Prevent the PDSA Wheel from Rolling Back Down the Improvement Hill
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.