Explore before Exploit, Round 2
Two years ago, I wrote about psychologist Alison Gropnik’s description of the difference between children and adults. Children are wired to explore, while adults are conditioned to exploit, to “…find resources, make plans, make things happen…”.
Gropnik’s perspective prodded me to think about how I coach individuals and teams to learn by doing, using the Plan-Do-Study-Act (PDSA) method embedded in the Model for Improvement.
Steve Spear made the case for pervasive learning by doing in organizations: “No one team can design a perfect system in advance, planning for every contingency and nuance…people can discover great systems and keep discovering how to make them better.” (The High-Velocity Edge, 2009, p. 92, emphasis in the original text).
How can I change my PDSA coaching to help people improve their learning-by-doing skills?
Over the past eight months, I’ve coached teams in a collaborative project sponsored by the National Network for Oral Health Access (NNOHA) to improve care for patients with diabetes treated at seven community health centers. In the first few weeks of the project, I asked participants to explore aspects of care through purposeful observation, “Go See.”
I made another change to my teaching this year. I introduced a monthly PDSA workshop inspired by a Job Instruction course I took in December 2024. This workshop approach seems valuable: each health center could share a story about a change in care for their patients with diabetes. The stories demonstrated the elements of a PDSA cycle. More importantly, the stories showed how each team deepened its understanding of NNOHA’s integrated care model to improve patient care.
The introduction of “Go See” at the beginning of our project inspired a few participants to observe clinic operations and gain context for subsequent changes. The PDSA workshop showed promise. However, a review of this year’s project indicates that health center teams still struggle to apply and document structured PDSA independently.
What are we missing?
Lessons from the Mr. Potato Head simulation
I regularly use a simulation developed by Dr. Dave Williams to teach PDSA, Mr. Potato Head.
We give teams a three-part work standard: the definition of a good outcome, the tools to build and document their work, and the roles and steps involved in the job.
Reflecting on recent sessions, I’ve realized that the simulation presents two challenges.
Getting a feel for the job: Some people have never built Mr. Potato Head. While other people might have played with the toy many years ago, bringing relevant knowledge to the simulation session, no one has built Mr. Potato Head according to the specific rules of the simulation. In other words, the simulation task is new work.
Improving the job: Build Mr. Potato Head in less than 20 seconds, with perfect quality.
I now give Mr. Potato Head teams a “baseline cycle,” free from the requirement of rigorous PDSA thinking and documenting, to get a feel for the job. After an initial exploration cycle, it is easier for teams to move to planning and testing specific actions to improve performance.
Explore before exploit.
Exploring a New Job and Building PDSA Skills
The NNOHA project focuses on integrating dental and medical care to improve the health of patients with diabetes. Over the past four years, NNOHA faculty and participants have developed specific changes to dental and medical visit workflows. We also see ways to strengthen the referral pathway between medical and dental to reduce time to appointments and provide better feedback on referral status.
In this year’s integrated care project, Dr. Anila Khalid, Chief Dental Officer at HealthFirst Family Care Center in Fall River, MA, investigated blood glucose testing in the dental clinic. This was a new job for the dental team at her health center.
After Dr. Khalid learned to do blood glucose testing on herself, she tried it with a patient. She then asked another dentist to get a blood glucose reading on a patient; they found a problem with the EHR set-up that slowed documentation but had an easy fix. A few days later, the second dentist needed to get a blood glucose reading for a patient with diabetes just before an invasive procedure. The dentist tested and documented the blood glucose in less than two minutes.
In setting up her initial trial of blood glucose testing, I asked Dr. Khalid to consider three questions:
Can you achieve the desired outcome?
How long does it take to do the work?
How confident are staff in doing the work as part of routine care?
For each question, Dr. Khalid predicted the answers the trial would provide.
Dr. Khalid and I discussed how she would get answers from the trial to compare to her predictions. For each question, how would she capture the answer given by the trial?
We set up this planning cascade of questions, predictions, and data collection.
The cascade is the heart of the Plan step in a formal PDSA cycle.
Dr. Khalid compared her predictions to the answers that the test generated, practicing a fundamental element of the Study step in a formal PDSA cycle. She used the same question-prediction-data collection outline for the subsequent trials, which were guided by what was learned previously.
Dr. Khalid and her colleagues gave us a clear example of exploring a new job and discovering their way to a better care system.
Application to our project: Guided exploration before rigorous PDSA
While a team can learn a lot just by trying something new and gaining direct experience with a job, we can direct the initial job trials to enhance learning and build the skills used in formal PDSA testing.
Just like in the Mr. Potato Head simulation, what would it look like to outline the elements of a work standard for any new job before asking people to explore and enhance performance? For the blood glucose testing example, here’s what we need:
Applying the “explore before exploit” lesson, what would it look like to explore blood glucose testing before inviting rigorous improvement via PDSA? Dr. Khalid and her team showed us an example, incorporating the planning cascade, reflecting on their experiences, and engaging other providers.
Using the lessons from Mr. Potato Head, let’s guide the exploration of new jobs while building participants’ PDSA skills, supported by the PDSA workshop. I predict teams in the new project cycle will show better progress on our project assessment scale and more evidence of effective testing than this year. Our project faculty has its own PDSA work to do!
Acknowledgment: Thank you to Dr. Anila Khalid, DMD, for permission to share her team’s story.