Model for Improvement. “The definition of insanity is doing the same thing again and again and...
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Transcript of Model for Improvement. “The definition of insanity is doing the same thing again and again and...
Model for Improvement
“The definition of insanity is doing the same thing again and again and expecting a different result”
Albert Einstein
Scientific Method
• Analytic in nature with the focus on the development/discovery of new knowledge
What are we trying toaccomplish?
How will we know that a change is an improvement?
What change can we make that will result in improvement?
Model for Improvement
Act Plan
Study Do
Langley, et al.
Langley et. al
PDSA Learning Cycle:
Most important part of any PDSA cycle is the Prediction as it represents current knowledge about how a process or system will behave in the future.
When predictions are compared with actual outcomes they can reveal gaps in our current understanding of why a process or system behaves the way it does
This comparison/examination generates knew knowledge about what change might work or what modification is needed
Inductive learning begins here
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Langley et al
Scoping PDSA cycles
• Learn/Develop change ideas
• Test under multiple conditions
• Implement/make permanent
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© Improvement Science Consulting
Appropriate Scope for a PDSA Cycle
Current Situation Resistant Indifferent Ready
Low Confidence that change idea will lead to Improvement
Cost of failure large
Very Small Scale Test
Very Small Scale Test
Very Small Scale Test
Cost of failure small
Very Small Scale Test
Very Small Scale Test
Small Scale Test
High Confidence that change idea will lead to Improvement
Cost of failure large
Very Small Scale Test
Small Scale Test
Large Scale Test
Cost of failure small
Small Scale Test
Large Scale Test Implement
Staff Readiness to Make Change
Langley et. al
Final Thoughts on PDSA
• The opportunities for learning about many aspects of the change from testing are expected to be significant, including learning from failures. Some percentage of tests—perhaps 25 to 50 percent—is expected to result in no improvement, to “fail,” but to result in substantial learning nevertheless.
9
Langley et al
Let’s try it out
10
Mr Potato Head
Please decide at your table
• Who will be:–Time Keeper
–Quality Assurance Officer
–Data Analyst
PDSA Simulation
PDSA Measures
Accuracy
• 3 – All pieces on Mr. P & positioned correctly
• 2 – All pieces on Mr. P, but one or more is out of place
• 1 – One or more pieces are not on Mr. P.
Time
• Start: When time keeper says go.
• Stop: When Assembly indicates last piece is in place AND removes hand.
Plan Do Study Act
PDSA Cycle #
Level Test Cycle Aim
Test Cycle Measures/Learning Questions
Predicted Cycle Outcomes
Capture Relevant Data
Observations expected/unexpected Results
Test Cycle Learning
Test Cycle successful Yes/No
Action Taken
Alternate Pathways Uncovered
Test Cycle completed Yes/No
If No, reason
1 2
Start with feet and work to top
Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy
Time = 120secAccuracy = 3
2
Plan Do Study Act
PDSA Cycle #
Level
Test Cycle Aim
Test Cycle Measures/Learning Questions
Predicted Cycle Outcomes
Capture Relevant Data
Observations expected/unexpected Results
Test Cycle Learning
Test Cycle successful Yes/No
Action Taken
Alternate Pathways Uncovered
Test Cycle completed Yes/No
If No, reason
1 2
Start with feet and work to top
Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy
Time = 120secAccuracy = 3
Time = 2.37Accuracy = 3
Struggled to get pieces organized in order.
2
Plan Do Study Act
PDSA Cycle #
Level
Test Cycle Aim
Test Cycle Measures/Learning Questions
Predicted Cycle Outcomes
Capture Relevant Data
Observations expected/unexpected Results
Test Cycle Learning
Test Cycle successful Yes/No
Action Taken
Alternate Pathways Uncovered
Test Cycle completed Yes/No
If No, reason
1 2
Start with feet and work to top
Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy
Time = 120secAccuracy = 3
Time = 2.37Accuracy = 3
Struggled to get pieces organized in order.
Time improved by 20 sec. Accuracy improved from 2 to 3
Organization of parts helps time & accuracy. Yes
2
Plan Do Study Act
PDSA Cycle #
Level
Test Cycle Aim
Test Cycle Measures/Learning Questions
Predicted Cycle Outcomes
Capture Relevant Data
Observations expected/unexpected Results
Test Cycle Learning
Test Cycle successful Yes/No
Action Taken
Alternate Pathways Uncovered
Test Cycle completed Yes/No
If No, reason
1 2
Start with feet and work to top
Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy
Time = 120secAccuracy = 3
Time = 2.37Accuracy = 3
Struggled to get pieces organized in order.
Time improved by 20 sec. Accuracy improved from 2 to 3
Organization of parts helps time & accuracy. Yes
Next test to include ordering pieces. Need to set order before test. None Yes N/A
3 – All pieces on Mr P & positioned correctly
2 – All pieces on Mr P, but one or more is out of place
1 – One or more pieces are not on Mr P.
PDSA Simulation
• Accuracy• 3 – All pieces on Mr. P &
positioned correctly• 2 – All pieces on Mr. P, but one
or more is out of place• 1 – One or more pieces are not
on Mr. P.• Time
• Start: When time keeper says go.
• Stop: When Assembly indicates last piece is in place AND removes hand
Mr. P must look exactly like this
3 – All pieces on Mr P & positioned correctly
2 – All pieces on Mr P, but one or more is out of place
1 – One or more pieces are not on Mr P.