Several recent tests to sustain safety improvements in ambulatory surgical centers emerged from the development of our IHI white paper, Sustaining Improvement (http://www.iecodesign.com/index.php/272-sustaining-improvement).

The improvements were promoted through an AHRQ sponsored program for ambulatory surgical centers as described here.

I've already sketched the initial tests and lessons in the use of daily huddles (here and here).

The daily huddles are just one part of a system of management actions aimed at sustaining and improving safety work by ASC staff.

The map shows the management actions organized into a couple of chunks, control and improvement.

(Thanks to my colleague Richard Scoville, Ph.D., for important clarifying edits to the original picture.)

As many managers and consultants have figured out over the past 75 years, continuous improvement with no backsliding seems to require a system for control that is integrated with a system for improvement, which includes ways to surface and solve problems small and large.

In fact, there's another critical system, quality planning, that complements systems for quality control and quality improvement; an early description of the three systems comes from Joseph Juran and is known as the Juran Trilogy, www.juran.com/elifeline/elifefiles/2009/09/Juran-Trilogy-Model.doc.)


In a couple of recent blog posts (here and here), I discussed the use of daily huddles to help staff in ambulatory surgical centers maintain focus on safety methods like surgical checklists.   We introduced the daily huddles using the Model for Improvement, to specify aims, measures, changes and test cycles.

Our work with the ambulatory surgical centers is an application of research summarized in an IHI whitepaper “Sustaining Improvement” published on 3 June (Scoville R, Little K, Rakover J, Luther K, Mate K. Sustaining Improvement. IHI White Paper. Cambridge, Massachusetts: Institute for Healthcare Improvement; 2016, http://www.ihi.org/resources/Pages/IHIWhitePapers/Sustaining-Improvement.aspx.) From a literature review and interviews with leading healthcare organizations, we connect Juran’s perspective on Quality Control with the practice of standardized work for managers that is integral to Lean production systems.

We summarized the drivers of an effective first-tier management system in a diagram (p. 12):

Daily huddles are a way to practice drivers S1 and S2, which in turn contribute to a management system that is organized to anticipate and detect defects, maintain stable operations and respond to abnormalities.


I like to borrow an image of Plan-Do-Study-Act wheels rolling up a hill from my API colleagues.

The picture suggests that PDSA cycles that generate data help you move from initial tests of ideas—changes that might work to improve a system—to implementation of changes that actually result in improvement.

How do you keep the wheels from rolling back down the hill, wiping out improvements?

The suggestion on the right side of the image says “use more cycles.” This has two meanings. First, you can use PDSA cycles to figure out effective training materials, training sessions and job descriptions. There’s a second meaning: use PDSA to study how well the new changes are maintained.

How Do You Know If a New Policy and Method are Reliably Followed?

Two weeks ago I attended a session that reviewed a major redesign at a primary care practice. The practice aims to improve health outcomes for its patients and the individual experience of care while reducing costs of care.

Led by the medical director and the practice manager with help from the assistant medical director, the supervisor of the front-desk staff, and one of the medical assistants, the practice has been testing a range of changes.

Looking at their test documents and hearing their explanations, the project team appears to have a sophisticated understanding and experience with the Plan-Do-Study-Act cycle.

Part of the redesign work involves changes to the clinic’s policy and method for meeting patient needs for same day appointments.

How have the staff and front-desk supervisor integrated the new policy and method into their work?

The lead reviewer asked the supervisor an important question: “If I call in to the clinic, will I get the same answer to my questions no matter who answers the phone?”

The supervisor promptly answered, “Yes, of course! We train the front-desk staff!”

The practice management team in fact can do more than rely on training to assure every person on the phone will answer a question the same way. They can build on their demonstrated PDSA skills.

A Model for Maintenance

The supervisor can observe how hard or easy it is to follow the new policy that he has trained his team to use. Now the plan is the agreed-to work. Do means you observe the work or try it yourself. Study: compare the agreed-to work with the actual work. Act: if there are important gaps between planned work and actual work, engage the team to revise the agreement or figure out ways make it easier for staff to follow the agreement as it stands.

If you get the logic of the Model for Improvement, you will get the logic of the sister model, a Model for Maintenance.

Of course, many times when you try to follow a policy and use a method, there will be problems--gaps between the planned way of doing the work and what actually happens.

Problems will require improvement, closing the gap. Then you have the Model for Improvement to guide your problem-solving.

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