Last week we looked at the SOAP format as an effective but under utilized care improvement tool at the level of the individual patient. Let’s now look at the PDSA cycle, a systems improvement tool that underlies most of the complex and designer quality improvement (QI) methodologies that circulate in healthcare (e.g. Six Sigma, Lean, Kaizen, TQM). Like SOAP, the PDSA cycle addresses many of the same “new” concepts that surface in QI, including evidence-based care, continuous and collaborative improvement. When used as it is intended, the results are measurable, significant and sustained. As with SOAP, however, the challenge is to stay on course with the PDSA process and we often overlook key elements, which lead to suboptimal results.
“P” is for plan – the objective of using the PDSA cycle is to identify the critical variable(s) in a system needing improvement and to develop a corrective plan. Rather than implement the plan on a large scale, the corrective plan is executed in a pilot area, a controlled environment where data collection, action and oversight is manageable. Identification of the system in need of improvement and its critical variable(s) are the key to a successful plan. This requires that the PDSA team completely understand and visualize the system being addressed, which is only possible if those using this system, namely frontline staff, are part of the team. Further, since it is the frontline staff that will be directly affected by the proposed systems changes, it is vital for them to be part of the crafting of the plan if the improvement is to be sustained. Finally, including only voluntary frontline staff to participate on a PDSA team is critical; by including only those who are interested in active participation, collaborative effort and a willingness to engage in the next step of the cycle are optimized.
“D” is for do, or action – This is where the team implements the plan in the pilot area. The key element for successful action is team member accountability: NO ACCOUNTABILITY = NO ACTION = NO CHANGE! It is the responsibility of the PDSA team leader(s) and senior leadership to hold team members accountable to the action plan. This is facilitated by making well-defined action items: WHO, WHAT, and BY WHEN? Action is also facilitated by a plan that has been created and agreed upon by the voluntary frontline staff comprising the PDSA team. Action items must be manageable: SMALL ACTIONS TAKEN ALL THE TIME are what create great results. Team members in action must be proactively visible in their efforts so that other staff members in the pilot area are aware of the improvement initiative underway. Not only does this generate overall interest but it also can generate a willingness of staff to assist team members with their action items.
“S” is for study – the results of the prior action taken are analyzed for success and for opportunities to make further improvements. WHAT is measured and HOW it is measured are key (sound familiar?). This data drives the continuous improvement process. Wrong data = wrong direction. The team makes an assessment of the collected information relative to the initial plan; any revisions that might further improve the existing plan are discussed and incorporated before proceeding to the next implementation step.
“A” is for act, or do, or action. In this step the PDSA returns to the pilot area with a revised action plan. Accountability, well-defined action items and proactive visibility again take center stage to bring successful action forward. Data is collected and results are measured so that critical revisions can again be incorporated into the plan in the next step, the “P” at the beginning of the cycle.
The PDSA cycle continues to circle in this fashion until an optimized improvement process has been created in the pilot area. If the PDSA cycle has been successful, not only is there an effective improvement plan but there is also the necessary visibility and interest among other staff members and leadership for broader implementation. This may require the creation of additional teams comprised of voluntary staff and always the continued strong support of leadership.
Food for thought:
- Think about the planning step: We often don’t spend the necessary time and effort in the planning process, nor do we include the right team members. How often do we bring in the expert consultants into our organizations to implement their one-size-fits all improvement plan? How often do our own quality departments assume complete responsibility for improvement initiatives? How often are frontline staff actively included in the process of making the system to be improved visible and understandable? If there is staff participation, is it active, sustained and voluntary? What’s the buy-in of the staff that participate?
- Think about the action step: Absence of accountability plagues healthcare in general. Most improvement initiatives are not voluntary and in an already stressed work environment, participants understandably try to avoid additional tasks. Again, how often are teams voluntary in nature? How many times do teams become gripe committees, all talk and little action? How frequently to we create well-defined action items that are small and manageable? Do staff in improvement areas really understand what is going on, what the goals are?
- Think about the study step: Many times our data collection and results measurement are poor and misdirected. Many times we take short cuts in our reassessment or skip over it completely. How many times do we “jump” to solution? How many times to we let an improvement team disassemble? How many times do the “experts” assume control of the process once the initial plan is underway?
We have seen that both SOAP and the PDSA cycle have inherent weak spots when used individually. What happens when we combine them under an umbrella of universal systems principles? It turns out that we can create a robust model that incorporates all the critical elements and that can serve as a template for any care improvement process. Next week we will look at this combination: The Universal Soap Cycle.
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