Quality_Improvement_Tools___collaborative_Learning_Session_May2021.pptx

Quality Planning Policy, resources, coordination, accountability,
implementation design
QUALITY MANAGEMENT
Quality Assurance, Quality Planning, Quality
Control and Continuous Quality Improvement
CQI
1. Aims: what are the “gaps”
in performance and outcomes
2. Measures: tools to
measure and feedback
processes and outcomes
3. Changes: QI change
activities for leadership, admin
and frontline to close the “gap”
IMPROVED
OUTCOMES
Standards/ Guidelines/
protocols
Professional oversight
Accreditation
Performance review
Quality Assurance/
Quality Control
© 2012 P Barker/L Provost

Maternal Newborn and Child Health Quality
of care Network
• QoC Aim: To halve
institutional Maternal,
Newborn and Child
deaths by 2022
• Baseline assessment for all
facilities less than 50%

Quality Management in improving
outcomes

Implementing Levels for Quality
Management
• National: QMD at MOH HQ and QM TWG, 4 divisions (Norms and
Standards, QI, M&E and Digital Health)
• Regional Level: QM Satellite Offices (5)
• Central Hospitals: Central Hospital Quality Management (CHQM) Focal
Person, QIST, WITs
• Districts and Health Facilities: District QM Focal persons, Facility QM
Focal Persons, QIST and WITs

Quality Management Teams
• A team is a group of people with multidisciplinary
skills, working together on a common goal
• 12 – 15 members in a QIST
• 10 – 12 members in a WIT
QIST - Quality Improvement Support Team
WIT - Work Improvement Team

• Head of the institution
• District Nursing Officer/Chief Nursing Officer
• Heads of departments/Ward In-charges
• Environmental Health Officer
• Administrator
• Health statistician/HMIS officer
• Transport Officer
• QM focal person
• Pharmacy
• Laboratory
• A community representative
• Hospital Ombudsman
• *5 – 10 members
• Nurse-midwife
• Clinician
• Anesthetist
• Pharmacist
• Laboratory
• Hospital Attendant
• Biomedical Technician/ maintenance
officer
• Cleaner
• Patient
Quality Improvement Support Team (QIST)
Hospital level
Work Improvement Team –
Ward/ Health Centre level

QIST TORs
• QIST leads and coordinate all Quality Improvement Programs at hospital
level
Develop Quality Improvement Plan
Coordinate resources for quality activities with hospital management
• Form the WITs and assign gaps/ QI projects to the WITs
• Advise and supervise the WITS
• QIST report to District QM Focal Person through Facility QM Focal Person
• Document change ideas that worked in the change package which can be
used to spread changes

WIT TORs
• Conduct regular review meetings at department level (every 2 weeks)
• Train or orient new staff members in QI
• Identify and analyze problems in their day-to-day work (using data)
• Develop and test change ideas
• Document QI projects in documentation journal
• Document QI project successes and failures in a change package
• Participate in collaborative learning sessions or data review meetings
• WITs report to District/ Facility QM Focal Person

Team Members Names Job Titles Position in the Team Contact Number
1
2
3
4
5
6
7
8
9
10
QUALITY IMPROVEMENT DOCUMENTATION JOURNAL
High level Improvement Aim: _____________________________________________________________________________
QI Project Title: __________________________________________________________________________________________
Name of District: ________________________________ Name of Facility: _______________________________
Name of the Team/Department: ____________________ Team Leader: __________________________________
Project Start Date: _______________________________ End date: _____________________________________

Quality in all hospital process
Both clinical and administrative oriented
Work/Services Improvement
With Client oriented approach
Working Environment
Improvement
With service provider oriented
The Quality Improvement Model For Malawi
IZEN-TQM concepts
High Quality Health Care
Services
KEY
CQI – Continuous Quality Improvement
TQM – Total Quality Management

Five S’s (5S)
• Originated from the Japanese
manufacturing sector
• Its focus is on “Work Environment
Improvement ”
• Improve productivity and safety
in all types of organizations
SUSTAIN
5
SUSTAIN
Shitsuke
1
3
5

Eliminate unnecessary
workplace clutter hence
reduce time lost looking for
an item and wasted space
1. SORT (Sankhulani)

• Goal: Effective and efficient
storage to make workflow
smooth (effort is not wasted)
• Group items based on function
and frequency of use
• Use labels, numbers or zoning
for ‘can see, can take, can
return’
• Items similar in appearance
should not be placed together
2. SET (Sanjani)
BEFORE
AFTER

2. SET (Sanjani) ….
Zoning & color coding
Color coding Taping
Alignment
symbols
Signboard

2. SET (Sanjani) ….
Labelling
Alphabetical coding
Numbering
Visual
Management
Board
X – Y axis

• Shine aims at
Keeping everything clean at all
times
Checking that tools and
equipment are well maintained
and in good working condition
• Results in a safe workplace for both
health workers and clients
• Prevent nosocomial infections
3. SHINE (Salalitsani)

• Develop SOPs and checklist to maintain a regular and continuous
practice of maintaining S1 – S3
• Give opportunities to employees to take active part in the
development of these standards
• If not done things go back to the way they were before the first
3S’s
4. STANDARDIZE (Samalitsani)

An example
of checklist
11/15/2022
SECTION/UNIT _________________________________
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15
All staff participated in 5 minutes
work place orderliness strategy
Used trays/utensils sorted and
returned to appropriate places
Patients belongs sorted according
to set standards and additional
kitted or given to relatives
SETTING/SETI ACTIVITIES
Medicines and materials is
placed into correct labeled space
in cupboard/emergency trolley
Stock controlled (no supply in
danger zone or empty space
without O/S tag)
Each item/equipment is placed to
its set/labeled/zoned area
Beds, bedside cupboard, patients
belongings etc well aligned
Notice board well arranged (X-Y
axis maintained)
SHINE (Standard for Ward/Clinic Structure cleaning )
Floor - Mopping at least once per day
Sinks/Sluice - Cleaned Daily
Standard for Toilets/WC/Washrooms cleaning
Toilet Floor - Scrubbed daily
Toilet Walls -Scrubbed Daily
Toilets items- Scrubbed daily
Sinks/bath basins- Cleaned
Daily
Standard for Care Equipment/Linen/Beddings cleaning
Care Equipment - additionally
cleaned any time when soiled
Linen/Beddings - Changed every
48 hrs or when soiled/dirty
Furnitures - Dusted Daily
Protective Gears - (if not
disposable) cleaned, dried and
stored after use
MBEYA CONSULTANT HOSPITAL; 5S-CQI-TQM SYSTEMATIZE AND CUSTOMIZATION
CHECK LIST FOR DAILY MONITORING OF 5S ACTIVITIES
DATE:- (dd-mm=yyyy)- ____/____ 20____
SORTING/SASAMBUA ACTIVITIES
S1
S2
S3
Contents
of the
daily
checking
Check
daily basis

• It focuses on defining a new mindset and a standard in workplace
• Standardized procedures must be continuously applied until it becomes habitual
Monitoring 5S activities
Continuous professional development program
Regular communication through 5S corner
Motivation (reward system)
• Without sustaining things fall apart and 5S concepts are forgotten
5. SUSTAIN (Sungitsani)

Combination of tools
21
Tools used Labels, Zoning
Improvements • Clear specification of each place for
keeping medicine
• Avoiding mix up the medicines
Tools used Symbol, Zoning
Improvement
s
• Staff can easily and immediately get the machine from
fixed place of each machine
• Everybody understand appropriate location of each
machine

Combination of tools
Tools used Labeling, Zoning, Color coding
Improvements • Staff can easily and immediately recognize the how wastes are segregated
• Everybody understand appropriate location of each waste bin

4 step approach to
Continuous Quality Improvement (CQI)
STEP 1 -
Identifying a
problem,
forming a
team and
setting an aim
STEP 2 –
Analyzing the
problem and
Developing
change ideas
STEP 3 –
Measuring
Quality of care
and testing
changes
STEP 4 -
Sustaining
improvements
Adapted from Collaborators: WHOCC-AIIMS, USAID ASSIST, UNICEF, UNFPA, WHO-SEARO

Step 1: Identifying a problem, forming a
team and setting an aim

• Select a problem from the bundle of interventions
• Use these tools for evidence based decision:
Quality of care assessments/ supportive supervision
Data review
Audit of clinical care or deaths
Patient feedback (satisfaction survey, suggestion box etc.)
Identifying a problem to solve

MNH QoC Bundle of interventions
Antenatal Care
a) Comprehensive ANC (history, exams, investigations, management)
b) 8 ANC contacts
c) Management of pregnancy-related complications (Antepartum
Hemorrhage, Malaria, Anemia, Post-Abortion)
Intra-partum care
a) Use of partograph (correct use, completeness)
b) Management of complications of labor and delivery (preterm labor,
prolonged/ obstructed labor, Caesarian Section, Eclampsia, Post-
partum Hemorrhage, mental health)
c) Unnecessary harmful practices
Post-partum care
a) Immediate postnatal care for the mother
b) Essential newborn care for the newborn
c) Sick newborn care (asphyxia, preterm/ RDS, sepsis)
d) 1-week and 8-week postnatal contacts for mother and newborn
Community based MNH
a) Community visits during antenatal care
b) Community visits for mother and newborn during postnatal care
c) Community engagement on MNH QoC
d) Strengthening Hospital Ombudsman

Paeds QoC areas for improvement
Emergency care
a) Emergency Triage Assessment and Treatment (ETAT)
b) Adequate monitoring for sick children
c) Management of fever and serious bacterial infections
d) Management of cough or difficult breathing
e) Management of diarrhoea
f) Management of acute malnutrition and anaemia
g) Management of child at risk for TB and/or HIV infection
h) Management of surgical emergencies
i) Management of maltreatment (neglect and violence)
Community care
a) Community IMCI
b) Community engagement to improve child care
c) Strengthen Hospital Ombudsman
Primary care of children
a) Correct assessment for growth and development
b) Breastfeeding, nutrition and appropriate support and counselling
for carers
c) Immunisations

List all problems
Important
to patient
outcomes
/ staff
safety
(1-5)
Affordable
in terms of
time and
resources
(1-5)
Easy to
measur
e
(1-5)
Under
control of
team
members
(1-5)
Total
(4-20)
A) Inadequate documentation in
patient files 5 5 4 5 19
B) No patient identification
4 1 3 4 12
C)Inadequate IPC monitoring
5 4 4 5 18
D) Inadequate preventive
maintenance (inconsistent temp
monitoring)
2 3 2 2 9
E) Inadequate security of medicines
3 2 1 3 9
F) Inadequate policies or guiding
documents 1 4 5 1 11
Example: Prioritization Matrix
Score all root
causes against
each criteria (each
column) – rank
from highest to
lowest

Problem statement
• What is the problem?
• Where was the problem observed?
• When was the problem first observed?
• How often does this problem occur?
• How did I know that there is a problem?
• What is the current/ baseline performance (percentage or
rate)?

Problem statement …
• Develop a problem statement for the selected problem using the
template above

The Model for Improvement
Aim Statement

SMART Aim
Specific improvement topic (what)
Measurable (How good)
Achievable but ambitious (How big)
Relevant
Time-frame (By when/how long)

Structure of aim statement
We aim to ( what do you want to achieve )
in ( which patient group)
from (what is the current performance)
to (what is the desired level of performance)
by when (how long).
Follow the structure:
20
Adapted from Collaborators: WHOCC-AIIMS, USAID ASSIST, UNICEF, UNFPA, WHO-
SEARO

Example of an Aim statement
Problem: Babies are cold at one hour following birth
We at ABC Hospital aim to reduce the % of newborns with low
temperature (<36.5 C ) from the 50% on 1 July 2020 to less than 10%
by 12 Aug 2020
• Who (which patients) - Newborns
• What (the outcome) - low temperature (<36.5 C )
• How much (the amount of desired improvement ) - from 50% to less than 10%
• By when (time over which improvement will occur) – July to August 2020 (6
weeks)

Exercise
• Develop a SMART aim statement for your prioritized problem

STEP 1: IDENTIFYING A PROBLEM AND WRITING AN AIM STATEMENT
1.1 Problem identification: How was the problem identified (Data review/ QoC assessment/ audit/ patient feedback)
1.2 Problem Statement
Tip: The problem statement should answer the following questions:
What is the problem? Where was the problem observed? When was the problem first observed? How often does the problem occur?
How did I know about the problem? What is the baseline performance?
Problem Statement
1.3 Aim Statement
Tip: The aim statement should have the following format:
We aim to (what do you want to achieve) in (which patient group) from (what is the current performance) in (date/ month of baseline
data) to (what is the desired level of performance) by (when – target date).
Aim Statement

4 step approach to
Continuous Quality Improvement (CQI) …
STEP 1 -
Identifying a
problem, forming
a team and
setting an aim
STEP 2 –
Analyzing the
problem and
Developing
change ideas

STEP 2 - Analyzing the problem
and Developing change ideas

Problem/ Root Cause Analysis
• A root cause is an initiating cause of either a condition or a causal
chain that leads to an outcome
• Every system will have a different root cause to a problem

Problem Analysis Tools
Pareto Chart
Process Flowchart
5 Why
Fishbone

1. Pareto Chart
• Pareto charts use the 80/20
rule which states that, for
many events, roughly 80%
of the effects come from
20% of the causes
• Work on improving 20%
(vital few) of the causes to
improve 80% of the effects

2. Process Flow Chart
• Graphic display of the process as it is known by the team
• Often used to represent a patient’s care pathway
• Different individuals may have slightly different views of how the
process really floes hence need to do this with a multidisciplinary
team
• Use when a single process is key to delivering the desired outcome

An example of a process map showing the patient flow in an
emergency department

Process Map Analysis
• Identify waste
Unnecessary steps, or duplication, or steps that do not add value
to the customer
bottlenecks or points of congestion
Poor order of steps
Unnecessary hand-off of patients
Too many steps that could have been run in parallel

3. Five Whys
Understanding why something is the way it is
1. Theatre was running very behind today, starting with the first patient. Why?
2. There was a long wait for a trolley to bring them in. Why?
3. A replacement trolley had to be found. Why?
4. The original trolley's wheel was worn and had eventually broken. Why?
5. It had not been regularly checked for wear. Why?
Root Cause: Because there is no equipment maintenance schedule.
Ensuring depth in our analysis

4. Fishbone / Ishikawa Diagram
Identifying all possible contributing factors (Can also use 5 Why to
get the Root causes)
Ensuring breadth in our analysis
People
Place
Provisions
Procedure
Major
influence
Minor
influence
Problem
Causes Effect
5 Why
Major
influence
Minor
influence

Prioritization matrix
• Need to prioritize which root causes to start working on:
 Under control of team
 Short turn about time: early success is motivating
 Use prioritization matrix

List all root causes
Important
to patient
outcomes
/ staff
safety
(1-5)
Affordable
in terms of
time and
resources
(1-5)
Easy to
measur
e
(1-5)
Under
control of
team
members
(1-5)
Total
(4-20)
A) No task allocation for review of
mothers in maternity waiting home
to identify labor
5 1 5 2 13
B) Inadequate planned CPD sessions
on management of birth asphyxia 3 3 3 4 13
C) No data validation (lack of
supervision for data quality by
DHMT)
4 5 4 5 18
D) No HBB protocols and Oxygen
source in labor ward from RHD and
CMST
2 4 5 1 12
E) No power back-up for frequent
power outages 2 2 4 1 9
F) Gaps in management of
equipment at facility level 1 5 2 3 11
Example: Prioritization Matrix
Score all root
causes against
each criteria (each
column) – rank
from highest to
lowest

When To Use Which Tool?
• Pareto chart – Prioritizing the causes
• Process mapping/ Flow Chart – when a single process is key to the
delivery of the outcome you are seeking to improve
• 5 Why – when the cause of the problem is simple
• Fishbone – when the cause of the problem is multi-facetted/ complex
and probably stretches beyond the boundaries of the organisation that
experiences it
50

Exercise
• Use one of the Root Cause Analysis Tools to identify the
root cause for your selected problem

Documentation Journal
STEP 2: ANALYZING THE PROBLEM AND DEVELOPING CHANGE IDEAS
2.1 Root Cause Analysis
For the problem described above, use the root cause analysis tools to identify possible root causes: Pareto chart,
Process map, 5 Why and Fishbone Diagram.

Documentation Journal …
2.2 Prioritization matrix
List of possible problems/ root causes
Important
to patient
outcomes /
staff safety
(1-5)
Affordable
in terms
of time
and
resources
(1-5)
Easy to
measure
(1-5)
Under
control
of team
members
(1-5)
Total
(4-20)

Developing Change ideas
• A change idea is a specific idea that if applied may lead to an
improvement
• Change ideas are developed from root causes identified
• We need Innovative Change ideas in healthcare NOT more of the
same!!!

Developing change ideas
• Brainstorm change ideas for the root causes that were prioritized during problem
analysis
• Identify change ideas from literature
• From change concepts
• Benchmark change ideas from other hospitals/ health facilities

Some categories of changes (Change Concept)
Reduce waste (time and resources)
Change the order of steps
Eliminate steps
Involve patients & families
Reduce variation
Change who does what – reassign tasks
Make changes in the work environment
Improve knowledge & skills
Provide transport
Change concepts are NOT
specific and can be applied
to different systems

Change Idea 1
Provide a Train Ticket to
transport the pregnant
woman in emergencies
Change Idea 2
Provide a Vehicle Ambulance
for transport the pregnant
Change Idea 3
Provide a Bicycle ambulance
to transport the pregnant
Change Concept
Provide Transport
CHANGE IDEAS
ARE SPECIFIC TO
A SYSTEM
Change Idea 4
Use prequalified motorcycle taxis
(bodaboda) to transport pregnant

Developing change ideas
• Ask your team.
 Based on the analysis what changes can we make?
 Why will this change result in an improvement?
 How will it work?
 What will we expect to see as a result of this change?
• Organize changes according to importance, practicality, responsible
person, inputs vs processes
• Test one change at one time

2.3 Developing Changes
Brainstorm and prioritize the change ideas for the prioritized root cause
What changes do you think will help solve the
problem?
How will this change improve care?
1. -
2. -
3. -

4 step approach to
STEP 1 -
Identifying a
problem,
forming a
team and
setting an aim
STEP 2 –
Analyzing the
problem and
Developing
change ideas
STEP 3 –
Measuring
Quality of care
and testing
changes

Step 3: Measuring Quality of care
and Testing changes

Process and outcome indicators?
 If you don’t measure
process
How will you know whether the
action you want done is really
happening or not
 If you don’t measure
outcome
How will you know whether you
are making progress towards
your aim or not?
How will you know whether the
action is really leading to the
desired outcome or not

Outcome Measures
 Reflect the customer/patient experience
 How is the overall system performing?
 Relates to overall aim
 Aim: Reduce the percentage of neonatal mortality due to birth
asphyxia from 25% to 10% in ABC hospital over the next 3
months (1st Nov – 28th Feb 2017)
 Outcome Measure:
• % of neonatal deaths due to birth asphyxia

Process Measures
 Reflect the workings of the system
 Are the parts/steps in the system performing as planned?
 Immediate indicators
 Often speaks to / measures the change idea
 Change Idea(s):
─ Nurse/ midwives do biweekly resuscitation drills
 Process Measure:
- - % of resuscitation drills done

Balancing Measures
 Unintended consequences – affecting other parts
of the process or system
 What happened to the system as we improved
outcome and process measures?
 “side effects”; can be good, can be bad
 Balance Measure:
Number of topics covered by nurse midwives in
the CPD program
Cost of conducting biweekly drills

Example of good indicator
Indicator: The percentage of neonatal deaths due to birth asphyxia
(Case fatality)
 Numerator: Number of asphyxiated newborns that died
 Denominator: Number of babies born with birth asphyxia
 Source: Sick newborn register and Maternity register
 Person responsible: Nurse-midwife in NICU
 Frequency: To be reviewed weekly
Number of mothers received
prophylactic oxytocin X 100
Number of deliveries
percentage of neonatal deaths
due to birth asphyxia
(Case fatality)
=

Exercise
Produce one outcome and one process measure for your project
Indicator:
Numerator:
 Denominator:
 What data source will you use:
 How frequently will you review the data:
Who will be responsible for data collection:

Documentation
Journal
STEP 3: MEASURING QUALITY OF CARE AND TESTING CHANGES
3.1 Measuring Quality of Care
Outcome measure (Measures the aim statement)
Indicator name
Numerator
Denominator
What data sources will you use?
How frequently will you review
data?
Who will be responsible for data
collection?
Process measures (Measures the change idea)
Process measure 1 Process measure 2 Process measure 3
Indicator name
Numerator
Denominator
What data
sources will
you use?
How frequently
will you review
data?
Who will be
responsible for
data
collection?

So you have collected data … What next?
Time Percentage of babies
resuscitated successfully
Jan 43
Feb 56
Mar 44
Apr 40
May 58
June 45
July 44
Aug 38
Sep 60
Oct 65
Nov 68
Dec 74
Jan 81 71
Is there any improvement?
When did it happen?
What change led to improvement?
Is the improvement sustained?

Summary Statistics
35
75
0
10
20
30
40
50
60
70
80
Avg. Before Change Avg. After Change
%
of
asphyxiated
babies
resuscitated
successfully
Is there any improvement?
When did it happen?
What change led to improvement?
Is the improvement sustained?
Vs.
Run Chart
Plot a graph &
interpret findings

Plotting a time series chart/ Run Chart
• Clear and well defined title and
labels
• X is time days/weeks/months
• Y is measurement in %,
proportion
• 100% scale on Y-axis
• Include Annotations – indicate
when changes were tested or
something special happened

Calculating the median
• 10, 12, 15, 12, 13
10, 12, 12, 13, 15
Answer = 12
• 10, 12, 15, 12, 13, 13
10, 12, 12, 13, 13 15
Answer = 12.5

Run Charts Rules
• There are four rules that can be applied to a run chart to help
determine whether or not the variation within the dataset is due
to
Normal or Random variation typical of performance of that process
Special Cause or non-random attributable to a change in the process
S-hift
T-rend
A-stronomical point
R-uns

Rule 1 ( a “shift” in the process)
Six or more consecutive POINTS either all above or all below the
median.
Skip values on the median and continue counting points. Values
on the median DO NOT make or break a shift.
Median=10
Median=11
Rule 1
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
Measure
or
Characteristic
Median 10

Rule 2 (Trend)
Five points all going up or all going down.
If the value of two or more successive points is the same, ignore one
of the points when counting; like values do not make or break a trend.
Rule 2
0
5
1
0
1
5
20
25
1 2 3 4 5 6 7 8 9 1
0 1
1 1
2 1
3 1
4 1
5 1
6 1
7 1
8 1
9 20 21 22 23 24 25
Measure
or
Characteristic
Median 11

Rule 3 Too many or too few runs
A run is a series of points in a row on one side of the median. Some points fall
right on the median, which makes it hard to decide which run these points
belong to.
An easy way to determine the number of runs is to count the number of times
the data line crosses the median and add one.
Count the number of data points that do not fall on the median
DG Fig 3.22

Total no. of data points
that do not fall on the
median
Lower limit for no. of
runs (<this no. of runs
is “too few”
Upper limit for no. of
runs (>this no. of runs
is “too many”
10 3 9
11 3 10
12 3 11
13 4 11
14 4 12
15 5 12
16 5 13
17 5 13
18 6 14
19 6 15
20 6 16
21 7 16
22 7 17
23 7 17
24 8 18
25 8 18
26 9 19
27 10 19
28 10 20
29 10 20
30 11 21
Source: Swed, Frieda S. and
Eisenhart, C. (1943) “Tables
for Testing Randomness of
Grouping in a Sequence of
Alternatives.” Annals of
Mathematical Statistics. Vol.
XIV, pp. 66-87, Tables II and III.
This means that there are
too few runs Hence there is
a special cause

Rule 4 – an astronomical point
Blatantly obvious different value
Rule 4
0
5
10
15
20
25
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24
Measurement
or
Characteristic

0
10
20
30
40
50
60
70
80
90
100
# Median
Exercise: Identify the run chart rules

4 step approach to
STEP 1 -
Identifying a
problem and
writing an aim
statement
STEP 2 –
Analyzing the
problem and
Developing
change ideas
STEP 3 –
Measuring
Quality of care
and testing
changes

Testing the change idea: The PDSA Cycle
Plan the test
Who, What, Where,
When, How?
On what scale?
Remember to plan for
data collection and date of
PDSA review
Adapt?
Adopt ?
Abandon?
Increase the scale?
Test under different
conditions?
Next cycle?
What happened? What’s
the process and outcome
data telling us?
Summarize what
was learned
Carry out the plan
Document what
happened and
any unexpected
observations
Act Plan
Study Do

Planning Example
What change will you test? New protocol for post-partum assessment to pick up PPH earlier
Who will make the change? Two of the nurses (Monica and James) involved in developing the protocol
Where will they do it? They will test the protocol in the post-natal ward
When will they test? They will test it on their next shift on Thursday
How long will they test? They will test on one shift only on Thursday from 7:30am – 4:30pm
Plan for data collection and PDSA
review
Data will be collected by nurse James
Team will meet to review PDSA on Friday
What do you want to learn? • Is it feasible to follow the protocol?
• Do we need to adapt the protocol?
• Do we need to change anything on the ward to make it easier to follow
the protocol?

Example: The Plan-Do-Study-Act Cycle
Adapted from The Improvement Guide, Chapter 5, p. 97
PLAN:
Tomorrow Nurse Monica
and James will test the
new protocol on early
identification of PPH
during the day shift from
7:30 am – 4:30pm
DO:
Nurse James and Monica
tested the new protocol
until 10:00am then had to
do the postnatal
discharges. 3 PPH patients
were identified.
STUDY:
Screened 20 of the 35 mothers and
it was easy to identify mothers with
PPH. All three were initiated on
PPH management. Mothers were
not reviewed using the protocol
after 10am because the nurses
were busy with postnatal
discharges but for those they did
screen everything went well
ACT (adapt):
Tomorrow nurse James and
Monica will screen until
10:00am. Then Nurse James
will continue screening using
the PPH protocol while nurse
Monica does the postnatal
discharges.

CHANGES: What
change can we make
that will result in an
improvement?
MEASURES: How will
we know that a
change is an
improvement?
AIM: What are we
trying to accomplish?
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
PLAN
DO
STUDY
ACT
Rapid Change Cycle
Small test of change
1 shift, 1 HCW,
1 patient, 1 ward/ office
Adapt the change,
Increase the scale,
Test in different contexts
Implement and Sustain
the improvement
PLAN
DO
STUDY
ACT
Spread improvement to
other locations

Clinical care
Policies, guidelines, CPD
Equipment and
preventive maintenance
Information
systems
Multiple Ramps of Changes Towards a
Single Aim
Halve Neonatal Mortality
IPC/ WASH

Testing changes
 Few people are involved
less resistance
 Rapid cycles
take less time
 Support needed low: Testers do not
yet intend changes to be permanent
 Tolerance for failure is high: A failed
test is an opportunity to learn
 Low level of certainty that the idea
will work
Implementing changes
 More people involved
 expect more resistance
 Longer cycles
More time, people, resources
needed.
 More support needed from all levels
 Tolerance for failure is less
 Implement only those changes that
have been tested and show
improvement in indicators
Vs

3.2 Testing Changes using the Plan-Do-Study-Act cycle
Change Idea 1: Change Idea 2: Change Idea 3:
PLAN (Document the
following)
 Who will make the change?
 When will it be made?
 Where will they test the
change?
 How long will the change
be tested?
 Who will collect PDSA
data?
 When will we review the
PDSA?
 What do you want to learn
from the test?
 What are the predicted
results following the test of
the change?
DO (Document the following)
 How you carried out the
plan
 Describe what happened
 What data did you collect?
 What expected &
unexpected observations
did you make?
Change idea 1 Change idea 2 C
STUDY
(Document the following)
 Analyze the results and
compare them to your
predictions in the plan
 Did the change idea lead
to an improvement? Was
the change idea tested
according to plan?
 Document what you
learned from this change
ACT (Document the following)
 Make a decision about the
change
 What ideas do you have
for next PDSA

4 step approach to
STEP 1 -
Identifying a
problem ,
forming a
team and
setting an aim
STEP 2 –
Analyzing the
problem and
Developing
change ideas
STEP 3 –
Measuring
Quality of care
and testing
changes
STEP 4 -
Sustaining
improvements

Step 4: Sustaining improvements

Take specific actions to sustain improvement
 Praise & celebration
 Documenting the flow of the new process — the new way of doing things
 Teaching people new skills, changing beliefs and behaviors
 Making changes in job descriptions, policies, procedures
 Addressing supply and equipment issues
 Needs to evolve — Set new goals
 Assigning day-to-day ownership for the maintenance of the new process
 Having senior leaders remove any barriers that might allow slippage back
to the old process

STEP 4: SUSTAINING IMPROVEMENTS
Give brief explanations for any notable changes (shift, trend, astronomical data points, too few or too many runs)
in the graph above and annotate on the graph as well.
Checklist for sustaining improvements
Is the new process clearly documented?
Is there a day-to-day leader to maintain the new process?
Are leadership and relevant stakeholders engaged?
Have you made adjustments in policies/ job description/
SOPs?
Have healthcare workers been trained in the new process?
Have you addressed supply and equipment issues?
End of Journal

Acknowledgements
• Slides have been adopted and adapted from Collaborators: WHOCC-
AIIMS, USAID ASSIST, UNICEF, UNFPA, WHO-SEARO
•
• Institute for Healthcare Improvement (IHI)

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