1. The PDSA Cycle A Means of Improving PLAN ACT DO STUDY Welcome
Introductions
History of this Training – to begin setting up the presentation, itself, as an experience of the PDSA Cycle for the training participants.
Opportunity – Introduction of revised Plan, in September; noting that, given that the Plan identifies the PDSA Cycle as the process used by the RSN for PIP’s, a broad-based understanding of the PDSA Cycle would be important to the goal of having an effective Improvement Program.
Planning – Identified training as one means of getting to that goal, and decided that the QMOC would be the place to begin that.
Then noted that, because of all the data the UM Committee is responsible for, it would be important for those members to begin thinking from this perspective as well.
So that brings us to today, but before beginning the presentation, I’d like to make a quick assessment of your current level of understanding of this cycle, to help me gear this presentation to the appropriate level, and take advantage of expertise in the room.
Measure: I am already sufficiently knowledgeable about the PDSA Cycle to explain it to others.
Ask someone with calculator to enter scores as they are given, in order to calculate average.
Scale: 1 = No way; 10 = No Problem
Draw scale on board. Go around table getting each person’s self-assessment and marking it on continuum.
Do Mean, Median and Mode, based on data.
Acknowledge the high scorers.
GOAL – My goal for today’s presentation is twofold:
First, that you’ll discover that the PDSA Cycle is not really new, but something you have been doing for a long time.
And Second, that by the end of this presentation, you’ll understand it well enough to begin explaining it to others.
CLICK – To start the wheel turning. Okay, let’s get rolling. CLICK.
The PDSA Cycle
ACT
PLAN DO
STUDY
A Means of Improving

2. “Doing Quality”
Six Sigma
Total Quality Management
The activities by which an organization systematically and continuously evaluates the performance of key business processes, and works to improve those that produce outputs which are inconsistent with identified standards.
It’s a planned, comprehensive and ongoing endeavor.
It focuses on processes, not people.
It’s concerned with measurable indicators of quality.
Quality Assurance
“Doing Quality” – It has been called a lot of things over the years.
Don’t worry about trying to differentiate between them.
They do have varying shades of meaning, but they all basically boil down to
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Present the definition.
Claim it as your own.
Invite the other experts to embellish it.
Quality Improvement
Process Improvement
Statistical Process Control
Performance Improvement
Quality Assessment
Continuous Quality Improvement

3. “Doing Quality” – A Look Across Time
Then (1980’s)
Quick fixes, based on hunches and “pet” ideas.
“Thresholds” below or above which you let things ride.
Delegated by leaders to the nerd in the basement office.
Projects completed quickly (or not at all), with change sustained only as long as the whip got cracked.
Now (2006)
A structured approach to change, based on data.
Continual improvement, based on the belief that things can always be made better.
Promoted and practiced by leaders, who engage the rest of the organization.
A long term endeavor that gives each improvement initiative the support it needs to succeed, and that builds the change into the culture.
Spend a little time doing Compare & Contrast
Invite participants to discuss their own experiences relative to either of these portrayals of quality improvement processes.

4. A Primary Ingredient for Change
DATA
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Quality processes have always involved data, but sophistication in the use of that data to inform change has grown markedly, over the years.
When I began, pretty much everything was expressed in terms of averages and percents relating to broad measures of process performance.
Such broadly focused statistics are now considered as having limited usefulness for informing change.
Processes are analyzed in much greater depth, using a broad array of statistical and non-statistical tools, which we’ll look at briefly in a little bit.
You can hardly miss the evidence of how things have changed if you look at the Appendix in the current version of the PI Program Plan that includes all the measures the RSN is required to track.
Most of them focus on performance relating to very specific parts of service delivery processes.
The underlying assumption is that anecdotal evidence is not sufficient to demonstrate that meaningful change has occurred. YOU NEED NUMBERS FOR THAT!
I suspect that most of you can think of situations in which you’d want to argue this point, and I probably wouldn’t disagree with you regarding at least some situations you might describe.
But that wouldn’t change the fact that many things CAN be measured, if we will take the time, and that we live in a time when numbers are considered the best evidence of change.
How will you know you’ve changed it if you haven’t measured it?

5. The Process of Getting Better
DATA DATA DATA
Improvement is a journey,
DATA DATA DATA
Quality Improvement professionals now view change as a never ending process, blanketed in data every step of the way.
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Improvement is a journey, not a destination. It may sound a bit trite, but it is a mantra that is taken very seriously these days by quality professionals, by accreditation organizations like JCAHO…
And now, based on the requirements articulated in the RFQ, by the State of Washington.
DATA DATA DATA
not a destination.

6. PDSA: The Improvement Process
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PLAN DO
STUDY
Acknowledge the 4 phases of PDSA, then state that you have found it advantageous to explicitly include two other elements.
CLICK
IDENTIFY the opportunity to improve
Referred to by some as problem identification
But improvement can also be about getting even better at something you are already doing reasonably well!
ESTABLISHING A GOAL – established with an eye toward how you will measure your progress toward it.
Usually, at least some of the measurements are explicit in the statement of the goal.
So let’s spend a few more minutes looking at these two elements before focusing on Plan-Do-Study-Act.
IDENTIFY
GOAL
Opportunity to Improve
Desired Outcome

7. Getting Started – The Sources of Inspiration
Required Measures
Ad Hoc Data Analysis
Consumer/Staff Feedback
Audit Findings
…And just looking around!
You don’t have to look far to identify opportunities to improve. The evidence turns up in all sorts of places.
Progress through elements on the slide.
Choosing from among the many possibilities is generally the hard part.
And, having once found a place to focus, it seems that it’s even more difficult to take the time to do what comes next…..
CLICK
IDENTIFY
Opportunity to Improve

8. PLANNING: The First Step
GOAL
…Establish clear goals.
CLICK to “What do you want to accomplish?”
EXAMPLE: Let’s suppose that I have just told you that I am really unhappy with the way my clothes are fitting me these days, and that I want to do something about that. In other words, I’ve identified an opportunity to improve and I want to do some planning.
What guidance might you give me at this point?
Sort out which of their responses focus on solutions, and which focus on identifying a desired outcome.
Note the variety of solutions proposed, and ask how you would choose the best solution if you hadn’t first gotten clear about what outcome I wanted to achieve.
Part of the American culture is a preference for action over thought.
When the question, “What do you want to accomplish?” is posed, there’s a high probability that people will respond with suggested actions, rather than identifying the new state of being that they believe these actions would create.
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Once you have identified the desired outcome (state of being), the parameters by which you will measure your progress toward that state become a great deal more apparent, and are often expressed in the language of the goal itself.
Expressed in Measurable Terms
What do you want to accomplish?
Think “Outcomes” not “Solutions” at this point.
How will you know when you’ve done it?
Identify specific parameters by which you will measure your progress toward the goal.

9. Decide Upon A Solution/Change
Identify the business processes involved.
If necessary, collect additional data to help focus your understanding of the issues.
Gather input from people who routinely work in, or experience, the processes.
Identify a course of action that appears feasible to carry out, and likely to produce the desired outcomes.
The Planning phase is about identifying a course of action that will result in different outcomes from those currently being produced.
Planning includes some very important steps that are often not done well in organizations when they want to make changes.
I’ve always found it a bit curious that most people do a much better job of planning change for themselves than they do when planning it for their organizations.
Walk through the bulleted point, one by one.
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Spend a minute focusing on “Plan a Pilot.”
This is what differentiates the PDSA Cycle from many other changes processes.
The recognition that rapid, wholesale change often leads to momentous, wholesale failure is a keynote of PDSA.
The PDSA Cycle is meant to produce incremental change.
How long it will take to achieve the outcomes you want will be a matter of how complex the goal is, and how great the gap between where you are and where you want to be.
The point of approaching change by piloting proposed changes is to avoid throwing systems into disarray with solutions that prove to be less effective than predicted.
Then…Plan a Pilot.

10. It’s the Process, Not the People
Process: A sequence of steps or actions carried out in order to provide a particular service and/or to deliver a specified outcome.
Planning involves:
Identifying the processes that are producing the results you want to change.
Defining the boundaries of each process.
Figuring out which parts of a process you want to alter, and how that may affect other parts of the process, or other processes.
Throughout this presentation, thus far, I have used the work “process” repeatedly.
Because processes are what the PDSA Cycle is designed to improve, we’re going to take a few minutes to make sure we’re all on the same page in our understanding of what a process is.
Key to creating sustained improvement is the understanding that…
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Processes deliver the outputs they are designed to deliver!
Staff may learn how to compensate for poorly designed processes in order to achieve better outcomes, but gains achieved by this means are rarely sustainable over time and tend to result in staff burnout.
If you want real change, you have to deal with the way work is designed to happen.
So let’s take a look at what a process is.
Walk through the remaining elements of the slide.
Processes deliver the outputs they are designed to deliver!

11. “It’s The Process” – A Somewhat Silly Example
Opportunity for Improvement: Suzanne is late to work 80% of the time.
Goal: Suzanne will begin working by 8:00 AM at least 95% of the time.
Processes: “Getting Ready for Work” and “Traveling To Work”
Process Boundaries:
Getting Ready for Work – First Step: Get out of bed; Last Step: Get in the car
Traveling to Work – First Step: Start the car; Last Step: Arrive at desk
Okay, let’s put feet on what we’ve just covered with a completely fabricated example.
And once we’ve done that, I’m going to ask you to spend a few minutes practicing with some very real examples.
Walk through the slide elements.
Now, let’s take a look at pictures of Suzanne’s two processes.

12. Suzanne’s Processes Getting Ready for Work Traveling To Work
Get out of bed
Get in the car.
Clean up and get dressed.
Prepare and eat breakfast.
Prepare lunch to take to work.
Prepare dinner for evening; refrigerate it.
Walk through the steps of each process
Spend time with the two questions.
Relate whatever happens back to earlier content.
One last question before we move on: What kind of diagram are each of these two pictures?
Flowcharts – High level
Although we will not spend more time with this particular tool today, I do want to point out that learning to think in terms of flowcharts, and to see them in your mind’s eye whenever you are considering how to improve something, is one of the core competencies associated with successful quality improvement efforts.
Traveling To Work
Start the car.
Arrive at desk.
Drive to Starbucks
Use the drive-up window to get a latte.
Drive from Starbucks to office.
Go to the break room to drink latte.
What measures of process performance might you collect data for before you decide where to make changes?
Given your understanding of Suzanne’s current processes, what changes might you recommend piloting?

13. Exercise: Name That Process
Instructions:
Work in groups of 2-3
Name the processes that impact each measure on the worksheet.
Process names usually begin with a verb that ends in “ing,” (e.g., Doing an Intake, Authorizing a Service, Scheduling an Appointment, Documenting a Service, etc.)
Measures are usually impacted by more than one process.
For each measure, select one of the processes you named and identify its first and last steps, i.e., define the “process boundaries.”
Introduce the exercise
Pass out the exercise worksheets
Debrief the exercise
What did you learn?

14. Tips for A Successful “Plan” Phase
Take time to understand how the involved processes currently work, and why they are structured as they are.
If you need more data in order to understand the situation, take time to get it.
Take time to listen to people who actually work in the process, and to gather their ideas about how to get better results.
Take time to come up with more than one potential solution before settling on the solution to pilot.
Take time to develop an implementation plan that makes sense to those who will have to carry out the solution.
Okay, let’s summarize some of the key aspects of carrying out the Plan phase of the PDSA cycle.
Introduce each bulleted point, one-by-one.
Ask---What is the underlying theme of all these points?
TAKE TIME!
Leaders often feel like time is the one thing they don’t have much of. But, just for a moment, imagine yourself as someone who has never heard this presentation, and who is being expected to change the way they’ve been doing things forever.
Now, from that perspective…
is there anything on this list of tips that you would consider a waste of time?
And still from the perspective of that staff person…
How supportive of the change you’re being asked to make are you likely to be if it becomes apparent to you that leadership has not taken the time to do these things?
What I’ve learned over the years since I first began facilitating improvement efforts is this:
Do—”CHANGE TAKES THIS LONG” example

15. Tools for the “Plan” Phase
Statistical Tools
Pareto Diagram
Histogram
Scatter Diagram
Run Chart
Control Chart
Other statistics and forms of data presentation
Non-Statistical Tools
Process Flow Chart
Cause/Effect Diagram
Failure Modes and Effects Analysis
Brainstorm
Affinity Diagram
Inter-relationship Diagram
Prioritization Matrices
Activity Network Diagram
We’ve already spent some time with one of the primary tools of the Planning phase—the Flowchart—although there is a great deal more you’ll eventually need to know about creating and using flowcharts.
And before moving on to the next phase of the PDSA Cycle, I want to briefly introduce you to other tools commonly used to plan change.
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Don’t panic; I’m not going to ask you to work with statistics---TODAY!
Let me also point out that you can use the PDSA Cycle without employing all of these tools.
That said, especially for formal projects like the Performance Improvement Project’s (PIP’s) that the State requires of the RSN, a great many of these tools are essential.
Because of that, it WILL eventually be necessary for you to understand most of them, and for some of you to become expert in their use.
Briefly introduce each tool, describing what it does.
We’ve just looked at the basic statistical tools, but there are also non-statistical tools that are useful for understanding issues and helping groups of people think productively together.
FINAL CLICK
I’ve introduced these tools as part of the Plan phase of the PDSA Cycle, but many of them are likely to be used again during the Study phase.
Many of these tools also come in handy during the “Study” phase of the cycle.

16. DOING: Piloting Your Solution
Begin by making sure that people understand why a change is needed, and how to implement the solution to be piloted.
Present the timelines for implementing the pilot and assessing its success.
Whenever I present the PDSA Cycle, I spend most of the time with the Plan phase, for two reasons:
This phase is the most critical to a successful change process, and
If you do the Plan phase well, the rest of the cycle just seems to occur quite naturally if you’re paying attention.
I’m going to cover the remaining phases—Do, Study, and Act—fairly quickly. But please stop me if you have questions or have not addressed something that should be said about any of them.
Walk through the points on the slide
Monitor the progress of the pilot project.
Don’t just “tell and run.”
Assign a “champion” with whom staff can work to resolve implementation glitches.
Make sure the data you’ll need to evaluate success is collected.

17. STUDYING: Did It Work? What did you learn during the pilot?
What do the data tell you about process performance after the change was implemented?
What do staff/consumers have to say about how well the solution worked?
If there is one trait that needs to characterize the Study phase of the cycle, it would be CURIOSITY.
Walk through the questions on the slide.
Focus on the importance of the final question.
Did you get any surprises?
Did you make any messes?
Did you get where you wanted to go?
In hindsight, what are the pro’s and con’s of your solution?
Now that you’ve tried it, do you believe this change can be sustained?

18. Improvement is a journey,
ACTING: The Next Steps
If the change you piloted was successful:
Publicize your success.
Take whatever steps are necessary to formalize the change.
If the change you piloted did not create the desired outcomes:
The last phase of the PDSA cycle is a beginning, not an ending.
It is a point at which you pause to determine what needs to happen next.
CLICK
Will you make the change you piloted permanent, as is?
If so, what must happen next in order for a broader implementation to be successful?
Was your pilot less successful than you hoped?
Do you need to tweak your solution?
Do you need another pilot, to determine whether your solution works in a different context?
Do you need to abandon the solution altogether, and identify a new approach to reaching the goal?
Do you need to recalibrate the goal, to take a less aggressive path toward change?
These are all questions that you consider, and each one suggests that your work is not done.
Don’t give up! Remember, PDSA is about incremental change.
Celebrate the small successes along the way to the goal.
Share the results.
Gather feedback from staff and consumers who participated in the pilot.
Use the lessons learned to formulate a new solution to pilot.
Don’t give up!
Improvement is a journey,
not a destination.

19. Opportunity to Improve
PDSA: A Review
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PLAN DO
STUDY
We have now considered the PDSA Cycle in its entirety, and before we move on to the final portion of this training, I’d like to revisit the measure I used at the beginning of the presentation to assess our progress.
STUDY: REVISIT THE MEASUREMENT CONTINUUM. Re-plot individual scores and recalculate Mean, Median and Mode.
Discuss the meaning of the data.
ACT: Discuss what it would take to have wide-spread understanding of the PDSA cycle, and how to use it as a process for making improvements in their agencies.
Review the PDSA Cycle in light of the training.
This presentation was designed to include every element of the PDSA Cycle. In other words—each of you has just experienced a PDSA Cycle.
Ask them to identify the activities that constituted each element of the Cycle.
Identify Opportunity: Presented during the opening history of how a need for training was identified.
Plan: The decision to do a training. The collection of data at the beginning of the training.
Goal: That each would understand the cycle sufficiently to be able to explain it to others.
Do: The training itself, which has been presented as a pilot relative to how well it addresses the need for understanding.
Study: Their feedback, and the 2nd round of data collection to test whether there was any change from the initial measurement.
Act: The discussion about how to cultivate understanding of the PDSA Cycle throughout the RSN.
Turn the time back to Jack and Glen, for any Next Steps they would like to suggest.
IDENTIFY
GOAL
Opportunity to Improve
Desired Outcome