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Opening the "black box" of PDSA cycles: Achieving a scientific and pragmatic approach to improving patient care Chris McNicholas, Professor Derek Bell,

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Presentation on theme: "Opening the "black box" of PDSA cycles: Achieving a scientific and pragmatic approach to improving patient care Chris McNicholas, Professor Derek Bell,"— Presentation transcript:

1 Opening the "black box" of PDSA cycles: Achieving a scientific and pragmatic approach to improving patient care Chris McNicholas, Professor Derek Bell, Dr Julie Reed –National Institute for Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London, Imperial College London –The Health Foundation United Kingdom 1

2 2 Types of evidence Key questions about the QI methodology Sources of evidence to answer those questions Theoretical evidence How and why does it work? What is the underlying ‘programme theory’? Descriptions of the methodology's intended mechanism or action, setting out the programme logic or intended causal sequence and drawing on appropriate social science theory Empirical evidence When, for whom and how well does it work? What effects does it have? What does it cost? Qualitative and quantitative evaluations of the methodology's implementation, using rigorous and robust comparative methods to quantify effects, and undertaken independently Experiential evidence What is it like to use? What has been learned about its application in a wide variety of settings or contexts? Descriptive accounts of the methodology in use, synthesis of practitioner experience and feedback, collation of learning and interchange among networks of users A more sceptical and scientifically rigorous approach to the development, evaluation and dissemination of QI methodologies is needed, in which a combination of theoretical, empirical and experiential evidence is used to guide and plan their uptake.

3 Outline Theory of PDSA (Systematic Review) Reality of PDSA (International Observational Study) Revisiting Theory PDSA 3 Theory Empirical Experiential

4 PDSA Cycles – Why the interest? 4

5 Research Questions What are the perceived functions and benefits of PDSA method? Are these functions and benefits applied in practice? How do social and organisational contextual factors influence the improvement work and the use of PDSA in practice? 5

6 An International Observational Study 4 International Sites Specific improvement initiatives, Organisational improvement support, Broader organisational context Methods: Interviews (65), Observations (70 hours), Focus groups (6), Document analysis (PDSA cycles) Technical, Social and Contextual research lenses 6 MUSIQ (Model for Understanding Success in Quality) Kaplan et al, 2013)

7 Observing the reality of PDSA Selected Themes from Preliminary Analysis Using quantitative data to inform progression of cycles Managing complexity of emergent learning - scaling up and iterative cycles Social factors influencing PDSA use 7 FeatureOrg 1Org 2Org 3Org 4 Documentation of cycles Iterative cycles Start testing on small scale Use of regular data over time Prediction-based test of change

8 8 The nitty gritty of having data metrics in a database… …we had a concept, we revisited it and we said we need this; by the way, that data isn’t currently being captured…that had to be designed, that had to be added, the data started being collected… and maybe three, four, five months goes by when all that is happening and now our data just started last week… And then, of course, the physicians will get frustrated, because it’s, like - ‘I thought we defined this months ago’. Using quantitative data to inform progression of cycles

9 Time Scale of testing 1 patient 3 patients Formal education Reminders in notes 5 patients Daily verbal reminders 9 All patients for one week All patients for another week Scale Up and the Disappearing PDSA ? DATA

10 Unpacking a “single” large scale PDSA 10 Ward A Process 1 Following Plan Process 2 Not Following Plan Job Plans Doctor Availability Coding of Patient Notes Data Availability Completion of Post Take Notes Time Scale of testing Sphere of contextual influence Microsystem Macrosystem

11 “its all about social skills – the technical are important but you wont be successful without social skills” 11 “That’s actually where I think the most value comes in… you have to have a conversation with people to realise most of us don’t hold with all of it, right? …that’s a two-hour conversation sometimes …just getting to that point is what takes a long time, but also where… the most valuable conversation can happen.” "If I got my laptop out in the meeting and went through a PDSA, people wouldn't come back. It's a fine line between being useful and pushing people away” Engagement tactics No Prior QI experience Using the Plan to negotiate different perspectives Prior QI experience

12 Enhancing the theory of PDSA PDSA as complex social-technical tool PDSA as boundary object between different groups Using quantitative data in social and contextual dependent world How can we structure the management of PDSA cycles? How do we prepare people for the reality of using PDSA? What are the generic implications for change management, learning organisations and knowledge mobilisation? 12 Theory Empirical Experiential

13 Time Scale of testing 1 patient 3 patients Formal education Reminders in notes 5 patients Daily verbal reminders 13 All patients for one week “Implementing” “Testing” All patients for another week ? Usability Applicability Scalability Current process Ability to measure Sustainability (self-sufficient) ‘Maintaining’ Structuring Complexity Learning and Improvement

14 Walshe, K. (2009). Pseudoinnovation: the development and spread of healthcare quality improvement methodologies. International journal for quality in health care, 21(3), Taylor, M. J. et al (2013) Systematic review of the application of the plan-do- study-act method.BMJ Quality & Safety. doi: /bmjqs Kaplan, H. C. et al (2012) The Model for Understanding Success in Quality (MUSIQ). BMJ Quality & Safety, 21(1), 13-2 Ogrinc, G., & Shojania, K. G. (2013). Building knowledge, asking questions. BMJ quality & safety, bmjqs Funders: -National Institute of Health Research (NIHR) Collaboration for Leadership in Applied Health Research and Care (CLAHRC) Northwest London -The Health Foundation 14


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