This document introduces PDSA (Plan-Do-Study-Act) problem solving and its use in continuous learning and improvement. It discusses key concepts related to PDSA including:
- Single-loop and double-loop learning, where double-loop learning involves testing underlying assumptions and theories.
- Program theory, which includes a theory of causation, theory of change, and theory of action that together explain an intervention's approach.
- The importance of explicitly stating a program theory and using tools like causal graphs to represent relationships between factors.
When results from a vaccine safety campaign unexpectedly decreased vaccination rates in some groups, revisiting the program theory using concepts like double-loop learning could provide insight into improving
A presentation on the continuous improvement tool of total quality management, i.e. PDCA- Plan,Do,Check,Act. Covers the basics of PDCA to give an idea on it's need, use, methodology etc. The presentation will help the beginners gain knowledge about the PDCA cycle and will cover their basic needs on it.
A presentation on the continuous improvement tool of total quality management, i.e. PDCA- Plan,Do,Check,Act. Covers the basics of PDCA to give an idea on it's need, use, methodology etc. The presentation will help the beginners gain knowledge about the PDCA cycle and will cover their basic needs on it.
Continuous improvement: the Deming Wheel (PDCA)encognize G.K.
To a certain extent, improving the performance of a company can be achieved through the improvement of its underlying structure, processes and organization. As part of the famous Kaizen practices, a common management method used to initiate and sustain a virtuous circle of continuous improvement is the Deming wheel, also known as the Shewhart cycle and more frequently referred as the PDCA cycle. This method simply consists in running iteratively four steps on the system to improve: Plan (define objectives, success criteria, contingencies), Do (execution), Check (analyse result against initial objectives and success criteria), Act (adjust).
Simple demonstration for the PDCA tool that was popularized by Edwards Deming as a continuous quality improvement tool.
Deming has credited Walter Shewhart (American physicist, engineer and statistician) for inventing the tool
A card deck that describes the Lean Cycles of CAP-Do, SDCA, PDCA, and EDCA. Taking this type of view allows us to move from micro to macro thinking while still applying Lean Practices. We keep Lean in its simplest by breaking it down to the 4 Cycles, CAP-Do, EDCA, PDCA, EDCA and providing overall scope and assembling a team using the SALES acronym.
The High Achieving Governmental Health Department in 2020 as the Community Ch...Tomas J. Aragon
This paper was prepared by RESOLVE as part of the Public Health Leadership Forum with funding from the Robert Wood Johnson Foundation. John Auerbach, Director of Northeastern University’s Institute on Urban Health Research, also put substantial time and effort into authoring the document with our staff. The concepts put forth are based on several working group session (See Appendix B for members) and are not attributable to any one participant or his/her organization.
Continuous improvement: the Deming Wheel (PDCA)encognize G.K.
To a certain extent, improving the performance of a company can be achieved through the improvement of its underlying structure, processes and organization. As part of the famous Kaizen practices, a common management method used to initiate and sustain a virtuous circle of continuous improvement is the Deming wheel, also known as the Shewhart cycle and more frequently referred as the PDCA cycle. This method simply consists in running iteratively four steps on the system to improve: Plan (define objectives, success criteria, contingencies), Do (execution), Check (analyse result against initial objectives and success criteria), Act (adjust).
Simple demonstration for the PDCA tool that was popularized by Edwards Deming as a continuous quality improvement tool.
Deming has credited Walter Shewhart (American physicist, engineer and statistician) for inventing the tool
A card deck that describes the Lean Cycles of CAP-Do, SDCA, PDCA, and EDCA. Taking this type of view allows us to move from micro to macro thinking while still applying Lean Practices. We keep Lean in its simplest by breaking it down to the 4 Cycles, CAP-Do, EDCA, PDCA, EDCA and providing overall scope and assembling a team using the SALES acronym.
The High Achieving Governmental Health Department in 2020 as the Community Ch...Tomas J. Aragon
This paper was prepared by RESOLVE as part of the Public Health Leadership Forum with funding from the Robert Wood Johnson Foundation. John Auerbach, Director of Northeastern University’s Institute on Urban Health Research, also put substantial time and effort into authoring the document with our staff. The concepts put forth are based on several working group session (See Appendix B for members) and are not attributable to any one participant or his/her organization.
Population Health Data Science, Complexity, and Health Equity: Reflections fr...Tomas J. Aragon
Annual Population Health Sciences Colloquium at the Stanford Center for Population Health Sciences on October 26, 2015.
This one-day program will showcase population health sciences research from the Stanford community and experts around the world.
This one-day program will showcase population health sciences research from the Stanford community and experts around the world. The PHS Initiative aims to bring together basic, translational and clinical scientists, along with researchers from disciplines across the entire University, to provide resources and facilitate collaborations focused on population-level questions, data and approaches.
We have an exciting full-day session with keynote speakers - Lloyd Minor, Dean of the Stanford School of Medicine; Muin Khoury, Associate Director of Epidemiology and Genomics Research Program at NCI; and Tomas Aragon, Director of Population Health Division at the San Francisco Department of Public Health - and some time to do the vital work of growing our center.
Ini adalah model pembelajaran terbaru yang merupakan hasil dari penelitian Dosen saya Di Universitas Mulawarman.
Semoga dapat menjadi model pembelajaran acuan dan pedoman bagi para Guru Di Indonesia dimanapun berada.
ini adalah salah satu contoh buku buatan sendiri..
buku ini merupakan TUGAS dalam rangka Ujian Tengah Semester yang ditugaskan salah satu dosen pada mata kuliah Belajar Pembelajaran..
Buku ini diposting hanya sebagai contoh dalam mendesain dan menempatkan (mengatur layout sebuah buku pembelajaran) yang diharuskan untuk dikemas semenarik dan sekreatif mungkin, menggunakan media terbarukan..
After Action Report: a structured support to the practice of continuous impro...Learning Everywhere
This paper is about Lean and Continuous Improvement principles and tools, focusing in the After Action Report as the way to practice the “check” and “adjust” at PDCA cycle.
It presents the After Action Report - a Lean and Continuous Improvement tool, as a tool for those who are interested in supporting continuous improvement, practicing “check” and “adjust”, individually and in organizations and teams. This tool can be applied everywhere, in every projects or daily situations, and every time (as it is “continuous”). The main goal is to clarify that, when we have a structure, it becomes easier to support the practice of continuous improvement.
Designing a Learning Health Organization for Collective ImpactTomas J. Aragon
"Designing a Learning Health Organization for Collective Impact" was my presentation given at the California HealthCare Foundation (CHCF) Health Care Leadership Program final seminar and graduation. Congratulations to the amazing fellow graduates!!!
Preparing for Microbial Threats to Health: What Every Professional Should KnowTomas J. Aragon
In this presentation I introduce the "SFDPH Population Health Division Controlling Infectious Diseases Model." This model integrates concepts from understanding transmission mechanisms, transmission dynamics, and transmission containment. The Model is most useful when facing novel microbial threats and we need simple framework for public health action.
Sugar MADNESS: How metabolic syndrome drives obesity and what you can do abou...Tomas J. Aragon
Sugar consumption, especially from sugary drinks, is the single largest and preventable contributor to the global epidemic of diabetes, heart disease, high blood pressure, bad cholesterol, and unhealthy weight gain. Fructose is the part of "sugar" that is the culprit. Fructose in liquid form is worse! Fructose is metabolized by the liver. With repeated exposures, it causes fatty liver, high insulin, insulin resistance, excessive fat storage, and leptin resistance. We call this metabolic syndrome. Our brain is tricked into believing our body is starving. Hence, we eat more and exercise less. It's a complicated, but important story: "Sugar MADNESS" is a memory aid to learning about sugar, metabolic syndrome, and what to do about it.
Ethanol (CH3CH2OH), or beverage alcohol, is a two-carbon alcohol
that is rapidly distributed in the body and brain. Ethanol alters many
neurochemical systems and has rewarding and addictive properties. It
is the oldest recreational drug and likely contributes to more morbidity,
mortality, and public health costs than all illicit drugs combined. The
5th edition of the Diagnostic and Statistical Manual of Mental Disorders
(DSM-5) integrates alcohol abuse and alcohol dependence into a single
disorder called alcohol use disorder (AUD), with mild, moderate,
and severe subclassifications (American Psychiatric Association, 2013).
In the DSM-5, all types of substance abuse and dependence have been
combined into a single substance use disorder (SUD) on a continuum
from mild to severe. A diagnosis of AUD requires that at least two of
the 11 DSM-5 behaviors be present within a 12-month period (mild
AUD: 2–3 criteria; moderate AUD: 4–5 criteria; severe AUD: 6–11 criteria).
The four main behavioral effects of AUD are impaired control over
drinking, negative social consequences, risky use, and altered physiological
effects (tolerance, withdrawal). This chapter presents an overview
of the prevalence and harmful consequences of AUD in the U.S.,
the systemic nature of the disease, neurocircuitry and stages of AUD,
comorbidities, fetal alcohol spectrum disorders, genetic risk factors, and
pharmacotherapies for AUD.
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
Title: Sense of Smell
Presenter: Dr. Faiza, Assistant Professor of Physiology
Qualifications:
MBBS (Best Graduate, AIMC Lahore)
FCPS Physiology
ICMT, CHPE, DHPE (STMU)
MPH (GC University, Faisalabad)
MBA (Virtual University of Pakistan)
Learning Objectives:
Describe the primary categories of smells and the concept of odor blindness.
Explain the structure and location of the olfactory membrane and mucosa, including the types and roles of cells involved in olfaction.
Describe the pathway and mechanisms of olfactory signal transmission from the olfactory receptors to the brain.
Illustrate the biochemical cascade triggered by odorant binding to olfactory receptors, including the role of G-proteins and second messengers in generating an action potential.
Identify different types of olfactory disorders such as anosmia, hyposmia, hyperosmia, and dysosmia, including their potential causes.
Key Topics:
Olfactory Genes:
3% of the human genome accounts for olfactory genes.
400 genes for odorant receptors.
Olfactory Membrane:
Located in the superior part of the nasal cavity.
Medially: Folds downward along the superior septum.
Laterally: Folds over the superior turbinate and upper surface of the middle turbinate.
Total surface area: 5-10 square centimeters.
Olfactory Mucosa:
Olfactory Cells: Bipolar nerve cells derived from the CNS (100 million), with 4-25 olfactory cilia per cell.
Sustentacular Cells: Produce mucus and maintain ionic and molecular environment.
Basal Cells: Replace worn-out olfactory cells with an average lifespan of 1-2 months.
Bowman’s Gland: Secretes mucus.
Stimulation of Olfactory Cells:
Odorant dissolves in mucus and attaches to receptors on olfactory cilia.
Involves a cascade effect through G-proteins and second messengers, leading to depolarization and action potential generation in the olfactory nerve.
Quality of a Good Odorant:
Small (3-20 Carbon atoms), volatile, water-soluble, and lipid-soluble.
Facilitated by odorant-binding proteins in mucus.
Membrane Potential and Action Potential:
Resting membrane potential: -55mV.
Action potential frequency in the olfactory nerve increases with odorant strength.
Adaptation Towards the Sense of Smell:
Rapid adaptation within the first second, with further slow adaptation.
Psychological adaptation greater than receptor adaptation, involving feedback inhibition from the central nervous system.
Primary Sensations of Smell:
Camphoraceous, Musky, Floral, Pepperminty, Ethereal, Pungent, Putrid.
Odor Detection Threshold:
Examples: Hydrogen sulfide (0.0005 ppm), Methyl-mercaptan (0.002 ppm).
Some toxic substances are odorless at lethal concentrations.
Characteristics of Smell:
Odor blindness for single substances due to lack of appropriate receptor protein.
Behavioral and emotional influences of smell.
Transmission of Olfactory Signals:
From olfactory cells to glomeruli in the olfactory bulb, involving lateral inhibition.
Primitive, less old, and new olfactory systems with different path
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Tom Selleck Health: A Comprehensive Look at the Iconic Actor’s Wellness Journeygreendigital
Tom Selleck, an enduring figure in Hollywood. has captivated audiences for decades with his rugged charm, iconic moustache. and memorable roles in television and film. From his breakout role as Thomas Magnum in Magnum P.I. to his current portrayal of Frank Reagan in Blue Bloods. Selleck's career has spanned over 50 years. But beyond his professional achievements. fans have often been curious about Tom Selleck Health. especially as he has aged in the public eye.
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Introduction
Many have been interested in Tom Selleck health. not only because of his enduring presence on screen but also because of the challenges. and lifestyle choices he has faced and made over the years. This article delves into the various aspects of Tom Selleck health. exploring his fitness regimen, diet, mental health. and the challenges he has encountered as he ages. We'll look at how he maintains his well-being. the health issues he has faced, and his approach to ageing .
Early Life and Career
Childhood and Athletic Beginnings
Tom Selleck was born on January 29, 1945, in Detroit, Michigan, and grew up in Sherman Oaks, California. From an early age, he was involved in sports, particularly basketball. which played a significant role in his physical development. His athletic pursuits continued into college. where he attended the University of Southern California (USC) on a basketball scholarship. This early involvement in sports laid a strong foundation for his physical health and disciplined lifestyle.
Transition to Acting
Selleck's transition from an athlete to an actor came with its physical demands. His first significant role in "Magnum P.I." required him to perform various stunts and maintain a fit appearance. This role, which he played from 1980 to 1988. necessitated a rigorous fitness routine to meet the show's demands. setting the stage for his long-term commitment to health and wellness.
Fitness Regimen
Workout Routine
Tom Selleck health and fitness regimen has evolved. adapting to his changing roles and age. During his "Magnum, P.I." days. Selleck's workouts were intense and focused on building and maintaining muscle mass. His routine included weightlifting, cardiovascular exercises. and specific training for the stunts he performed on the show.
Selleck adjusted his fitness routine as he aged to suit his body's needs. Today, his workouts focus on maintaining flexibility, strength, and cardiovascular health. He incorporates low-impact exercises such as swimming, walking, and light weightlifting. This balanced approach helps him stay fit without putting undue strain on his joints and muscles.
Importance of Flexibility and Mobility
In recent years, Selleck has emphasized the importance of flexibility and mobility in his fitness regimen. Understanding the natural decline in muscle mass and joint flexibility with age. he includes stretching and yoga in his routine. These practices help prevent injuries, improve posture, and maintain mobilit
NVBDCP.pptx Nation vector borne disease control programSapna Thakur
NVBDCP was launched in 2003-2004 . Vector-Borne Disease: Disease that results from an infection transmitted to humans and other animals by blood-feeding arthropods, such as mosquitoes, ticks, and fleas. Examples of vector-borne diseases include Dengue fever, West Nile Virus, Lyme disease, and malaria.
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
1. PDSA problem-solving—with a gentle introduction to
double-loop learning, program theory, and causal graphs
Tomás J. Aragón1,2,∗
1
Health Officer, City & County of San Francisco
2
Director, Population Health Division
* tomas.aragon@sfdph.org July 16, 2017
1 Introduction
Humans have three core cognitive-behavioral processes [1]: deciding, acting, and learning. Adap-
tation comes from adjusting our decisions and actions based on what we learn. Improvements
are adaptations that make things better. These processes — mediated by emotions — are funda-
mental to all human activities, and form the basis for innovation and continuous improvement.
To become a learning organization, we must ensure: learning organization
1. decision quality (decisions, supported by data science)
2. strategic execution (actions; includes project and porfolio management)
3. performance improvement (learning; improves processes, achieves results)
4. positive and safe environments (emotions; for examples, see [1,2])
Population health population healthis “a systems framework for studying and improving the health of populations
through collective action and learning” [3]. Lean practice is “systematically developing people
to solve problems and consuming the fewest possible resources while continuously improving
processes to provide value to community members and prosperity to society” [4]. Population
health lean (PHL) population health leanis a transdisciplinary1
management system for continuous learning, adaptation,
innovation, and improvement based on lean thinking and practice, the PHL leadership philosophy
(Figure 1), and complementary frameworks2
[1].
Lean thinking lean thinkingconsists of three components that build upon each other:
1. Plan-Do-Study-Act (PDSA) problem-solving,
2. validated learning, and
3. A3 reporting.
Validated learning3
is rapid PDSA cyles with a purposeful goal. We embrace “failures” as
learning opportunities (“fail fast, fail cheap, fail forward”). A3 reporting uses a single A3-sized
paper4
to summarize the collaborative PDSA problem-solving. PDSA is at the core of lean
thinking, the PHL leadership philosophy (Figure 1), and leader standard work.5
Because of its
central importance, this paper covers PDSA problem-solving; for other topics see [1].
In this paper, “problem” is a general term that includes needs, problems, or opportunities.
A need is something that is considered essential (e.g., human drives). A problem is something
1Different disciplines working together to create new conceptual, theoretical, methodological, and practice
innovations that integrate and move beyond discipline-specific approaches to solve common problems.
2For example, design thinking, lean startup and production, and collective impact methods.
3Also called the "improvement kata."
4Or 17in × 11in paper.
5Leader standard work is, starting with self, developing people to solve problems and improve performance.
2. PDSA Problem-solving July 16, 2017
Figure 1. The population health lean leadership philosophy focuses on transformation with PDSA
problem-solving that aligns to purpose, people, process, and performance.
that is not meeting an expectation, including its root causes. An opportunity is the possibility to
pursue something new or different, and may include a new way to fulfill a need or fix a problem.
In this paper, “problem-solving” is a general term for seeking, finding, and defining needs,
problems, or opportunities; for discovering and testing root causes; and for discovering, designing,
testing, and selecting creative, doable solutions. Problem-solving goes beyond fulfilling needs and
fixing problems, but includes the creativity and innovation, and pursuing new aspirational goals.
2 What is PDSA?
PDSA stands for Plan-Do-Study-Act. PDSA is the scientific method and we have been using it
all of our lives. PDSA thinking and problem solving is part of human nature: it is how we try
things, learn, and adapt. Unfortunately, many believe, mistakenly, that the scientific method is
only for scientists. By recognizing that we are already scientific thinkers we can improve our
daily decision-making, problem-solving, innovation, and performance.
PDSA is both simple and profound. In practice, PDSA is a learning cycle based on experiments.
PDSA has two distinct, but related, purposes:
• knowledge deployment: experiments to test and spread a new practice
• knowledge discovery: experiments to test and spread a new theory
A theorytheory is a explanatory (cause-effect) model which may be explicit, invisible (e.g., cultural
norm), or implicit (i.e., unconscious; for example, implicit racial bias). In knowledge deployment
knowledge deployment we experiment to test a new practice idea without challenging or testing the underlying theory.
We hypothesize the new practice is better than the old. Our intent is to improve practice. In
knowledge discoveryknowledge discovery we experiment to test a new theory. We hypothesize the new theory is valid
(or invalid). Our intent is to improve theory. Linking the concepts of knowledge discovery and
deployment promotes translational research and double-loop learning (see p. 3).
PDSA can be used “as is”: just plan, do, study results, and act on what you learned. The
secret to PDSA is prediction:"The secret to PDSA is
prediction."
“People learn better when they predict. Making a prediction forces
us to think ahead about the outcomes. Making a prediction also causes us to examine more
deeply the system, question or theory we have in mind” [5]. “We will learn much more if we
Population Health Division, SFDPH http://phlean.org 2/9
3. PDSA Problem-solving July 16, 2017
Table 1. PDSA for daily problem-solving (and PDSA variants)
PDSA PDSA core activities PDSA variants
Design thinking Lean Startup
Plan Define Empathize ↓
Design Define ↓
Decide Ideate (Ideas)
Do Experimenta
Prototype Build (product)
↓ Test Measure (data)
Study Learnb
(learn) Learn
Act Improvec
(improve) (improve)
a Predict, Experiment, and Measure
b Mindfulness, Reasoning, and Reflection
c Adopt, adapt, or abandon (“pivot or persevere”; or “stop, pivot, or proceed”)
write down our prediction. Otherwise we often just think (after the fact), ‘yeah that is pretty
much what I expected’ (even if it wasn’t)” [6]. We learn by experimenting to close the knowledge
gap between prediction and results. We improve by using what we learn to close the performance
gap between current and desired results.
We can improve PDSA by understanding its core activities (Table 1) which are not always
obvious:
1. define (includes seeking, finding, and understanding) the problem, and set objectives;
2. design processes (a) to discover, test, and prioritize root causes; and (b) to discover, test,
and prioritze possible solutions;
3. decide on creative, doable solutions to prototype and test;
4. predict the results (outputs, outcomes), and conduct experiments;
5. learn by observing results with mindfulness (focus, free of bias and prejudgment); by
reasoning using sound logic; and by reflection (looking for deeper meaning); and
6. improve by adopting, adapting, or abandoning the option for the next iteration.
Also included in Table 1 are PDSA variants from two enormously effective, complementary,
and popular approaches called design thinking and lean startup. To learn more see [1] or
study references [7–10]. The critical point is that all these methods use the scientific method
(PDSA) for finding problems, discovering root causes, and designing, testing, and spreading
effective solutions.
3 What is double-loop learning?
Incremental performance improvements occur by improving practice. All practices have underlying
cause-effect assumptions, also called theories or schema. The typical approach is to use PDSA
cycles to test and adjust practice improvements. We plan to test a practice innovation, we make
a prediction and test (do) the practice innovation, we study the results, and we act on what we
learned. This leads to incremental practice improvements.
Chris Argyris called this single-loop learning [11–13]. He recognized that PDSA can also
be used for double-loop learning which can lead to new theories and breakthrough performance
improvements. Figure 2 depicts PDSA with single-loop and double-loop learning. For example,
when efforts to improve a practice are failing (unsatisfactory results), we have two choices:
• continue attempts to improve the practice (single-loop learning; possible incremental
improvements), or
• consider improving the theory (double-loop learning; possible breakthrough improvements)
Population Health Division, SFDPH http://phlean.org 3/9
4. PDSA Problem-solving July 16, 2017
Figure 2. PDSA single and double-loop learning. Most improvement projects focus on single-loop
learning. However, when practice results are not improving, question and test your assumptions
(double-loop learning).
Double-loop learning makes these possibilities explicit and encourages innovative (break-
through) thinking. We aspire to be creative PDSA problem-solvers where expressing, challenging,
and testing underlying assumptions (theories) is second nature. This requires intellectual honesty,
courage, and curiosity.
Figure 3 depicts a well-known, historical example of single and double-loop learning with
Olympic high jump performances [14]. Single-loop learning led to incremental improvements
during the “Scissors” era. However, when a new theory of high jumping emerged (i.e., “Western
Roll”), we witnessed breakthrough improvements, followed again by incremental improvements
until new theories emerged (“Straddle,” “Fossbury Flop”). Double-loop learning is powerful but
requires awareness of its availability. We also need better conceptual tools to discuss theory. For
this, we dive into program theory next.
Figure 3. Olympic gold medal winners in the high jump (Olympic Games were not held in 1916, 1940,
and 1944).
Population Health Division, SFDPH http://phlean.org 4/9
5. PDSA Problem-solving July 16, 2017
4 What is program theory?
Program evaluators have a holistic, practical view of theory called “program theory.” Adapting
from Funnell and Rogers [15], program theory consists of three components:
• theory of causation,
• theory of change, and
• theory of action.
Before we intervene, what is our underlying causal assumption (theory of causation)? For
example, the tobacco industry targeted youth with advertisements to induce them to “smoke”
electronic cigarettes. What intervention strategy will we select (theory of change)? For example,
we might select changing “social norms” as our behavioral intervention strategy. What specific
activities will we deploy to activate our theory of change (theory of action)? For example, we
might select to launch a “social marketing” campaign to change social norms around e-cigarettes.
Our program theory should be stated clearly and make intuitive sense to primary stakeholders,
including our staff.
In contrast, behavioral scientists use the term “social and behavioral theory” for complex
psychosocial constructs based on extensive academic research and validation [16]. The theories
can be categorized into
• individual health behavior theories;
• social, cultural, and environmental theories; and
• multi-level theories.
In my experience, some public health staff have limited experience with these behavioral
models; they tend to rely primarily on biomedical, epidemiologic models (exposure → disease),
and less on complex psychological, social, and behavioral theories. In any case, whether stated
or not, all public health interventions have a program theory (theory of causation, change, and
action).
In order for us to take advantage of double-loop learning, to improve our leadership coaching
and teaching, and to improve our leader standard work, we must get in the habit of (a) stating
our program theory, and (b) using humble inquiry to ask our staff about their program theory.
5 Case scenario for reflection and discussion
You are the new health educator for the local school district. The superintendant wants to
increase student vaccination rates. You survey the parents about their level of concern
regarding vaccines (adverse events, “autism”, etc.). You hypothesize that you can increase
vaccination rates by providing scientific facts about vaccine safety, including debunking myths,
such as “vaccines cause autism.” Your team decides to launch a targeted social marketing
vaccine safety campaign.
Epidemiologist thinking (Dr. Juan Nieves)
A medical epidemiologist, Dr. Juan Nieves,6
was assigned to assist you. His working hypothesis
is that parents who are exposed to the vaccine safety campaign (yes vs. no) are more likely to
vaccinate their children (yes vs. no). He proposes to conduct multivariate regression analysis in
SAS to control for “confounding,” and, possibly, “interaction,” but needs for you to pay to renew
his expired SAS license.
Health educator thinking 1 (theory of causation)
You believe that parental knowledge gaps about vaccine safety lead to an increase in parental
concern and a decrease in vaccinated children. You recognize this as your Theory of
6Dr. Juan Nieves is a fictitious character; any resemblance to anyone you know is purely coincidental.
Population Health Division, SFDPH http://phlean.org 5/9
6. PDSA Problem-solving July 16, 2017
Causation (Figure 4).
Theory of Causation
Parental
knowledge
Parental
concern
Vaccinated
children
Figure 4. Causal graph depicting the Theory of Causation
Health educator thinking 2 (theory of change)
You hypothesize that if you narrow parental knowledge gaps about vaccine safety, parental
concern will decrease, and the number of vaccinated children will increase.
After reviewing many options, your team selects transforming social norms as the primary
strategy to narrow parental knowledge gaps. You recognize this as your Theory of Change
(Figure 5).
Theory of CausationTheory of Change
Parental
knowledge
Parental
concern
Vaccinated
children
Social
norms
Figure 5. Causal graph depicting the Theory of Change, and of Causation
Health educator thinking 3 (theory of action and program theory)
Of all the available interventions to impact social norms, your team selected to implement
a social marketing vaccine safety campaign. You recognize this as your Theory of Action
(Figure 6) and, together with the theory of change and of causation, is called the Program
Theory (Figure 6). As a health educator you recognize that, whether stated or not, all public
health interventions have a program theory (theory of causation, change, and action). You also
recognize that program theory aligns with Results-Based Accountability (RBA) [17].7
Program Theory
Theory of CausationTheory of Change
Theory of Action
Parental
knowledge
Parental
concern
Vaccinated
children
Social
norms
Social
marketing
campaign
Figure 6. Causal graph depicting the Theory of Action, of Change, and of Causation (collectively
called Program Theory)
7Program theory: (a) theory of causation (RBA: What is the story behind the curve? [root causes]); (b) theory
of change (RBA: What works to do better? [strategies]); and (c) theory of action (RBA: What do we propose to
do? [action plan])
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7. PDSA Problem-solving July 16, 2017
Discussion Questions (part 1/2)
Compare and contrast the approaches used by the Dr. Juan Nieves and the health educator.
1. What are the advantages and disadvantages to each approach?
2. How can they improve their collaborative approach?
3. What causal graph(s) does the epidemiologist have in mind? (extra credit)
Case scenario (continued)
After an extensive vaccine safety campaign you are very surprised to see student vaccination rates
significantly decline among families with “concerned” parents, yet moderately increase among
families with “nonconcerned” parents.
Discussion Questions (part 1/2)
Based on the surprising results, answer and discuss the following:
1. What might explain these observations? (think PDSA double-loop learning, including
program theory)
2. Propose a new program theory that might explain the surprising results. Start with a
root cause model (theory of causation), and then build up. Discuss with your learning
partner(s).
3. How will you test your new program theory?
Case scenario (closing thoughts)
Every public health intervention has a program theory, and it should be stated explicitly. When
available, adapt evidence-based frameworks for your target population and intervention. For
example, Figure 7 depicts a conceptual framework for vaccine hesitancy that may help you design
your program theory [18]. Although a framework is not a causal model, it can be a very useful
conceptual tool to support your causal thinking and program theory design.
Figure 7. Conceptual model of vaccine hesitancy
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8. PDSA Problem-solving July 16, 2017
APPENDIX
A What are causal graphs?
Causal graphs, also called directed acyclic graphs (DAGs), are used to display causal links. If
the value of Y depends, in some way, on the value of X, then Y = f(X), and Figure 8 applies:
X Y
Figure 8. A directed acylic graph.
Directed acyclic graphs have three fundamental forms: chain, fork, and collider (Figure 9).
All causal graphs are constructed from chains, forks, and colliders. DAGs cannot cycle (“acyclic”);
for example, this form (X → Y → X) is not permitted.
Chain (sequential causation) Fork (common cause) Collider (common effect)
X1
Y1
Z1
X2
Y2 Z2
Y3
Z3
X3
Figure 9. Directed acyclic graphs have three fundamental forms (chain, fork, and collider)
DAGs are very powerful because they can be constructed from expert knowledge, common
sense, and/or scientific evidence. It is very important for us to visually display causal pathways
so we can discuss and improve our work. Drawing DAGs only requires common sense and subject
matter familiarity.
Then epidemiologists can then use DAGs to design analyses, and to test if the causal links are
supported by the observed data. To learn more about DAGs for causal inference and statistics
study Pearl [19].
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