This document provides an overview of quality improvement models and tools. It begins with an introduction to common quality improvement models including Plan-Do-Study-Act (PDSA), Total Quality Management, the Model for Improvement, Six Sigma, Lean, and Lean Six Sigma. It then discusses key founders and theories that helped establish the foundations of quality improvement such as Walter Shewhart, W. Edwards Deming, and Avedis Donabedian. The document focuses on explaining the PDSA model in detail and provides examples of how to apply it. It also introduces common quality improvement tools that can be used with the PDSA model including process mapping, metrics, data analysis and display. The goal of quality improvement is

1. Quality Improvement
Models: PDSA
Rebecca S. (Suzie) Miltner, PhD, RN
Associate Professor, School of Nursing

2. UAB Mission
To improve the health and well-being of society,
particularly the citizens of Alabama, by providing
innovative health services of exceptional value
that are patient- and family-centered, a superior
environment for the education of health
professionals, and support for research that
advances medical science.

3. UAB Mission
To improve the health and well-being of
society, particularly the citizens of
Alabama, by providing innovative health
services of exceptional value that are
patient- and family-centered, a superior
environment for the education of health
professionals, and support for research
that advances medical science.

4. And we have opportunities for
improvement…

5. Opportunities for improvement…
Admission process/Bed assignment
Equipment availability
Training and competency
Prioritization
Supervision/Oversight

6. In the “past”…
 People were disciplined (maybe terminated)
 New rules came down from managers/leaders
 Everyone had to sign the inservice sheet as a
record that they knew the new policy.
 No changes within system…just waiting for the
next incident.

7. What do you do to change a
process to make it better?

8. The Quality Foundation
Avedis Donabedian, MD, MPH
(1919-2000)
 Father of quality assessment
 Structure-process-outcome framework for QI and health
services research
 Famous quotes:
 “People have a big problem understanding the relationship between quality and systems. System
management doesn’t get taught in medical school or nursing school.’’
 ‘‘There’s lip service to quality and, goodness knows, propaganda, but real commitment is in short
supply.’’
 ‘‘Systems awareness and systems design are important for health professionals, but are not enough.
They are enabling mechanisms only. It is the ethical dimension of individuals that is essential to a
system’s success. Ultimately, the secret of quality is love. You have to love your patient, you have to
love your profession, you have to love your God. If you have love, you can then work backward to
monitor and improve the system.’’

9. What IS Quality Improvement?
-9-

10. What IS Quality Improvement?
Quality Improvement is a data-driven,
formal approach to the analysis of
performance and the systematic
efforts to improve it.

11. What IS Quality Improvement?
The combined and unceasing efforts of
everyone – health care professionals, patients
and their families, researchers, payers,
planners, administrators, educators – to make
changes that will lead to
better patient outcomes,
better system performance, and
better professional development.
-11-
Batalden P, Davidoff F. Qual. Saf. Health Care 2007;16;2-3

12. Quality Improvement:
Bridging the Implementation Gap
Implementation Gap
Scientific
understanding
Patient care
Progress
Time

13. 13
Rubenstein, L. & Pugh, E. 2006. Strategies for Promoting
Organizational And Practice Change by Advancing
Implementation Research. Journal of General Internal Medicine,
21, S58-64.
What is Quality Improvement?

14. Models for Improvement
14

15. Frameworks or Models?
Essentially, all models are wrong,
but some are useful.
Box, George E. P.; Norman R. Draper (1987). Empirical Model-
Building and Response Surfaces, p. 424, Wiley. ISBN
0471810339.

16. Why Use Frameworks or Models?
 System of rules, ideas or beliefs that is used to
plan or decide something
 A supporting structure around which something
can be built
 A way to operationalize abstract concepts
 Visually depict how something should work
 Frame of reference and common language
when working in a group

17. Improvement Models
Plan-Do-Study-Act (PDSA)
Total Quality Management/Continuous
Quality Improvement
Model for Improvement
Six Sigma
Lean / Toyota Production System
Lean Six Sigma
17

18. The Quality Foundation
 Walter Shewhart (1891 – 1967)
 Western Electric Co.
 Variation and statistical control
 Designed to assist Bell telephone in their efforts to
improve reliability and reduce frequency of repairs
 Developed the Plan-Do-Check-Act (PDCA) cycle

19. 19
SHEWHART CYCLE
Plan
DoCheck
Act

20. 20
FOCUS-PDSA
► Focus Find an opportunity
► Organize A team
► Clarify Understand process / problem
► Understand Variation, root causes, barriers
► Select Opportunity and strategy
► Plan Intervention
► Do Intervention
► Study Measure the results
► Act To hold gains continue to improve

21. 21
MODEL FOR IMPROVEMENT

22. What is Lean?
Goes by many names (e.g. Lean manufacturing,
Toyota Production System
Key theory is removal of waste
Emphasis is on work flow
Key steps
 Identify which features create value
 Identify the sequence of activities called the value
stream
 Let the customer pull the product or service
through the process
 Perfect the process
22
Bevan et al, (2005). Lean Six Sigma:
Some Basic Concepts. NHS Institute for
Innovation and Improvement

23. Method developed in industry at Motorola in
the 1980s under the leadership of Bob Galvin.
Won the Baldrige Award in 1988.
Further popularized by General Electric under
Jack Welch and became the company’s
operating strategy in 1995.
Goal is to achieve defect-free performance at
the level of 3 or fewer defects per million (6
sigma)
What is Six Sigma?

24. Sigma calculation is related to number of
defects.
 6 sigma = 3 defects per million (99.99966%)
 5 sigma = 233 defects per million (99.98%)
 4 sigma = 6210 defects per million (99.4%)
 3 sigma = 66807 defects per million (93.3%)
 2 sigma = 308537 defects per million (69.1%)
 1 sigma = 691462 defects per million (30.85%)
Goal for any individual measure is set
(specification limit) and this is used to
determine if there is a defect or not.
Six Sigma Measure

25. Lean and Six Sigma
25
Specify
Value
Understand
Demand Flow Level Perfection
Improved
efficiency
and speed
Lean: Focuses on dramatically improving flow in the value
stream and eliminating waste.
Six Sigma: Focuses on eliminating defects and reducing variations
in processes.
Define Measure Analyse Improve Control
Improved
effectiveness
Bevan et al, (2005). Lean Six
Sigma: Some Basic Concepts.
NHS Institute for Innovation and
Improvement

26. Lean Six Sigma
Combines lean and six sigma concepts
Define, measure, analyze, improve, control
Sigma yield decreases as complexity increases,
so first reduce complexity (steps in the process),
then improve sigma per part or step

27. Comparison of different models
27

28. Quality Improvement
Quality Improvement is a data-driven,
formal approach to the analysis of
performance and the systematic
efforts to improve it.

29. Plan
Do
Study
Act
Identify a problem
Organize a team
Define the process
Understand process
performance - data
Choose a process
change
• This framework serves as the
basis for most improvement
methodologies
• QI tools are the enablers for
these components. They
allow efficient, effective
completion.
• QI is a team sport. All
stakeholders are key to
understanding the process
and choosing rational
interventions

30. 30
CQI elements
Key features
systematic data guided activities
designing with local conditions in mind
iterative development
Rubenstein et. al. 2013. How can we recognize CQI?

31. Improvement Tools
 Team building
 Group decision making techniques
 Brainstorming
 Affinity diagrams
 Multi-voting
 Nominal group technique
 Process mapping
 Aim statements
 Developing measures (metrics)
 Analyzing (and displaying) data
 Tests of change (PDSA)
31

32. MODEL FOR IMPROVEMENT
32

33. 33
PDSA CYCLE
Plan
DoStudy
Act

34. 34
PDSA Cycle
Plan
 Define the aim, question, and predictions
 Plan your data collection to answer the questions
Do
 Try out the change idea and collect data
Study
 Analyze the data and compare to your predictions
Act
 Plan the next cycle
 Can you implement the change?

35. 35
Stage Description Steps
Plan
Plant the test or
observation, including
a plan for collecting
data.
1) State the object of the test.
2) Make predictions about what will happen and why.
3) Develop a plan to baseline the current process and test the
change. (Who? What? When? Where? What data need to be
collected?)
Do
Try out the test on a
small scale
1) Carry out the test.
2) Document problems and unexpected observations.
3) Begin analysis of the data.
Study
Analyze the data and
study the results.
1) Complete analysis of the data.
2) Compare the data to your predictions.
3) Summarize and reflect on what was learned.
 Adapt, Adopt or Abandon?
Act
Refine the change
based on what was
learned from the test.
1) Determine what modifications should be made.
2) Prepare a plan for the next test.
PDSA Cycle

36. PDSA Cycle
Example
Note:
• Prediction
• Measures
• Responsible Persons

37. P D
S A
Ideas
Changes in the system
resulting in improvement
Modify the protocol and
make it standard practice
Use the protocol with all
the patients
Modify the protocol and try with
other patients
Create a protocol and try with
a few patients
PDSA Cycles: Iterative Process

38. Tomolo A M et al. Qual Saf Health Care
2009;18:217-224
Revised conceptual model of rapid cycle change.

39. LEARNING BY DOING
An improvement simulation
exercise
*Thanks to my colleague, Brant Oliver, PhD, MS,
MPH, at the Dartmouth Institute

40. Learning Objectives
After completing this simulation exercise,
participants will be able to:
(1) describe the IHI Model for Improvement,
including the Plan-Do-Study-Act Cycle;
(2) conduct simple PDSA cycles in a simulated
environment;
(3) create simple data displays for performance
measurement; and
(4) describe and interpret Run Charts.

41. In this exercise we will
simulate the model for
improvement…
IHI (2004)

42. 42
PDSA CYCLE
Plan
DoStudy
Act

43. Simulation Exercise: Mr. Potato Head
A scene from “Toy Story” (Pixar Studios)
Credits:
• Original program: Institute
for Healthcare
Improvement (IHI),
Cambridge, MA (2004)
• Adapted by Steve
Harrison, Sheffield MCA,
Sheffield, UK (2013)
• Adapted for collaborative
simulation with real time
measurement dashboard
and registry (B. Oliver,
2015, 2016) & playbook (M
Godfrey (2015).

44. Imagine that building Mr. Potato Head is improving the
quality of falls prevention in an academic medical center...
0
2
4
6
8
10
12
14
16
Jan-…
Mar…
May…
Jul-04
Sep…
Nov…
Jan-…
Mar…
#MeetingCriteria
# Patients Meeting Criteria
20
30
40
50
60
70
80
Jan-04
Mar-…
May…
Jul-04
Sep-…
Nov-…
Jan-05
Mar-…
%MeetingCriteria
% Of Patients Meeting Criteria

45. Your Evidence Based Practice Bundle of
Care: Potato Head

46. 46
What we aim to achieve…
• “Build it right” (adhere to the
evidence based practice guideline)
• “Build it fast” (optimize access to care)
• “Do it consistently” (optimize reliability)
• “Continuously improve” (optimize value)

47. Facility Teams for the PDSA
Simulation…
• Unit Nurse Manager
• Staff RN: Timer
• Staff PCT: Recorder
• PT/PharmD/MD: Observer(s)

48. Falls Prevention Program Components
 Hat = Risk Assessment
 Glasses = individual care plan
 Tongue = medication s
 Mustache = orthostatic HTN
 Nose = interprofessional team
 Right ear = mobility program
 Left ear = feet/footwear
 Eyes = vision
 Pants = hip protectors
 Left arm = environment
 Right arm = goal
setting/feedback

49. We have to pretend!
 We can’t do all these
interventions, so…
 Accuracy will represent
getting the right
preventive measures to
the right patient
 Speed of putting the
parts together will
represent efficiency

50. How will we measure our success?
 Accuracy = score 0-3
 How does the scoring work?
 Let’s figure that out!
 0 = xxx
 3 = xxx
 Speed = time measured
with stopwatch on smart
phone

51. We will simulate a facility level
improvement collaborative…
• 1 Baseline cycle and successive PDSA cycles
• Simulate rapid cycle improvement
in separate microsystems
• Track performance (building speed and
accuracy score) using Run Charts and
descriptive displays
• Cascade measures and simulate an
improvement collaborative

52. P D
S A
Ideas
Changes in the system
resulting in improvement
Modify the protocol and
make it standard practice
Once you are happy, try the set of
interventions with all the patients
Modify the interventions and try with more
patients
Try one set of interventions on 5 patients
PDSA Cycles: Iterative Process

53. Potato Head Simulation…

54. PDSA Plan Time Accuracy
1 Baseline
2
3
4
0
20
40
60
80
100
120
140
Time
0
0.5
1
1.5
2
2.5
3
Accuracy

55. Common Cause
Variation caused by chance causes,
by random variation in the system,
resulting from many small factors.
Example: Variation in work
commute due to traffic lights,
pedestrian traffic, parking issues.
Special Cause
Variation caused by special
circumstances or assignable cause
not inherent to the system.
Example: Variation in work
commute impacted by flat tyre,
road closure, heavy frost/ice.
Types of Variation
Statistically significant
56

56. Common Cause Variation
Reduce Variation (Increase Precision):
Make the process even more reliable.
Sub-Optimal Average Performance:
Redesign process to get a better result.
Special Cause Variation
Identify the Cause:
If Positive: “Maximize, optimize, replicate, or
standardize.”
If Negative: “Minimize or eliminate”
57
Application – Responding to Variation

57. Benchmarking helps to
empower improvement
collaboratives…

58. Potato Head “Best Practice” Flow Diagram
to Standardize for Playbook

59. “Potato
Head
Playbook”

60. The “light” side

61. I expect
continuous
improvement!
The “dark” side

62. Final Thought:
Our job is not only to DO our work, but also
to IMPROVE our work – ultimately to improve
patient care quality.
-Paul Batalden