Implementing Quality
Improvement
Introduction to PDSA cycles
Objectives
After this session participants will:
• Understand how to do a gap analysis
• Understand the main steps in
implementing a change to improve
quality
• Understand the concepts of PDSA
You’ve done the measurement.
What should you do with all that
data?
Your data shows: Only 70% of eligible
patients are routinely screened for TB.
How can you improve this?
How do we improve a problem?
Some general principles
• Need to ensure there is an atmosphere of
improvement
• The discussion is not accusatory or seeking to
blame
• The problem is in the process not the
individual
– Clinic procedures, information, materials/supplies,
equipment
QI methods
• Many approaches, some overlaps, but all with
the same goal: Improve a gap
• Some basic questions that the team must ask
– Why does the gap exist?
– How can we close the gap?
– Did we succeed?
6
Introduction to PDSA
A process that helps us to organize how we
will improve a gap
• Plan
• Do
• Study
• Act
Remember the link between
measurement and QI
Measure quality
Identify a gap
Understand why gap exists
Work to address the gap: QI
PDSA cycles focuses on the
highlighted areas
Measure quality
Identify a gap
Understand why gap exists
Work to address the gap: QI
Adapted from JSI
PDSA cycles focuses on the
highlighted areas
Measure quality
Identify a gap
Act
Plan*
Understand why gap exists
Work to address the gap: QI
Study
Do
The PDSA cycle
Identify a gap
Expand and integrate
Act
Does the intervention
need to be modified?
OR
Is the change ready to
expand and integrate?
Study
Did the measurement
show the expected
difference?
Were other changes
seen?
Share with team
Plan*
*Plan as response
Understand why gap
to identified gap
exists
Make a plan to fix the gap
Decide how to implement
plan (who, what,
where, when)
Do
Carry out the plan on
small scale
Document problems
Begin analysis
Adapted from IHI, HIVQUAL
JSI and others
So how do you plan what your
change (QI project) will be?
Step 1: Planning to improve a
quality gap
1. Understand where in the system things are
not working:
1. Make a Flow chart
2. Brainstorm - Where do we think problems are?
3. Cause and Effect (Fishbone)
2. Develop the solution
3. Make a plan to fix the gap
4. Decide how the plan will be implemented
(discussed in next talk)
Make a flow chart
• A map of what should happen
• Work with the QI team and others as needed
• Draw out each of the detailed steps required
to have the desired outcome
– An eligible patient is started on ART
• Start with patient registering to clinic, end with patient
started on ART.
– Patient receives Cotrimoxazole prophylaxis
• Start with patient comes into clinic and end with
patient leaving clinic with CTX pills
Flow chart 1: TB screening , diagnosis and
referral for treatment at the OPC
Patient
Three sputum:
- 1: on-site
- 2: morning after
- 3: on-site
Registration nurse
Document in the registration book
& patients chart:
- Check pt’s ID card
-Stamp TB screening (if used)
Doctor
- Physical examination
-TB screening: check questions
Lab: taking
specimens
Any suspected symptom
Lab: smear or culture
2 days
Get result
BK positive
1-5
days
Refer to TB unit for
treatment
Giving to the registration nurse for
documentation
Brainstorming
• Refer to the flow chart as a guide
• List all potential causes of the quality gap
• Work as a team and continue until you have
exhausted all ideas
• Categorize into potential groups
–
–
–
–
–
–
–
Human resources
Patient factors
System/protocols
Guidelines
Infrastructure
Resources
Other factors
Flow chart 2: List all the possible gaps
1
Patient
Forget to ask about
symptoms
Forget to document
Do not take
sputum
3
Document in the registration book
& patients chart:
- Check pt’s ID card
- Weight, temperature, BP
- Stamp TB screening (if used)
Stamp not available
Forget to stamp chart
Registration nurse
2
Three sputum:
- 1: on-site
- 2: morning after
- 3: on-site
- Physical examination
-TB screening: check questions
- Baseline tests: CBC, CD4, LFT,
HBV, HCV, VDRL
Doctor
Lab: taking
specimens
Lab: smear or culture
Any suspected symptom
Lost or poor specimens
4
2 days
Get result
Giving to the registration nurse for
documentation
5
BK positive
1-5
days
Refer to TB unit for
treatment
No result
Result not documented
Cause and effect/Fishbone
• Developed by Ishikawa
• Helps to categorize the potential causes of the
gap
– Ex. those developed by brainstorming
• Guides where you might try to improve
Systems and
guidelines
Resources
Other
factors
Gap
Staff
Physical Infrastructure
Patients
Guidelines and systems
Screening guidelines not
clear
Charts not well
organized
Resources
Stamp lost
Other factors
Patient not
screened
for TB
Staff
Too few
Not trained
MDs get called
away
Physical Infrastructure:
Inadequate space,
Too crowded
Patients
Come late to
appointment
Step 1 Plan - Some tips
• Work as a team. Every voice counts.
• Start with a flow chart, then brainstorm
possible gaps in each step of the process.
– The “change” or first QI project may be found
after this step.
• Categorizing into systems will help to further
organize and guide where the change can be
focused.
• Ask representative from leadership to join and
develop the detailed plan
Step 1: Example of a plan to improve TB
screening from 70% to 90% of patients
• After discussion of the possible causes, the
clinic decides the biggest problem is that
nurses and doctors forget to ask about
symptoms and a reminder is needed.
• Solution: Place signs on the desk and use a
stamp that had been provided, but not
regularly used.
Step 2: Do
Do
• Carry out the plan
• Document
problems
• Begin analysis
The PDSA Cycle
Do: Principles
• Is there something easy that another clinic has
already done?
• Start small and simple
– What can we change by next week?
• Test it out – don’t be afraid to just try
something small to see if it works
• Document what happens, both good and bad.
– Do a mini chart review
– Note any affects on resources or other systems
PDSA Quality
Cycle Center
Ref.The
National
Example simple solution
Step 3: Study
Study
Did the measurement
show the expected
difference?
Were other changes
seen?
Share with team
The PDSA Cycle
Did the stamp improve TB screening?
• Quick review of 10 charts: 9 screened for TB
• Minimal work for nurses
TB screening
stamp with
symptom put
on doctor’s
desk
13%
70%
Step 3: Study
Yes! This plan
worked
Study
Did the measurement
show the expected
difference?
Were other changes
seen?
Share with team
The PDSA Cycle
No effects on
resources
Step 4: Act
Act
Did the plan work?
Yes: How will you expand
or sustain it?
No: What will you try next?
The PDSA Cycle
Act: What Will We Do (Based on
What We Learned)?
In our example:
1) we will continue to use the stamp
2) make sure that it has a secure place to stay
3) add signs to remind staff and patients about
TB screening
4) continue to monitor.
The PDSA Cycle
Example: TB screening
TB screening
stamp with
symptom put
on doctor’s
desk
13%
- Remind staff
about TB
screening in
staff meeting
- Make a paper
reminder put
on the desk in
front of the
doctor
70%
90%
Goal: 90%
Another example
• Clinic ABC found that many patients were
missing clinic visits.
• After writing out a flow chart and
brainstorming potential causes they decided
the core cause was many patients had barriers
to keeping appointments
Plan:
Tool to improve on time visits.
• Objective: screen HIV patients for issues that might affect
their ability to come to clinic on time.
• Prediction: adding a screening tool will add time to the
patient visit, but we can keep this to a minimum
• Steps: Nurse Thuy and Counselor Ngoc researched and
identified possible tools that were reviewed by Ngoc and Dr.
Phuong. They selected one tool for Dr. Phuong to use with at
least three patients in the clinic on Thursday
• Necessary tasks: 1. Identify tool. 2. Copy tool and place in
patients' charts. 3. Dr. Phuong reviews instructions for using
tool. 4. Explain tool to patient. 5. Use tool
Adapted from the National Quality Center
Do: Implementing the adherence
tool
• Dr. Phuong used the tool on one patient the
next day
The PDSA Cycle
Study: What happened with the
tool?
• The tool was 5 pages long
• Added 35 minutes to the patient’s visit
• The next patient waiting for the doctor was
late for work so had to leave his appointment
• We made things worse!
The PDSA Cycle
Act: What happened with the tool?
• The clinic team sat down again to come up
with a new plan to screen patients for
barriers.
Emphasis point
All improvements require change,
however, all changes don’t lead to
improvement
Summary
• Goal of QI is to improve
• Requires team approach
• Many approaches exist – most use
incremental and continuous change
• Start small
• Measure before, during and after to make
sure there is improvement
• Make sure the change is institutionalized so
the change is sustained.
Summary slides - Quality
Improvement: first step
Guidelines and standards
95%
Performance goal
Performance gap
80%
Actual performance
Quality
Improvement
Intervention
Quality Indicators
Adapted from JSI and EGPAF
Quality Improvement: second intervention
Guidelines and standards
95%
Performance
goal
Performance gap
90%
85%
Actual performance
Second QI
Intervention
Quality Indicators
Adapted from JSI and EGPAF
Resources
•
•
•
•
•
NationalQualityCenter.org
HIVQUAL
John Snow International
Institute for Healthcare Improvement
Partners in Health
Resources