1. PDSA Cycles Kyrie Shomaker, MD February 3, 2009

2. Features: Small-scale Temporary Methodical Allows you to: Adjust your belief in the change Gain buy-in Try it out

3. PDSA Cycles Model for Improvement PDSA Planning Worksheet Team Name: __________________________________________ Cycle: ___________ Date: _______________________ PLAN Objective for this cycle: Questions: Predictions: Plan for change or test: who, what, when, where: Plan for collection of data: who, what, when, where: DO Carry out the change or test. Collect data and begin analysis. Describe observations, problems encountered, and special circumstances. STUDY Complete analysis of data. Summarize what was learned. ACT Are we ready to make a change? Plan for the next cycle. Act Plan Study Do

4. Example 1

5. Overall aim: To use non-work time more efficiently Most pressing problem: Too many trips to the store and nothing for dinner Ideas for change: 1) Buy more stuff 2) Make a weekly dinner menu

6. Example 1 Model for Improvement PDSA Planning Worksheet Team Name: __________________________________________ Cycle: ___________ Date: _______________________ PLAN Objective for this cycle: Questions: Predictions: Plan for change or test: who, what, when, where: Plan for collection of data: who, what, when, where: DO Carry out the change or test. Collect data and begin analysis. Describe observations, problems encountered, and special circumstances. STUDY Complete analysis of data. Summarize what was learned. ACT Are we ready to make a change? Plan for the next cycle. Act Plan Study Do

8. Breakthrough Results Theories, hunches, & best practices Learning and improvement AP SD Evidence & Data AP SD AP SD AP SD PDSA Ramps

9. Appropriate Scope for PDSA Current SituationResistantIndifferentReady Low Confidence that change idea will lead to Improvement Cost of failure large Very Small Scale Test Cost of failure small Very Small Scale Test Small Scale Test High Confidence that change idea will lead to Improvement Cost of failure large Very Small Scale TestSmall Scale Test Large Scale Test Cost of failure small Small Scale Test Large Scale TestImplement Readiness to Make Change

10. Example 2: Duty Hours

11. Problems/BarriersSolutions Residents do not understand importance of issue (i.e. single violation can result in probabtion)  Make residents aware of survey and repercussions  Increase repetition of importance (weekly email, tips in lounge) Rounds are lasting too longRemind attendings of the importance of duty hours and duty hour intiative (i.e. weekly emails, direct feedback on violations) Interns not rounding first Interns have too many tasks after roundsLimit post call tasks to notes only (plus TPN in the NICU).  No calling consults  No updating families  No answering pages Interns are spending time after rounds to work with and review medical student notes Post call work is not delegated well Double sign out (sign out during rounds and then again prior to leaving) Make a policy to interrupt rounds at a set time (i.e. 11 am) or create culture where rounds can be interrupted at any time Family centered rounds make it difficult to finish early Overall resident efficiency still needs improvement  Make a list of efficiency skills &post in visible locations  Write notes the night before  Write the whole note in hospital course so that not toggling between screens.

12. Example 2: Duty Hours Improvement Planning Form Name: Duty Hours Improvement Aim : To eliminate duty-hours violations for all residents on pediatric rotations; including compliance with 30- hr, 80-hr, 10-hr, and “no new patients” rules. Measures (goals): Self-reported violations (hours log), violations reported by chief phone call, violations reported on RRC survey Cycle No. Change TestedPerson Responsible Week 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 1Compare 30-hr data from GME1 and chief phone calls Sarah 2Limit post-call intern duties to notes (& TPN in NICU) ? 3

13. Key Points For initial cycles, Use the smallest scale possible (“cycle of one” is best!) Failed cycles are good learning opportunities when small For implementation cycles, Test under many different conditions (busy days, different staff, things nay- sayers worry about)

14. Activity Given an aim and a list of brainstormed ideas, have each group come up with an initial PDSA cycle to test a selected change

15. Make your own PDSA Aim To free up more beds in the Children’s Hospital by increasing throughput. Problem Even when the discharge date is known in advance, patients often do not vacate their room until afternoon, creating delays in the work-up and management of incoming patients. Ideas for change: Complete the brief summary and any other necessary paperwork the night before Schedule a ride for the patient in the morning Round on the patients to be discharged first (beginning at 9am) Round on the patients to be discharged earlier (i.e. before morning conference) Have the night team discharge the patient Tell the charge nurse the night before that the patient is to be discharged Communicate the discharge goals to the family/nurses in writing (i.e. the “discharge board”) Communicate the discharge goals to the nurses with an anticipate discharge order (i.e. “anticipate discharge when…”) Move the patients out of their rooms to a waiting area once they are discharged so the rooms can be cleaned and used again Other ideas?