Chapter 6. Continue to Improve

Reality has a way of exposing the weaknesses of even the best plans. In a complex environment like a hospital, there will always be unforeseen glitches when trying something new.

Learning in the Clinical Setting: Plan-Do-Study-Act

Teams should start small and scale quickly by using rapid cycles of action-oriented learning. A great way to do this is by using the Plan-Do-Study-Act (PDSA) model.

The team should start by planning (plan) the intervention and then test (do) it. In the next step, team members should observe (study) the test firsthand, paying close attention to competing demands and physical space. They should listen to individuals involved in the test to hear what worked and what did not. They should ask for alternative ideas and discuss them on the spot. The idea is to understand what could or should be done differently from how the team originally planned it. Whoever observes and studies the test should record lessons and suggested alternatives. These lessons and alternatives should be shared at the next multidisciplinary team meeting. The Institute of Healthcare Improvement has a PDSA Worksheet on its Web site that may be useful (http://www.ihi.org). In the last step, the team should revise the plan and try it again (act). Table 6 highlights the advantages of PDSA as well as principles for doing it well.

Table 6. Advantages of Plan-Do-Study-Act and Principles for Success

Advantages of PDSA Allows for valuable modifications to improve effectiveness or preserve productivity. Allows "failures" to come to light without undermining performance and momentum. Identifies areas of resistance that might undermine spread to other units. Allows costs and side effects of the change to be assessed. Increases certainty that change will result in improvement. Allows for detailed documentation of improvement. Principles for Success Start new changes on the smallest possible scale, e.g., one patient, one nurse, one doctor. Run just as many PDSA cycles as necessary to gain confidence in a change, then spread the change incrementally. Spread change incrementally to more patients, then more nurses, then doctors, and finally units. Balance changes within the overall system to ensure that other processes are not adversely stressed. Pay special attention to preserving productivity and workflow.

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Spreading Improvement to Other Units

Spreading successful improvements to other areas of the hospital requires the new process that was refined in the pilot test to be woven into the wider fabric of everyday clinical work. The IHI white paper, "A Framework for Spread,"³⁰ offers the following field-tested lessons for disseminating improvements:

• Committed organizational leadership is crucial.
• Begin planning for spread as early as possible.
• Be specific in the aims of spread (who, what, where, when).
• Leverage existing infrastructure and identify infrastructure gaps.
• Execute the spread plan but learn and revise as you go.

Just as for the pilot, let the key principles for layering effective QI interventions discussed in Chapter 5 guide the team's efforts to spread the improvement.

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