to measure, assist in design of effective measurement tools, and provide guidance on collection, interpretation and presentation of data
• Local Leadership
  • The local leader is often the driver of the project, assuring that tests are implemented and overseeing data collection
  • This person understands not only the details of the system, but also the effects of making change(s) in the system
  • This person needs to be able to work effectively with the clinical champion(s)

A Rounded Team

• Be sure that the team includes members familiar with all the different parts of the process
• Include managers and administrators as well as those who work in the process, including doctors, nurses, pharmacists, and other front-line workers

Part 4: Establishing Measures

• Measurement is a critical part of testing and implementing changes
• Measures tell a team whether the changes they are making actually lead to improvement
• Measurement for improvement should not be confused with measurement for research

Research versus Improvement

	Measurement for Research	Measurement for Process Improvement
Purpose	To discover new knowledge	To bring new knowledge into daily practice
Data	To gather as much data as possible, "just in case"	To gather "just enough" data to learn and complete another cycle
Duration	Can take long periods of time to obtain results	"Small tests of significant changes" accelerates the rate of improvement

Seek Usefulness Not Perfection

• Remember, measurement is not the goal; improvement is the goal
• In order to move forward to the next step, a team needs just enough data to know whether changes are leading to improvement

Plot Data Over Time

• Much information about a system and how to improve it can be obtained by plotting data over time, such as data on length of stay, volume, patient satisfaction - and then observing trends and other patterns
• Tracking a few key measures over time is the single most powerful tool a team can use

Use Sampling

• Sampling is a simple, efficient way to help a team understand how a system is performing
• Sampling can save time and resources while accurately tracking performance.
• For example, instead of monitoring the time from catheterization to cardiac surgery continuously, measure a random sample of 10 to 20 cardiac surgery patients per month

Qualitative & Quantitative Data

• In addition to collecting quantitative data, be sure to collect qualitative data, which often are easier to access and highly informative.
• For example, ask nursing staff how weaning from medications is going or how to improve the immunisation protocol.
• To focus efforts on improving patient satisfaction, ask patients/families about their experience of process to be changed

Integrate Into the Daily Routine

• Useful data are often easy to obtain without relying on information systems
• Don’t wait three months to receive data from the information department on number of children immunised in primary care clinics.
• Develop a simple data collection form, and make collecting the data part of someone’s job

Part 5: Selecting Changes

• All improvement requires making changes, but not all changes result in improvement
• Organisations therefore must identify the changes that are most likely to result in improvement

Are We Falling Short?

• Health care around the world is in need of revolutionary change. We are not performing at the level our patients deserve
• There are huge gaps between knowledge and practice. Adverse events harm patients far too often. Too many people don’t get the care they need
• The system propagates waste: waste of time, waste of resources, and waste of good will

Good News

• Yet there is also good news: examples of results from around the world demonstrate that breakthrough improvement in health care is possible

Example of a good change

• In 2000 the UK National Health Service launched its National Primary Care Collaborative improvement project
• Now encompassing 2,000 practices covering 11.5 million patients, the Collaborative has helped to reduce by an average of 60% the waiting time for an appointment with a GP

Some Changes to Focus On

• Eliminate Waste
  • Remove any activity or resource in the organisation that does not add value to an external customer/patient
• Improve Work Flow
  • This is an important way to improve the quality of service provided by any process
• Stock Control
  • Stock of all types is a possible source of waste; understanding where stock is stored is the first step in finding opportunities for improvement
• Focus on Variation
  • Reducing variation improves the predictability of outcomes and reduces the frequency of poor results

Part 6: Testing Changes

• Once a team has set an aim, established its membership, and developed measures to determine whether a change leads to an improvement, the next step is to test a change in the work setting
• The Plan-Do-Study-Act (PDSA) cycle is shorthand for testing a change
• This is a scientific method for action-oriented learning

Reasons to Test Changes

• Increase your belief that the change will result in improvement
• Decide which of several proposed changes will lead to the desired improvement
• Evaluate how much improvement can be expected
• Decide whether the proposed change will work in the real world
• Decide which combinations of changes will have the desired effects on the important measures of quality
• Evaluate costs, social impact, and side effects
• Minimise resistance upon implementation

Plan - Do - Study - Act

• Use the PDSA cycle

Part 7: Implementing Changes

• After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team can implement the change on a broader scale
• During implementation, teams learn valuable lessons necessary for successful spread of changes

Spreading Change

• Spreading is the process of taking a successful implementation process from a pilot and replicating that change in other parts of the organisation
• During implementation, teams learn valuable lessons necessary for successful spread, including key infrastructure issues, optimal sequencing of tasks, and working with people to help them adapt a change

Permanent Change

• Implementation is a permanent change to the way work is done and, as such, involves building the change into the organisation
• It may affect documentation, written policies, hiring, training, compensation, and aspects of the organisation's infrastructure that are not heavily engaged in the testing phase
• Implementation may also require the use of the PDSA cycle

In conclusion

• The Model for Improvement centres on 3 questions that are fundamental to all improvement activities, and the PDSA cycle
• Improvement requires setting aims that should be time-specific and measurable
• Effective teams include members representing 3 kinds of expertise: executive leadership, technical expertise, and local leadership
• Measures are a critical part of testing and tell a team whether the changes they are making actually lead to improvement
• All improvement requires making changes, but not all changes result in improvement
• The PDSA cycle is shorthand for testing a change
• During implementation, teams learn valuable lessons for successful spread of changes

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[Principal author(s): Richard Jones]

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See also…

PDSA cycle: The "Plan-Do-Study-Act" (PDSA) cycle is shorthand for testing a change — by planning it, trying it, observing the results, and acting on what is learned. This is the scientific method, used for action-oriented learning.