PI Model
Mike Davies, MD FACP
“Improving our work IS
our work, not a
distraction from work!”
“All teach all learn”
“Healthcare is a team sport”
Discussion
• Think of a “big change” that was not
implemented very well….
• What Went Wrong?
Why change strategies
often don’t work
• Lots of planning then lots of
implementing
– Analysis paralysis
– Lack of consensus on problem and
solution
– Risky change process
Why change strategies
often don’t work
• Pushing one solution/idea
–
–
–
–
One person’s perspective
How do we know it works?
Lack of agreement
Ignores all of the
context/circumstances
Improvement Involves
“Experimentation”
•
•
•
•
•
Setting aims/goals
Generating ideas
Testing
Measuring progress
Reflection
Lots of activity doesn’t
necessarily mean lots of
improvement!
• Focus changes on aims and goals
• Are the changes we’re making really an
improvement (according to the aims and
goals)?
– Avoid the “my idea” trap
– Take the emotion out – Measure!
-“It is not enough to be busy, so are the
ants. The question is, what are you so busy
about?”
Thoreau
3 Questions
• 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 an
improvement?
Nolan
A Model for Improvement
What is our aim?
How will we know a change is an improvement?
What changes can we make to make an improvement?
Plan the test: the experiment
Act differently
the next time
ACT
STUDY
Assess the
results
PLAN
DO
Execute it
Langley, Nolan, et.al. The Improvement Guide: A Practical Approach to
Enhancing Organizational Performance. Jossey-Bass. San Francisco, CA.
1996
The ‘unofficial version’!
• Hunch
– What could be happening here?
• Test
– Let’s try something different
• Reflect
– How did it work?
• Change
– Should we keep doing it?
From Sarah Frasier
“Kinds” of Data
• Judgment
– Research
– Performance appraisal
– “do something TO you”
• Improvement
– Process improvement efforts
– “do something WITH you”
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Minutes
Average Cycle Time Run Chart
129
119
109
99
89
79
69
59
49
39
29
Repeated Use of the
PDSA Cycle
Changes That
Result in
Improvement
A P
S D
Model for Improvement
What are we trying to
accomplish?
How will we know that a
change is an improvement?
Implementation
of Change
What change can we make that
will result in improvement?
A P
S D
Hunches
Theories Very Small
Ideas Scale Test
Followup Tests
Wide-Scale
Tests of
Change
PDSA Cycles
• Are Not Plans!
• Are small in scale
– Thinking months – think weeks; thinking
weeks – think days; thinking days – think
hours
– Thinking facility – think unit; thinking
unit – think teams; thinking teams, think
ONE team
– Thinking all patients – think a type of
patient; thinking a type of patient, think
a sample; thinking sample then 3-5 may
be enough
Exercise
• AIM- find the rule underlying a
series of numbers
• Measure - feedback from the
instructor
• Changes - are new ideas suggested by
the team
PDSA Test Results
Team
Cycle
1
2
3
4
5
6
7
8
9
10
11
12
13
14
Sequence to Test
Correct
Incorrect
Repeat PDSA
Hunch
Theory
Idea
A
P
S
A
A
P
S
D
A
P
S
D
Changes
A
P
S
D
Implementation
Wider Tests
Follow-up Tests
Small Scale Test
How to Implement a
Change
High
Successful
Change
Belief that
change will
result in
improvement
Still Needs Further Testing
Unsuccessful Change
Low
Developing
Testing
Implementing
From Lloyd Provost
A
P
S
A
A
P
S
D
A
P
S
D
S
P
S
A
Balance
Demand
And Supply
Decrease
Appt. Types
P
S
D
A
A
A
A
S
P
D
A
P
S
A
Decrease
Demand
P
A
P
S
D
D
A
P
S
D
A
P
S
D
A
P
S
D
Readiness for Change
Current State
Low
Confidence
that change will
lead to
improvement
High
Confidence
that change will
lead to
improvement
Resistant
Neutral
Ready
Large
cost of
failure
Very Small
Scale Test
Very Small
Scale Test
Very Small
Scale Test
Small
cost of
failure
Very Small
Scale Test
Very Small
Scale Test
Small Scale
Test
Large
cost of
failure
Very Small
Scale Test
Small Scale
Test
Large Scale
Test
Small
cost of
failure
Small Scale
Test
Large Scale
Test
Implement
From Lloyd Provost
Successful PDSA
• Think multiple tests over wide range
of conditions
• Think a couple of PDSA’s ahead
• Scale down the size
• Learn from the last experience
3 Questions
• 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 an
improvement?
Nolan
Change Thinking
• It is NECESSARY to be successful
– So….. get started!
• It may not be SUFFICIENT to be
successful only a few times
– So……keep going!
• Build up data, experience and
evidence over time!
– This is true learning!
Summary
• Keep focused on Aim – Measure –
Change
• Changes are “small experiments”
• Experiment wisely – PSDA
• Learn from small changes over wide
conditions before implementing
widely
• Get started and keep going