Rapid Cycle, Small Scale Testing

David M. Williams, Ph.D.Institute for healthcare Improvement

leaseoomethingnything!

PDSA

Building Knowledge &

Making Improvement

Aim Statement: Improve what? By how much? By when?

Building Knowledge &

Making Improvement

Measure(s)

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10%

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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25

weeks

Percent

Building Knowledge &

Making Improvement

Change Ideas

Building Knowledge &

Making Improvement

AP D

S

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D S

APD

S

A P

DS

Now, let’s focus on the PDSA part of the MFI and tests of change

Building Knowledge &

Making Improvement

… the PDSA cycle!

Act Plan

Study Do

Plan, Do, Study, Act Cycle

1939

1. Design the product (with appropriate tests).2. Make it; test it in the production line and in the laboratory.3. Put it on the market.4. Test it in service, through market research, find out what the user thinks of it, and why the non-user has not bought it.5. Re-design the product, in the light of consumer reactions to quality and price. Continue around and around the cycle.

1951

1986

Development of the Shewhart Cycle

Materials courtesy of Ron Moen and Cliff Norman

Deming’s Sketch of the Shewhart Cycle - 1985

Walter Shewhart(1891 – 1967)

Act Plan

Study Do

Plan, Do, Study, Act Cycle

AIM

Act

PlanObjectiveQuestions and predictions (why)Plan to carry out the cycle (who, what, where, when)

Study Do

Plan, Do, Study, Act Cycle

Plan

Act Plan

Study

DoCarry out the planDocument problemsand unexpectedobservationsBegin analysis of the data

Plan, Do, Study, Act Cycle

Do

Do

Do

Do

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Act Plan

Study Complete the

analysis of the dataCompare data to

predictionsSummarise what

was learned

Do

Plan, Do, Study, Act Cycle

Study

Act

Adopt? Adapt? (New Plan)?

Abandon?

Plan

Study Do

Plan, Do, Study, Act Cycle

Act - Adapt

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in Improvement

A P

S D

APS

D

A P

S D

D SP ADATA

Very Small Scale Test

Follow-up Tests

Wide-Scale Tests of Change

Implementation of Change

1) What are we trying to accomplish?

2) How will we know that a change is an improvement?

3) What change can we make that will result in improvement?

Sequential building of knowledge under a wide

range of conditions

Results PDSA 2

Results of PDSA 3

Results of PDSA 4

Repeated Use of the PDSA Cycle

Hunches Theories

Ideas

Changes That Result in Improvement

A P

S D

APS

D

A P

S D

D SP ADATA

The PDSA Cycle for Learning and Improvement

Click icon to add picturePlan• Objective• Questions &

predictions• Plan to carry out:

Who?When?How? Where?

Do• Carry out plan• Document

problems• Begin data

analysis

Act• Ready to

implement?• Try something

else?• Next cycle

Study• Complete data

analysis• Compare to

predictions• Summarize

What will happen if we try something

different?

Let’s try it!Did it work?

What’s next?

PDSA Guidance

Test changes at the smallest level that is possible and reasonable.

One patient – one day – one admit - one doctor.

Test under various conditions before expanding.

What can you do by next Tuesday?

Fail often to succeed sooner.

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Activity ≠ Change

Is a change:

Establish a prompt to redose

Create a standing order

Provide staff with protocol compliance feedback

Test placement of alcohol rub dispensers

Is NOT a change:(but may be a necessary preliminary task)

Planning

Having a meeting

Educating staff

Creating a protocol

Assigning responsibilityFor each change idea, you should have an explicit

prediction of how it will impact the outcome.

Tips for Testing

Use a form to document your test.

Scale down – think “Drop Two”

Oneness

Make changes in parallel

Know the situation in your organization

• Year• Quarter• Month• Week• Day• Hour

• 1 patient• 1 day• 1 admit• 1 physician

“What tests can we complete by next Tuesday?”

Failed Test…Now What?

Be sure to distinguish the reason:

Change was not executed

Change was executed, but not effective

If the prediction was wrong – not a failure!

Change was executed but did not result in improvement

Local improvement did not impact the secondary driver or outcome

In either case, we’ve improved our understanding of the system!

The Value of “Failed” Tests

“I did not fail one thousand times; I found one thousand ways how not to make a light bulb.”

-- Thomas Edison

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A P

S D

AP

SD

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S D

D S

P A

A P

S D

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SD

A P

S D

D S

P A

A P

S D

AP

SD

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S D

D S

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S D

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SD

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S D

D S

P A

Early Intervention in Maternity Services Project(s)

Attachment and Child Development beyond maternity services Project(s)

Developing parents' skills Project(s)

Continuity of care in transitions between services Project(s)

A P

S D

AP

SD

A P

S D

D S

P A

27 - 30 month Child Health review Project(s)

AIM: BIG DOT EARLY YEARS

Change Concepts, Theories, Ideas

Attachment and Child Development beyond maternity services

27 - 30 month Child Health review

Early Intervention in Maternity Services

Continuity of care in transitions between services

MULTIPLE KEY CHANGES FOR A SINGLE AIM

Breakout Sessions Key changes – PDSAs

In the next session…

• Learn from examples of small tests (PDSAs) from Pioneer Sites.

• Think of ideas for small tests of change in your work.

• Develop a plan for a small test you can do by next Tuesday.

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