1. The PDSA Cycle or How Can We Accelerate Improvements in HIV Care? The Quality Academy Tutorial 13

2. 2 Learning Objectives: You will learn about… The importance of accelerating change The Plan-Do-Study-Act (PDSA) Cycle Concrete examples and tips how to best apply the PDSA Cycle Where to find references Learning Objectives

3. 3 Tips for Viewing This Presentation Skip to other slides in the presentation Read along with the narrator Search for keywords in the presentation Play, rewind and fast forward Review current slide View full screen Tips for Viewing

4. 4 In 1601, it was known that lemon juice prevented the disease scurvy, a Vitamin C deficiency. Select the year that the British Navy adopted this proven treatment. Submit History Question Why Accelerate Change? A) 1602 B) 1689 C) 1757 D) 1796

5. 5 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? a)1602 b)1689 c)1757 d)1796 Why Accelerate Change? (195 years later) History Question

6. 6 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 Why Accelerate Change?

7. 7 How long did the NIH take to recommend the treatment of ulcers as suggested by Marshall in his 1984 Lancet Article? Submit History Question Why Accelerate Change? A) 2 years B) 5 years C) 10 years D) 20 years

8. 8 How long did the NIH take to recommend the treatment of ulcer as suggested by Dr. Marshall in his 1984 Lancet Article? a)2 years b)5 years c)10 years d)20 years Why Accelerate Change? History Question

9. 9 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 Why Accelerate Change?

10. 10 In an article in the Journal of Quality Improvement 92 quality improvement projects were compared. What was the timeframe from problem identification to completion of first pilot? Submit History Question Why Accelerate Change? A) 23 days B) 50 days C) 397 days D) 504 days

11. 11 In a recent article in the Journal of Quality Improvement 92 quality improvement projects were compared. What was the timeframe from problem identification to completion of first pilot? a)23 days b)60 days c)397 days d)504 days Why Accelerate Change? History Question

12. 12 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 Why Accelerate Change?

13. 13 How can we accelerate change and improvements in HIV programs? Key Question: Why Accelerate Change?

14. 14 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 The PDSA Cycle

15. 15 Model for Improvement The PDSA Cycle

16. 16 The PDSA Cycle for Learning and Improvement The PDSA Cycle

17. 17 Plan The PDSA Cycle 1.Clarify your Objective 2.Make a prediction Formulate theory Objective + specificity 3.What is to be done Who What Where When How

18. 18 Plan: a New Adherence Screening Tool Objective: how can we screen HIV patients for issues that might affect their ability to adhere to their medication regimen, in a way that won’t disrupt patient flow? Prediction: adding a screening tool will add time to the patient visit, but we can keep this to a minimum Steps: Joanne and Sally researched and identified possible tools that were reviewed by Sally and Dr. Smith. They selected one tool for Dr. Smith 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. Smith reviews instructions for using tool. 4. Explain tool to patient. 5. Use tool The PDSA Cycle

19. 19 Do The PDSA Cycle 1.Carry out the plan 2.Document your observations Expected Unexpected 3.Begin analysis

20. 20 Do: What Happened? Tool was used on one patient Administration took 5 pages Added 35 minutes to documentation The PDSA Cycle

21. 21 Study The PDSA Cycle Complete Compare Summarize

22. 22 Study: Our Results (vs. Our Prediction) Theory still holds Need to test more tools The PDSA Cycle

23. 23 Act The PDSA Cycle 1.Adjustments Changes to previous test? What adjustments? Expand last cycle? 2.New cycles What are you planning? What are you going to test?

24. 24 Act: What Will We Do (Based on What We Learned)? We will test two different tools, each with three patients, by next Wednesday. The PDSA Cycle

25. 25 The PDSA Cycle for Learning and Improvement The PDSA Cycle

26. 26 Method for Change The PDSA Cycle

27. 27 How Do Tests Lead to Improvements? Applying PDSA

28. 28 Start Small and Do More Applying PDSA

29. 29 At the Beginning, Test on a Small Scale “What change could you implement by next Tuesday?” Use the “Rule of 1”: 1 facility 1 office 1 provider 1 patient Applying PDSA

30. 30 Scale Down the Time Frame Years Quarters Months Weeks Days Hours Minutes Drop down two levels! (years to months, weeks to hours) Applying PDSA

31. 31 Keep the First Tests Simple Volunteers at first Useful, not perfect, data Use “huddles” to report Applying PDSA

32. 32 Build Each Cycle on Its Predecessor “The shorter the timeframes between test cycles, the more tests can be conducted and therefore, more opportunities for learning will emerge.” HIVQUAL Workbook Applying PDSA

33. 33 Key Points The PDSA Cycle: Helps “test your hunches” Adapt these changes to your own environment. Start small Lead to more complex cycles Key Points

34. 34 Resources http://www.IHI.org/IHI/Improvement/ ImprovementMethods provides information on improvement methods, strategies, and changes.http://www.IHI.org/IHI/Improvement/ 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. Resources

35. 35 Which of these would be a good first PDSA Cycle? Test Question A) Test a new appointment system in the HIV clinic for two weeks. B) Test a new method for reading PPDs with all the patients who show up for readings from 10-11 am on Wednesday. C) Ask all providers to spend more time counseling patients on adherence, and check in at the next staff meeting on how it went.

36. 36 What data should you collect on your test of a new way of reading PPDs? Test Question A) How long the client had to wait B) Whether the client complained about waiting C) Whether the staff felt the new method worked well D) All of the above E) It depends on your hypothesis

37. 37 Your group found that changing the PPD reading method cut wait time in half. What would be a good “second cycle” PDSA? Test Question A) Implement it fully B) Try it for a full week C) Try the method with other follow-up services

38. 38 Please Rate This Tutorial By Indicating How Your Response To The Following Statements. Was this Tutorial helpful to you? Did this Tutorial meet your expectations and goals? Was the Tutorial clearly organized and easy to use? Would you recommend this Tutorial to colleagues of yours? Yes, a lot Yes, a little NeutralNo, not very muchNo, not at all Submit Evaluation

39. 39 Related Tutorials To learn more about the Model for Improvement, study Tutorial 12 To learn more about how to set up quality team for success, study Tutorial 11 Related Tutorials

40. 40 The Quality Academy For further information, contact: National Quality Center New York State Dept. of Health 90 Church Street, 13 th floor New York, NY 10007-2919 Work: 212.417.4730 Fax: 212.417.4684 Email: Info@NationalQualityCenter.orgInfo@NationalQualityCenter.org Or visit us online at NationalQualityCenter.org NationalQualityCenter.org In Closing