This document discusses using the Plan-Do-Study-Act (PDSA) approach for quality improvement. It provides an overview of the model for improvement and the PDSA cycle. An example is given of using PDSA cycles to test reducing the number of clinical documents GPs must review each day. Teams participated in an exercise to test spinning coins for as long as possible, recording their tests on PDSA tracker forms to build knowledge through small-scale testing. Key benefits of the PDSA approach include rapidly building knowledge through intentional testing of changes and measuring results.

1. #GPforwardview
TIME
FOR CARE
#GPforwardview
Quality Improvement for Practice
Managers
Implementing change with rapid cycle
methods. The benefits and practicalities of the
PDSA approach
Sue Collis
Karla Foster
7th March 2018

2. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Any improvement is a change
not every change is an improvement
but we cannot improve something unless
we change it
Goldratt E (1990), Theory of Constraints,
North River Press, Massachusetts

3. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Model for Improvement
Set AIMS that are measurable, time-
specific, and apply to a defined
population
Establish MEASURES
to determine if a
specific change leads
to improvement Select INTERVENTIONS most
likely to result in improvement
What are we trying to accomplish?
How will we know that change is an improvement?
What change can we make that will result in improvement?
Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress, June
1994

4. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
The Model for Improvement
Developed by Associates in Process Improvement’
Langley, G., Nolan, K., and Nolan, T., 1994. The Foundation of Improvement, Quality Progress,
June 1994
Test the change

5. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW Change through small steps
• with a clear purpose
• you can learn from (without fear of failure)
• which is less exhausting and with fewer unintended
consequences
• which builds engagement and optimism
Why test?

6. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
APDS
The PDSA Cycle
Describe
the idea
Questions and
predictions (why)
Plan to carry out
cycle (who, what
when where, how) &
data to be collected
Carry out the plan
Document problems/
Unexpected
observations
Begin data
analysis
Complete data
analysis
Compare data
t to predictions
Summarise
learning
What
changes are
to be made?
Next cycle?

7. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW The thing about testing…

8. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Traditional Approach to Activities
Suggested Approach
P D
P D S
 A

S A
Time
PDSA Cycles
Time saved

9. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Plan-Do-Study-Act cycles
Hunches
theories
ideas
changes that
result in
improvement
Very small
scale test
Follow-up
tests
Wide-scale
tests of
change
Implementation
of change
Testing and
refining ideas
Implementing new
procedures & systems
- sustaining change

10. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW PDSA Template completedWORKSHEET FOR A SMALL TEST OF CHANGE
Team: ___GPsand PracticeAdmin Staff____________________ Date: ____________________ 10th October 2015
AIM (overall goal):
R educe the number of clinical documents seen daily by all GPs in W incanton H ealth Centr e fr om a baseline of 100% in
October 2015 to 25% by the end of June 2016
Describe your first (or next) test of change Person
Responsible
When to be
done
Where to be done
A dmin staff r eview clinical letter s and r emov e those w hich
r equir e no action by GPs
D r . F ox W eek beg. 10t h
Oct
I n t he pr act i ce
office
PLAN:
List the tasks needed to set up this test of change Person Responsible When to be
done
Where to be done
1. A gr ee the letter s that do not need to be seen by GPs
2. A gr ee w ho on the admin team ar e to scr een the letter s
3. Check that these staff member s under stand the pr ocess
D r . Fox
Pr act i ce M an ager
D r . Fox / st aff
W eek
begi n n i n g 10t h
Oct
Pr act i ce M eet i n g
Pr act i ce M eet i n g
Pr act i ce M eet i n g
Predict what will happen as a result of this test
GPs w ill have less letter s to r ev iew each day
What measure(s) will you use to compare your results to what you predicted?
N umber of clinical letter s seen each day by all GPS
Baseline measur e(s): Cir ca 200 letter s per day ar e scr eened by GPs in the pr actice
DO:
Describe what actually happened when you ran the test
The r eduction in the number of clinical letter s w as not as gr eat as anticipated. A dmin staff w er e uncomfor table w ith the
pr ocess.
STUDY:
Describe your results including measures. How did they compare to your predictions and what did you learn from the cycle?
The number of clinical letter s for r ev iew r educed to ar ound 190 per day, w hich w as less than anticipated.
I t is possible for non-clinical staff to r ev iew letter s and dir ect them to the appr opr iate per son
ACT:
What will you do next? Describe the modifications for the next cycle based on what you have learned
M anagement staff (Pr actice M anger , D eputy Pr actice M anage & H ealth Coaches)to look at all letter s and sen d to the
most appr opr iate staff member for action
Example

11. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Mgt. staff vet
Daily number of clinical documents work flowed to GPs
Admin
staff vet
Document Handling
Protocol #1 (admin)
0
50
100
150
200
250
300
NumberofDocuments
Date
Document Handling
Protocol #2 (admin)
Document Handling
Protocol #3 (mgt.)
Obvious letters
removed
Example

12. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Your turn…
Learning how to use PDSA cycles… spinning a
coin
Exercise: David M Williams,
IHI

13. #GPforwardview
What are we trying to accomplish?
Aim: To spin the coin for as long as you can, on
any surface.
How will we know that a change is an
improvement?
Measure: the time taken
What change can we make that will result in
an improvement?
Intervention: what ideas do you have to test
out?
PDSAs Live: Fundamental questions

14. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
What to do ….
• In a few minutes, we will all ‘team up’ ie. 3- 5 people to work together as one
team.
• Each team will need a time piece eg. Smart phone is ideal, to record mins and
seconds
• A person who records the time taken
• A scribe, who records this on a PDSA tracker form ( to be supplied)
• Use one of the 4 different sized coins to spin ( 1p, 2p, 5p & 10p) – we have a
supply !
• Use the allocated time to intentionally test your theory/ies as many times as
possible in 15 minutes, not forgetting to…

15. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
What to do…
8
• Record your testing using the provided PDSA
TRACKER form and chart :
PLAN
What questions?
Predictions
What theory?
DO
What do you
see?
How long?
STUDY
How did what
you saw, match
your prediction?
ACT
What now ?
Adopt /Adapt or
Abandon ?
1 Eg. Use a 2p coin
As it is large ……….to spin
for 10 secs
Spun for 4 secs Spun less than
half predicted time
Adapt by using a
small coin…
2
Time
second
s
5
1
0
PDSA Test Cycle
1 2 3 4

16. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Guidance
• You define the surface you use to spin on
• The spinner may use any technique
• To time accurately- this is from first spin until the coin
completely settles on the surface motionless
• You may change the spinner and/or the coins ( from the four
provided) during the 15 mins.
• Record as you go, using the PDSA tracker form and plot the
dots on the chart
• A prize for the team with the longest spinning coin!

17. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Ready to have a go ?
How did it go ?

18. #GPforwardview#GPforwardview
GENERAL PRACTICE
FORWARD VIEW
So , what do successful teams look like
who use this approach ?
19
For instance definition of a surface
 Can lead to the creation of a hunch, theory
eg.Who is a better spinner at this table?
 ?Record - Some teams forget to collect data, as
they become focused on the DOING of the cycle.
So, not creating a prediction. If asked ’What was it
that worked ?They probably won’t know’.
Ask questions,(eg.which surface will be a good
one?) ; test a hunch multiple times and observe
when they are consistently collecting high data. So,
collecting just enough data to build their degree of
belief in the change.
Allows us to test assumptions without judgement
eg. Older people are better at spinning, as they
had more practice as a child.
 Openness to frequently
testing
 Diligence to process
 Curiosity
 Creativity
Attributes

19. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Reflections…
o Who had highest number
of spins ?
How did it feel ?
Intense ?
Prediction, Spinning, Did the
intervention work or not ? How are
we going to reiterate ?
How often are we trying to get a current system to perform
results higher than it can because we are not redesigning the
system ?
o Real world – What did you do to
achieve that improvement in pt
outcomes?
Evidence - explicit in your record
of testing
o Longest spin ?
Equals limits of current system
eg. 15 seconds

20. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
Recap - Key points
• Rapid, small scale testing using PDSAs builds knowledge quickly
• Planning a test, including predicting and measuring will increase
learning
• Planning and measurement can be simple and straightforward to do
routinely
• Collaboration and sharing help build knowledge and speed up learning
for improvement
• Reference : Black Box Thinking, 2015 by Matthew Syed

21. #GPforwardview
GENERAL PRACTICE
FORWARD VIEW
More case studies online…
https://www.england.nhs.uk/gp/case-studies/practice-saves-260-hours-of-gp-time-per-year-through-better-use-of-
practice-nurses-mundesley-medical-centre-east/

22. #GPforwardview
TIME
FOR CARE
#GPforwardview
Any questions?
Thank you