1. QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM 2018
MODEL FOR IMPROVEMENT
QUALITY IMPROVEMENT FAMILY MEDICINE CURRICULUM 2018

2. After this session you will be able to…
Describe the Model for Improvement
Identify opportunities for patient engagement in QI
Prepare your improvement charter
Develop your problem statement
Establish an AIM statement
Define measures relating to your AIM
Construct a driver diagram for your project
Develop change ideas
Use the PDSA cycle to test change ideas
There are 7 learning objectives for this session. After this session,
You will be better prepared to answer the three fundamental questions in the Model for Improvement which helps you structure your improvement plans. Those three fundamental questions also help you focus your quality initiative.
We will introduce the use a project charter to document your project efforts and you will learn the steps in the development of a problem statement that describes the reason for the effort for your improvement initiative.
You will better be able to establish an aim statement which will describe positive change and is SMART.
You will be better able to define measures for improvement and recognize the difference between outcome measures, process measures and balance measures.
You will be able to constructing a driver diagram to describe the relationship of your QI project to broader, organizational quality improvement activity.
And you will be better be able to use change concepts to develop specific change ideas you can test.

3. THE MODEL FOR IMPROVEMENT
Specify and set the aim
Establish measures
Change concepts & change ideas
PDSA Cycle
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.
This is the Model for Improvement. It was developed by a group of biostatisticians and engineers who worked with Dr. Deming – the guru of quality improvement. All of these authors are faculty with the Institute for Healthcare Improvement – IHI.
The Model asks 3 questions – What are we trying to accomplish? The AIM
How will we know that a change is an improvement? MEASURES
What change can we make that will result in improvement? CHANGE IDEAS
The change ideas that we generate as QI teams are tested using the PDSA – PLAN, DO, STUDY, ACT cycle.

4. IMPROVEMENT OPPORTUNITY (BASED ON YOUR SITE QI MEETING OUTPUT)
Your clinical team has completed and prioritized an improvement inventory that will guide you to an improvement opportunity and project idea.
Next, you will develop a problem statement leads to the development of the aim for your project – specifying what it is you want to accomplish.
Note, as per this visual, that during the course of your project you will identify many change ideas, select a handful to test and conduct many PDSA cycles with each change idea.

5. Quality Improvement Application Process
Project Set-Up
Diagnostic
Change Idea Generation
PDSAs Testing & Implementation
Spread/Sustainability
How will we know that a change is an improvement?
What are we trying to accomplish?
What changes can we make that will result in improvement?
This visual depicts t

6. QUALITY IMPROVEMENT APPLICATION PROCESS
What are we trying to accomplish?
What changes can we make that will result in improvement?
How will we know that a change is an improvement?
Project Set-Up
Diagnostic
Change Idea Generation
PDSAs Testing
PDSAs
Implementation
Problem Identification – Context Specific
Articulation of Aim
Review Data & Identify Measures
System Diagnostic Tools: Cause & Effect Diagram,,
Process mapping,
Data analysis, etc.
Research evidence base for leading practices & brainstorming
Design tests of change using PDSA Cycle & carry out
Sustain (Project)
Spread
Sustain (Organization)
Improve & Measure
This is a more detailed version of the application process highlighting:
The 3 questions of the Model for Improvement; the application process with details, and the inclusion of sustainability & spread focus

7. QUALITY IMPROVEMENT APPLICATION PROCESS W PT. ENGAGEMENT
What are we trying to accomplish?
What changes can we make that will result in improvement?
How will we know that a change is an improvement?
Project Set-Up
Diagnostic
Change Idea Generation
PDSAs Testing
PDSAs
Implementation
Use qualitative CAPTURE tools to identify evidence that patients perceive this issue to be a problem
Use qualitative CAPTURE tools to UNDERSTAND touchpoints and possibly root cause from a patient perspective
Bring patients and providers together to brainstorm/CO-DESIGN change ideas to address root cause(s)
IMPROVE & MEASURE: Consult with patients re: acceptability/
feasibility of design from a patient perspective
IMPROVE & MEASURE : Debrief with patients to understand whether the test had a positive impact on their experience
Design tests of change using PDSA Cycle & carry out
Problem Identification – Context Specific
Articulation of Aim
Review Data & Identify Measures
System Diagnostic Tools: Cause & Effect Diagram,,
Process mapping,
Data analysis, etc.
Research evidence base for leading practices & brainstorming
Sustain (Project)
Spread
Sustain (Organization)
Improve & Measure
With further detail, this visual includes (in dark blue boxes) the opportunities and examples of how to engage patients in aspects of the application of QI methodology.

8. DEFINITION - “CHARTER”
A written constitution or description of an organization’s functions
Your QI Team’s commitment to a “blueprint” as to how to structure its improvement efforts
A charter is a written constitution or description of an organization’s functions
It also serves as your QI Team’s commitment to a “blueprint” as to how to structure its improvement efforts
Charters in QI work are meant to be working documents with an iterative nature meaning you will come back to this document many times to change various elements of your project.
Ultimately the charter serves as an important communication tool surrounding your project for your team and beyond.

9. Keep in mind the opportunity for improvement that you have selected
YOUR OPPORTUNITY FOR IMPROVEMENT
Keep in mind the opportunity for improvement that you have selected
As we go through this module, focus on the opportunity for improvement that you prioritized after reviewing perceived and unperceived needs and reflecting on feasibility and impact. Write down the opportunity for improvement that you selected and refined in your improvement opportunity work.

10. CHARTER – RECALL YOUR PROPOSED TEAM MEMBERS AND ROLES
Proposed QI Team
Team Lead(s)
Member A
Member B
Member C
Supervisor
Roles -
To develop a charter for your QI project, recall your proposed team members and their roles.

11. CHARTER – PROBLEM STATEMENT
What is the problem you wish to address?
Why is it a problem?
Where do we observe the problem?
Who is impacted?
When is it ongoing or recurrent?
Which of the Quality Dimensions are involved?
“A problem well defined is half-solved”
An important element of the charter is the Problem Statement.
The problem statement addresses many elements that ultimately assist in justifying the reason for the improvement effort in a particular area.
A problem statement answers the questions:
What is the problem you wish to address?
Why is it a problem?
Where do we observe the problem?
Who is impacted?
When - Is it ongoing or recurrent?
Which of the Quality Dimensions are involved?

12. PROBLEM STATEMENT – EXAMPLE
WHAT
“No Shows” – Patients with appointments who fail to attend without cancelling
Let’s look an example of the development of a problem statement.

13. PROBLEM STATEMENT – EXAMPLE
WHY
Disrupts stable patient flow during clinic
Limits appointment availability for others in need
Uncertainty introduced into patient’s health care need – how do we follow up to ensure patient does not still need a visit?
Lack of knowledge as to root cause
Why do we think this is happening?
Note that we may need to do some data collection (qualitative and quantitative) to be able to answer this!

14. PROBLEM STATEMENT – EXAMPLE
WHERE
Greater problem in residents’ clinics as population seen often less attached
Where does this problem occur?

15. PROBLEM STATEMENT – EXAMPLE
WHO
Patients – those who fail to attend and possibly lack follow-up, and those who lack access to an appointment not kept
Staff – hard to allocate staff resources; reception – additional phone calls to f/u
Physicians – hard to decide what to do – wait, work on other task etc.
Who is affected?

16. PROBLEM STATEMENT – EXAMPLE
WHEN
Occurs regularly in residents’ clinics, much less commonly with staff MDs, nurses and allied professionals
When does this problem occur?

17. PROBLEM STATEMENT – EXAMPLE
WHICH
Access - ++
Efficiency - +++
Patient centered - +
Effectiveness - +
Equity - ?
Can you identify which quality dimensions are at play?

18. PROBLEM STATEMENT – EXAMPLE
Our problem is the number of appointments not kept, particularly for residents’ schedules. This disrupts the normal flow of patients, creates uncertainty in the need for follow-up, makes it difficult to assign time and resources, and limits appointments for others in need. We are uncertain where to assign cause – with patients or with our systems for appointment booking and follow up.
Here is an example of a problem statement that has been developed in follow-up to answering each of the questions.

19. EXERCISE Problem Statement (15 min) Create a Problem Statement
Discuss with a partner
Share at your table
Create a problem statement that relates to your improvement opportunity.
Discuss your idea with a partner and then share at your table.

20. THE MODEL FOR IMPROVEMENT
Specify and set the aim
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.
For this section of this module, we are focused on the first question of the Model for Improvement. We will be specifying and setting an aim for your improvement opportunity or project idea.

21. “Begin with the end in mind.”
THE MODEL FOR IMPROVEMENT
Specify and set the aim
“Begin with the end in mind.”
This is your
Aim Statement
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.

22. SPECIFY AND SET THE AIM
Describe what you are trying to accomplish. Benchmark against:
evidence-based best practice
knowledge experts – including local colleagues
medical literature
Set the aim, which defines the goal
When you describe what you are trying to accomplish, consider best practices as defined by the evidence from the medical literature. Consider best practices as refined by the expertise of people you respect.
Consider best practices refined again by the reality of your practice setting and peers together from different practices. It is important to use multiple, complimentary sources to benchmark your practice.
Setting the aim of your quality initiative defines the goal.

23. SPECIFY AND SET THE AIM What are we trying to accomplish?
What system is to be improved?
Who is the population of focus?
What is expected to happen?
What is the timeframe?
What is the goal?
The aim statement asks the following questions:
What system is to be improved?
Who is the population of focus?
What is expected to happen?
What is the timeframe?
What is the goal? 23

24. Aim statements should be “SMART”
SAMPLE AIM STATEMENT
Aim statements should be “SMART”
Specific
Measurable
Attainable
Relevant
Time-bound
SMART aim statements are very articulate descriptions of what you’re aiming to improve. They are :
Specific,
Measurable,
Attainable,
Relevant, and
Time-bound. 24

25. SAMPLE AIM STATEMENT Specific
Measurable
Attainable
Relevant
Time-bound
“60% of adult patients diagnosed with diabetes will achieve targeted blood pressure of < 130/80 mm Hg, within 12 months.”
One way to learn how to develop a SMART Aim statement, is to review some examples. Here’s an aim statement, “60% of adults diagnosed with diabetes will achieve targeted blood pressure of less than 130/80 within 12 months”.
It’s Specific - adults with diabetes.
It’s Measurable - I’m aiming for 60%.
It’s Attainable - I think I can do this within my practice.
It’s Relevant- an evidence based best practice for blood pressure of diabetics
And it’s Time bound - within 12 months.

26. SAMPLE AIM STATEMENT Specific
Measurable
Attainable ???
Relevant
Time-bound
“75% of patients will be seen by a health care provider within 5 minutes of the scheduled appointment, within 3 months.”
Let’s work through a second example: 75% of patients will be seen by a health care provider within 5 minutes of a scheduled appointment, within 3 months.
Specific – we’re talking about patients.
Measurable – I’m aiming for 75%.- not an unrealistic 100%
Attainable – my team can do that!
Relevant -we’re describing something that’s really relevant – we can do this at our practice
And time bound – we’re giving ourselves three months to work out the kinks.

27. INCORPORATING PRESENT AND FUTURE STATES INTO AIM STATEMENTS
We will reduce the number of patients failing to attend for their appointments with residents, from 15% of residents’ booked appointments to 10%, within the next six months.
You can be even more informative about your intention if you can incorporate present and future states into your aim statement.
Here is the aim statement from our case study. In this instance the practice intentions are specific, define the population, and set a time line – all of which they believe to be attainable and are relevant.

28. EXERCISE Aim Statement (15 min)
For your opportunity for improvement: Draft an Aim Statement. Is it SMART?
Working at your table on your own Quality initiative, take the time to develop a SMART Aim statement: Specific, measurable, attainable, relevant, and time-bound.

29. What Aim Statements did you craft?
DEBRIEF
What Aim Statements did you craft?
Regain attention of the group.
Can we have some examples?

30. THE MODEL FOR IMPROVEMENT
Establish measures
Measures must relate to the AIM statement
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.
Once you have specified and set your aim, measures are established that relate to your aim statement.
It is often stated that you cannot improve what you cannot measure so measurement is a critical element of a QI project and demonstrates the actual improvement to the degree that it has taken place.

31. MEASUREMENT
Measurement for Learning and Process Improvement
Measurement for Research
Measurement for Accountability or Comparison
Purpose
To bring new knowledge into daily practice
To discover new knowledge
Comparison, choice, reassurance, spur for change
Tests
Many sequential, observable tests
One large "blinded" test
No tests
Biases
Stabilize the biases from test to test (accept consistent bias)
Control for as many biases as possible
Measure and adjust to reduce bias
Data
Gather "just enough" data to learn and complete another cycle (small sequential samples)
Gather as much data as possible, "just in case"
Obtain 100% of available, relevant data
Determining if change is an improvement
Run charts or control charts
Hypothesis tests (T-tests, F-tests, Chi-square), p-value
No change focus
Source: Provost,, L. & Murray, S.. (2007). “The Data Guide: Learning from Data to Improve Health Care.” Associates in Process Improvement and Corporate Transformation Concepts.
When reflecting on measurement in QI, it is helpful to compare and contrast with other measurement foci such as measurement for research and measurement for accountability.
Reviewing each element, i.e. purpose, tests and read across to compare/contrast measurement in QI from measurement for research or accountability/comparison.
It is important to note that each of these plays a critical and important role in healthcare – they are just different.

32. MEASURING THE SYSTEM
A system is an interdependent group of items, people, or processes working together toward a common purpose
Healthcare systems – complex, adaptive
Requires a “family of measures” which includes outcome, process, and balancing measures
Follow measures frequently and continually while you improve through many tests of change
When we reflect on measurement in QI work, we are reminded that we are measuring aspects of a system.
Because a system is an an interdependent group of items, people, or processes working together toward a common purpose and because healthcare systems are complex, adaptive systems we:
Require a “family of measures” which includes outcome, process, and balancing measures and,
Follow measures frequently and continually while we improve through many tests of change.

33. OUTCOME MEASURES
Captures what is important to the patient and reflects how the overall system is working
Answer the question:
Are we fulfilling our aim?
This is the “so what” piece, and reflects what is most important to the patient
Examples:
1. Safety - Adverse events post hospitalization 2. Access - Seeing their preferred primary provider when sick
3. Patient-centered - Perceived ability of primary provider to hear and understand patients’ problems
Outcome measures look at the results of a process. What was the patient’s response to medication?
They assess performance of a process, such as a weight, loss program. They can also measure satisfaction.
Examples of outcome measures include blood pressure or blood glucose or waist circumference.

34. PROCESS MEASURES
Sometimes referred to as the “voice of the process” and reflects how steps in the system are performing
Answer the question:
Are we doing the things we thought would result in an improvement?
May not be as important from the patient’s point of view (compared to the desired outcome)
Examples: Safety - Time to first follow up appointment post discharge Access - Number of same day appointments available at start of day Patient-centered - “Red Zone” time – percentage of visit cycle time that patient spends with provider
Process measures are measures of a high level activity that provides a service.
You can measure whether a process or an activity has been completed.
You can measure parts of a system.
An example is recording the time that a patient waits to see a provider. That’s a process measure because what you’re measuring is a process or a step in the system of patient flow.

35. BALANCE MEASURES
Looking at a system from different directions/dimensions. What happened to the system as we improved process and outcome measures?
Answer the questions:
Are we inadvertently having a negative impact on other parts of the system through our actions?
What could go wrong if we do this?
Examples:
1. Safety - Unnecessary appointments
2. Access - Increase in variation of volume of appointments per day
3. Patient-centered - Leaving later in the day
Balance measures help ensure that improvement in one part of a process don’t impact (negatively or positively) something else.
A common balance measure in healthcare QI relates to the impact on a team member of a particular change. For example, if I am able to improve access to a primary care provider, is there a negative impact on the staff workload or a positive impact on no-show rates?

36. DO YOUR MEASURES ALIGN? Safety Adverse events post hospitalization (O)
Time to first follow up appointment post discharge (P)
Unnecessary appointments (B)
Access
Seeing their preferred primary provider when sick (O)
Number of same day appointments available at start of day (P)
Increase in variation of volume of appointments per day (B)
Patient-centered
Perceived ability of primary provider to hear and understand patients’ problems (O)
“Red Zone” time – percentage of visit cycle time that patient spends with provider (P)
Leaving later in the day (B)
It is helpful to see if your measures align and can describe different system perspectives.

37. SOME COMMON SYSTEMS (& MEASURES) IN PRIMARY CARE
Clinical
Screening (cancer screening)
Health Promotion (vaccination rates)
Acute Care (antibiotic use)
Chronic Disease (HbA1C)
End of life care (pain scores)
Administrative
Scheduling (same or next day access when sick)
Patient flow (cycle & wait times)
Billing – (Access bonus)
System Integration (% seen within 7 days post-discharge)
There are many systems in primary care, and hence many measures (often of interest to governments! Examples are -
Clinical measures including:
Screening – cancer
Health Promotion – vaccination
Acute Care – antibiotic use
Chronic Disease – effectiveness measures such as HbAIC
End of life care
There are also administrative systems and examples including:
Scheduling – same day access
Patient flow – cycle and wait times
Billing – efficiency - rejected claims
There are also higher level systems measures reflecting the integration between sectors such as -
Admission rates as a reflection of the interaction between primary and hospital care.

38. EXERCISE
Measures
(15 min)
Looking at your Aim Statement, what are appropriate measures for your QI initiative?
Outcome
Process
Balance
Now it’s time to evaluate and identify measures for your quality initiative.
For your aim statement, what are some process measures, outcome measures, and balance measures that you may employ?
Challenge yourself to identify at least one of each measure for your improvement opportunity to project idea.
Remember to make sure the measures align to your aim statement!

39. DEBRIEF Will a few of you share your Aim Statement, and a
Process measure?
Outcome measure?
Balance measure?
Regain attention of group.

40. DRIVER DIAGRAM
How do we demonstrate the relationships among system aims, system outcome measures, primary & secondary drivers?
How do we visually describe causality in our complex environments?
Where does my QI project fit?
How is it anchored to broader QI work?
Driver diagrams are useful in QI work as they describe the relationship between aims, measures and change ideas by thinking of them as respective drivers.
When we view content on a driver diagram, we are viewing the perceived “causality” between aims, primary drivers and secondary drivers. All your resident QI projects will be in the secondary driver category however it is helpful to see where your project fits relative to broader organizational QI work.

41. DRIVER DIAGRAM
Creates a logic model to develop and communicate an approach to achieving an aim
Identifies hypothesized relationships among primary and secondary drivers of change
Provides a structure for identifying and cascading measures
Read slide
Note that driver diagrams may use aim, primary and secondary (even tertiary) drivers OR aim, measures and change packages (which include change ideas).
Some driver diagrams include both for additional detail.

42. DRIVER DIAGRAM EXAMPLE
Here is a simple (maybe not if it’s you trying to lose the weight or support a patient to improve their health!) example of a driver diagram used to describe the relationships between secondary drivers (e.g. reduce amount of food) , primary drivers (e.g. reduce caloric intake) and the aim – losing weight.
This hyperlink takes us to an IHI YouTube video shared by Dr. Don Goldman. You can view this at your leisure.

43. IHI 100,000 LIVES CAMPAIGN A SYSTEM AIM
IHI will partner with participating hospitals to avoid 100,000 hospital deaths “over the next 18 months (by June 2006), and every year thereafter” beginning in December 2004.
Practices:
Rapid Response Teams
Medication Reconciliation
Prevent central line infections
Prevent surgical site infections
Prevent ventilator-associated pneumonia
Evidence-based care for MI
Wachter, R., Provonost, P. The 100,000 Lives
Campaign: A Scientific and Policy Review. Journal on Quality and Patient Safety. November 2006, vol. 32, No. 11.
As an example of a driver diagram application, this aim relates to the 100,000 Lives campaign that IHI initiated in 2004 at their annual Forum.
Note the 6 “practices” that are listed on the left – these are evidence-based practices (incorporating many change ideas) that IHI recommended teams implement via a QI approach.
For many teams, implementing even one of these practices was a considerable endeavor. To illustrate the relationship of these practices to the overall aim of reducing lives lost, development of a driver diagram describes the relationship between these practices and the specific change packages or bundles that respective teams focused on.

44. DRIVER DIAGRAM EXAMPLE
In this driver diagram example, the “practices” that are listed on the bottom of the previous slide are included as primary drivers. Achieving improvement in one of more of these drivers positively influences the goal of 100,000 lives saved.
It is challenging for teams to work at the level of primary drivers without more detail because our healthcare systems are so complex so the secondary driver related to one of the practices – PREVENT SURGICAL LINE INFECTIONS is noted in the blue box. Collectively these secondary drivers are a change package, however each one could be a small QI project for a team.
In this example, the driver diagram describes the relationship between a change idea - hand hygiene (specifically its relative improvement) and surgical line infections leading to lives saved.

45. DRIVER DIAGRAM EXAMPLE
Julie E Reed et al. BMJ Qual Saf doi: /bmjqs
In this example of a driver diagram for COPD, the red star on the right of the slide highlights a change idea or a small QI project – PATIENT INFORMATION LEAFLET.
Looking left, the next red star highlights the secondary driver – EDUCATION OF PATIENT ON THEIR CONDITION AND MANAGEMENT PLAN.
The next red star highlights the primary driver – APPROPRIATE PROVISION OF CLINICAL CARE.
This driver diagram illustrates the relationships between the aim – to improve quality of care for COPD patients, the primary drivers and secondary drivers with specific detail around some of the change ideas.
The contribution that a patient information leaflet can potentially make to improving education (secondary driver) and improving appropriate provision of clinical care (primary driver) is therefore described visually relative to the aim of improved quality of care for COPD.

46. EXERCISE Driver Diagram
Using flip chart paper and post it notes, develop a portion of a driver diagram including:
Aim Statement
Primary Drivers
Secondary Drivers – Your QI Project
(15 min)

47. THE MODEL FOR IMPROVEMENT
Develop change ideas
Reflect on your practice, brainstorm, use system diagnostic tools and use change concepts to develop change ideas.
The 3rd question in the Model for Improvement asks us to identify the changes we can make that will result in an improvement.
To identify changes that we believe will lead to improvement we may:
Reflect on your practice
Brainstorm as a team
Use change concepts, to develop change ideas.
Recall from the module 2 on system diagnostics that we can also use tools such as cause and effect diagrams and the 5 WHYs to assist us in identifying change ideas that are likely to be impactful.
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.

48. REACTIVE CHANGE Keeps the system running
Responds to an immediate problem
Short term impact
NOT QI
Hire someone to phone patients to come in for their screening tests
Change can be either reactive or fundamental.
Reactive change keeps a system running.
Reactive change is a response to an immediate problem.
Reactive change usually has only short term impact.
Reactive change is not QI.
An example of a reactive change is referring all your uncontrolled diabetics.

49. FUNDAMENTAL CHANGE Essentially alters an activity
Necessary to prevent problems
Lasting impact
= QI
e.g. Use electronic reminder systems to improve screening rates
Fundamental change, on the other hand,
essentially alter an activity.
Fundamental changes are necessary to prevent problems, rather than respond to them as they arise.
Fundamental changes have lasting impact.
Fundamental changes are Quality Improvement, a fundamental way of permanently improving primary health care.
An example is developing a dedicated health care for diabetes patients within your practice.

50. CHANGE IDEAS
Specific ideas that you can test and implement to effect change
Sources:
System diagnostic tools
Your team
Brainstorming
Change concepts
The number one source of change ideas is your QI team but you can also generate change ideas from your system diagnostic tools such as cause and effect diagram, brainstorming, and benchmarking against evidence informed practice, clinical practice, and medical literature.
Change concepts are another source for change ideas that we will discuss in greater detail in a subsequent slide.

51. SOURCES OF CHANGE IDEAS
System cause analysis informs change ideas – system diagnostic tools
Learn from knowledge experts. What has worked at other practices?
Think logically about current procedures. Involve those closest to the situation
Think creatively. Use technology
Copy, replicate, duplicate. No need to reinvent the wheel!
Begin. Don’t anticipate how impactful a change idea may be – be open to ‘testing’!
There are many sources of change ideas.
Use the output from the system diagnostic tools your team has used.
Learn from knowledge experts, people you respect, mentors, really good doctors.
Think logically and analyze current practice procedures.
Think creatively and use technology appropriately.
Copy, replicate, duplicate other’s good ideas.

52. CHANGE CONCEPTS
General approaches to change that have been shown to generate additional change ideas.
Read the slide
In your workbook, there is a list taken from the Improvement Guide Appendix A that includes over 70 change concepts.
Using change concepts can illicit specific change ideas for your QI initiative.

53. CHANGE CONCEPTS Eliminate waste Find & remove bottlenecks
Improve work flow
Minimize hand-offs
Do tasks in parallel
Use technology
Standardize
Force Function
Any duplication of effort?
Is there a step that slows the entire process?
Is the right person doing the right thing at the right time?
Are there technological efficiencies?
Is there unnecessary variation?
Make the right thing, easiest
Let’s look at some examples of change concepts:
One change concept is to eliminate waste.
Study your process for duplication of effort.
Change concept: find and remove bottlenecks.
Ask yourself if there is one step slowing the entire process.
Change concept: improve work flow.
Can you find efficiencies by changing who does what, and when it is done?
Change concept: use technology.
Would technological applications improve the overall efficiency of the process?
Change concept: standardize
Can you identify unnecessary variation?
Change concept: force function
How can we make the right thing to do, the easiest (and possibly the safest!)?

54. Other Considerations for Change Ideas
This visual depicts the effectiveness of interventions or change ideas noting that least effective interventions are those that are people-focused, whereas the most effective are based in the change concept of force functioning. An example of a force function in primary care is an EMR feature that does not permit medication prescribing without reviewing the patient’s allergy list.

55. EXERCISE Generate change ideas (10 min)
Select one person’s QI opportunity at your table
Review the opportunity
Review system diagnostic tools to find change ideas
Brainstorm change ideas
Choose a change concept to help generate more ideas
Read slide – offer tables the option of selecting on person’s QI opportunity or project idea.
Introduce flow – points 1 to 4 and see how many change ideas can be generated in 10 minutes.

56. DEBRIEF
Generate change ideas
How many change ideas did you generate?

57. THE MODEL FOR IMPROVEMENT
Testing change ideas
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.
Now we are ready to test the change ideas that we generated as a team as part of the third question in the Model for Improvement.
The PDSA – Plan, Do, Study, Act cycle is the testing approach we take with each change idea.

58. Improvement Opportunity
FROM OPPORTUNITY TO TESTING CHANGES  
Improvement Opportunity
Problem Statement
CHANGE IDEA
CHANGE IDEA
CHANGE IDEA
Note that there are many PDSA ramps in this visual of the Model for Improvement – for each change idea that we decide to test, we can anticipate a number of PDSA cycles or tests of change.
Because our healthcare systems are complex, we rarely test once and are ready to implement a change.
Langley, Nolan, Nolan, Norman, Provost;
The Improvement Guide, 1996.

59. EXERCISE Testing change ideas (10 min) October Sky movie clip
While viewing, pay attention to…
# of tests of change (PDSAs)
Team roles
Use of prediction
Let’s take a few minutes to watch this short movie clip as it depicts the essence of testing change ideas.
Pay attention to the # of tests of change, the roles of respective team members and the use of prediction for each test.

60. DEBRIEF Testing change ideas What did you observe?
# of tests of change (PDSAs)
team roles
Use of prediction
Debrief – what did you note in your workbook?

61. Please refer to the PDSA Worksheet
PDSA: PLAN-DO-STUDY-ACT
Please refer to the PDSA Worksheet
To facilitate learning about the PDSA cycle, please refer to the PDSA form in your Workbook. This is one version of a PDSA form that supports you to lead a team through the PDSA cycle.
The form documents your progress as your team tests each change step by step – plan, do, study act. This is something you will use throughout the quality improvement initiative to track your change idea testing.
This form will be available to you electronically so that you can adapt and edit it to meet the needs of your project. As we go through the remaining parts of the module, follow along on the form- which will support your learning.
You may also use a multi-cycle PDSA form (in your workbook) to enable a visual of tests of change on one idea as they evolve.

62. PSDA WORKSHEET
Plan: Describe the following: objective of the cycle and details
Data to be collected – who, what, when, where
Predictions & questions
Do: Carry out the change or test; document problems and unexpected observations
Study: Complete the analysis of data. Compare the data to your predictions and summarize the learning Act: What changes need to be made? Plan for the next cycle

63. TESTING A CHANGE IDEA PLAN State the purpose
Predict what you think will happen
What feedback will you be looking for from the test – quantitative or qualitative measure?
The first step in the PDSA Rapid Cycle for Improvement is Plan.
This is when you state the purpose of the test.
You predict what you think will happen, and
Select a measure as feedback in terms of the effectiveness of the test. The measure may be quantitative or qualitative and as simple as a number (e.g. output of something) or a yes/no answer (e.g. was a form easy to use)
Prediction is a critical element of the plan phase as it drives the learning about our systems. We predict as we would hypothesize – we measure to determine if we are correct in our prediction.

64. TESTING A CHANGE IDEA DO Prepare: detail the test actions & tasks
Conduct the plan
Collect data related to your measure
The next step is Do.
You prepare to Do by detailing the actions and tasks of your test.
Then you go ahead and conduct the test,
Collecting the data for your test of change measure.

65. TESTING A CHANGE IDEA STUDY Compare your results to your prediction
Then you’re going to study the results of the test of change.
Analyze the results of what happened - the test, the data you collected during the test – and compare that to what you thought might happen – your prediction.
This is a critical piece of the PDSA cycle linking back to Dr. Deming’s ‘building knowledge’. This is where we learn about our system – what do we think will happen compared to what actually happens.

66. TESTING A CHANGE IDEA ACT Decide what to do next
Implement your decision
After studying the results of the test of change, the final step is to Act on the rapid cycle test.
Decide what to do next … test again with minor adjustments, test under a different condition, stop the test or implement.

67. PDSA: ACT MODIFY - Good results; negative outcomes can be managed
TEST UNDER OTHER CONDITIONS - Negative outcomes may be related to certain manageable conditions
IMPLEMENT - Consistent results after several tests; minimal negative impact
SPREAD - Results merit test on larger scale
DROP - Results do not justify effort; substantial unexpected negative outcomes
So, what are the options with a completed PDSA cycle?
If the test showed some promise, with manageable problems, modify the test accordingly.
If you believe any problems arising during your test were situational, test under additional or different conditions.
If it was a resounding success, implement the test.
If you are quite pleased with the outcome, spread the test to other parts of your practice, and repeat the test there.
If the test was a bust, drop this idea and move on to your next test of change. If this happens, and it does, don’t be discouraged. It is precisely for this reason that the test was of a small change, rapidly implemented. No harm done.

68. EXERCISE Select one person’s change idea at your table
PDSA – Test of Change
(10 min)
Select one person’s change idea at your table
Review the change idea
Plan a test of change for the idea
Discuss your prediction
Determine the feedback you will be looking for during the test (measure)
Now – in your table groups, select one person’s change idea.
Follow steps 1 to 4.

69. DEBRIEF PDSA – Test of Change
Did your colleagues at the table predict differently for each test of change?
Did any table discuss a potential next test of change for the same idea?
Debrief as per slide.

70. PDSA actions must integrate with regular work activities
Designate time
Designate place
Designate people
PDSA rapid cycle tests of change must integrate into regular work activities in the practice.
You have to designate the time, the place, and the people to accomplish the test.
PDSA tests of change must be small enough that it’s easy and practical.

71. TESTING A CHANGE IDEA QI initiatives need to be feasible
Each incremental PDSA is small and quick
When working through a test of a change
remember the ideas have to be feasible and practicable.
Successful PDSA rapid cycles are small and quick.
Faculty at IHI often say – what can you do Tuesday by 2?!

72. “No one PDSA cycle will change the world.”
ALTERNATIVE PROCESS
Anticipate iterative cycles
Plan future modifications to test
Document your test
Innovate
Keep it small to keep it feasible
Keep it focused
“No one PDSA cycle will change the world.”
No one PDSA will change the world. A positive corollary to that may be that only iterative PDSAs will change health care, truly change it.
So anticipate iterative cycles.
Plan for future modifications and document, document, document, using the PDSA Worksheet because it really helps you.
Innovate, keep it small, keep it feasible, and keep it focused.

73. PDSA’S - SMALL, REPEATED TESTS OF CHANGE
PDSA cycles are small,
repeated,
iterative,
tests of change,
Leading to improvement.

74. PDSA CYCLES IN A SEA OF COMPLEXITY
In real life this is often what PDSA cycles look like – the complexity of our healthcare system often precludes us from a linear pathway and takes us on this more convoluted journey with each test of change increasing in complexity itself.
Don’t let this discourage you – even in failure we learn about our systems and can more effectively target our improvement efforts.

75. Improvement Opportunity
FROM OPPORTUNITY TO TESTING CHANGES
Improvement Opportunity
CHANGE IDEA
In conclusion, we have reviewed each element of the Model for Improvement in the context of how a project is developed and completed.
Review the flow – project idea – problem statement – aim – measures – change ideas – testing via PDSA cycle.
Remember that you will generate many change ideas and perform several tests of change (PDSA cycles) for each change idea.

76. Now you are able to … Describe the Model for Improvement
Identify opportunities for patient engagement in QI
Prepare your improvement charter
Develop your problem statement
Establish an AIM statement
Define measures relating to your AIM
Construct a driver diagram for your project
Develop change ideas
Use the PDSA cycle to test change ideas
Review learning objectives as on slide.

77. QUESTIONS
Consult with your table group facilitator for any questions.