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Applying the PDSA cycles for quality improvement

The essential components of the Plan Do Study and Act components of testing quality improvement interventions for healthcare services.
Quality improvement starts with an objective analysis of a problem within a process, followed by the identification of a change (the QI intervention) which may resolve the issue and improve outcome. It can seem obvious how to implement a QI intervention but quality health care is complex with many interconnected inputs (resources and people) and processes, which rely on each other to achieve good outcomes. As an example, when there is no list of preterm babies who need ROP screening, then the obvious solution is for a nurse to make one. However, if we consider the issue more closely we can see that, before starting the list,
the nurse will require training on: ROP screening criteria, how to gain and document parental permission, and what to do if a baby cannot be listed for screening, or is discharged. Replacement staff may also be needed to cover some of the nurse’s other duties. So, before any QI intervention is implemented it is very important to test it using an iterative method such as Plan-Do-Study- Act cycles and learn if it leads to quality improvement and better outcomes. If yes, is there enough improvement to adopt the change idea as it is, or does it need to be adapted? If no, the intervention should be abandoned and a new one selected for testing.
The first step is to assemble a quality improvement (QI) team of between 5 and 8 people. This QI team should include representatives from all the stakeholders who are part of the care process to be improved. It may be the same or differ from the QI leadership group that identified the QI intervention to be tested.
Key roles should be assigned to specific team members: The QI leader - someone is influential amongst their peers and can take everyone along, a communicator, a recordkeeper or rapporteur, and a data collector.
The four structured steps of the PDSA cycles - Plan, Do, Study and Act - enable the QI team to learn what happens when the QI intervention is implemented. The team first defines the aim. This is a clear statement of the purpose of the QI intervention to be tested. Objectives specify what will need to be done to achieve the aim.
Clearly defining the objectives is essential to: guide and motivate the team implementing the improvement and to measure the success of the QI intervention implementation.
A good objective is SMART: Specific, Measurable, Achievable, Relevant and Time-bound.
For example, this is NOT a SMART objective: ‘To increase coverage of first eye screening examination for ROP.’ This is a SMART objective, ‘To increase the coverage of first eye screening examination for ROP, by the recommended postnatal age from 60% to 90%, over the next eight weeks among preterm neonates born at less than 32 weeks of gestation.’
The next planning step is to set out activities to achieve the objective. To explore this, let’s return to our SMART objective. During an initial situation analysis, a process flow chart showed that a major obstacle to increasing the rate of ROP examinations is that when babies’ pupils are not successfully dilated they are dropped from the screening list without scheduling a new examination date. To address this, the QI team want to test an intervention where the neonatal nurse who instils dilating eye drops on ROP screening day, is also tasked to record data about dilation and specifically communicate with the ophthalmologist about any babies whose pupils do not fully dilate.
The team plan who, how and when this new activity will be carried out and tested. One of the QI team members, a nurse, volunteers to test the idea when she is on duty on the next ROP screening day. At the same time, the team plan the quantitative and qualitative data that needs to be collected. In our example, on ROP screening day,
the nurse will collect data on: The number of babies listed for screening. Whether or not each baby’s pupils achieve full mydriasis when dilating drops are instilled. and the names of the babies reported to the ophthalmologist to review lack of dilation. The QI team also plans to collect feedback from the ROP team and nurse on what they feel about the new activity and any difficulties they experience during the testing. The next phase of the PDSA cycle is to ‘Do’ the testing, carrying out the planned activities and collecting the data. QI interventions are usually put to the test just a few times, maybe once or twice, and this should take one or two weeks depending on how complex the change is.
In our example, the nurse first develops a form
to record information on: Which babies listed for ROP screening had their pupils dilated. The outcome of how many babies achieved dilation or not, and which babies were reported to the ophthalmologist for review and reschedule for screening. She then tests the form over two ROP screening days.
Next is the ‘Study’ phase where the QI team analyses and
studies the data collected in the ‘Do’ phase: Was the intervention implemented? Did it lead to improvement? If yes, how much? Was it enough? And if no, or not enough improvement was seen, what are the possible reasons for this? The team reflects on the answers to these questions and makes decisions on how to ‘Act’, the final part of a PDSA cycle. No PDSA cycle is a failure. Even those changes which do not lead to improvement impart learning about what works and what does not. In our example, the team found that the new activity did lead to more babies eyes being examined.
And that those babies whose eye did not fully dilate were found to have Plus disease when reviewed by the ophthalmologist and treatment was undertaken. The team decided that the activity worked well in achieving measurable improvement but that the data form needed more work.
The final phase in the PDSA cycle is ‘Act’ towards decision making. If the QI intervention idea is successful, the team may want to inform other involved care providers and hospital managers about it and how the change idea can be adopted and implemented into routine practice. If the QI intervention is not successful, the team is likely to decide to abandon it and test a new change idea. More commonly, the intervention works partially or with some difficulty. In this case, the team may want to adapt the idea and test the refined idea again. In our example, the team decide to adapt the form and implement it for a further four weeks.
The activity and adapted form are finally adopted across the NICU when the rate of successful monthly screenings goes up to 92%.
Teams undertaking their first quality improvement intervention should aim to complete the PDSA cycle in four to eight weeks. A shorter time may not be enough to analyse and test the change idea while taking longer can lead to loss of interest and enthusiasm. Many times one change idea, even if successful in itself, will not lead to reaching main objective. Quality improvement usually involves making multiple interventions, each change being tested in a series of PDSA cycles and each successful intervention stacking on the previous one to ultimately achieve the SMART objective.
In summary, you should now understand: How QI teams implement the four key stages of the PDSA cycles, Plan, Do, Study and Act. That each stage is interconnected and guides decision making on implementation of a quality improvement intervention, and that iterative PDSA cycles are used to fine tune change ideas before they are adopted and scaled up into complex care pathways to improve health outcomes.

The video on this step describes each of the PDSA components and how they can be applied, illustrated by a practical example from ROP screening. The importance of observing and monitoring improvements during the process is highlighted throughout.

As you watch the video, reflect on how different members of the QI team take responsibility for the various PDSA components.

Successfully applying PDSA cycles

The strength of the Plan-Do-Study-Act approach is in enabling healthcare teams to learn quickly whether a quality improvement (QI) intervention can work in their particular health setting.

By making adjustments in small steps healthcare teams increase the chances of delivering and sustaining a desired improvement to their process. It is important to remember that PDSA does not always lead to quality improvement. Some QI interventions will be adapted or adopted after PDSA testing but some will have to be abandoned.

The structured, reflective practice that PDSA requires can seem very counterintuitive to healthcare providers who are used to focusing on ‘doing’. This can make the time required for planning and reflection seem like a luxury rather than a necessity. As a result, QI teams often get stuck in the ‘Do’ phase and don’t spend enough time on the ‘Study’ phase. QI teams must be careful to avoid this trap when undertaking PDSA. It is the ‘Study’ phase and the iterative design of the PDSA cycles that will allow for the discovery of the unexpected and enable the team to make their QI intervention more successful.

Key success factors for any QI intervention

  • Strong leadership on performance improvement
  • Active staff involvement (buy-in and accountability) at all connected levels
  • Effective use of data for decision-making and an effective communication strategy
  • A positive culture in the organisation towards practice changes.

Common challenges

  • Convincing people that there is a problem that is relevant to them
  • Convincing them that the chosen solution is the right one
  • Getting the data collection and monitoring systems right
  • Excessive ambitions or lack of staff engagement
  • Clashes in organisational cultures, capacities and contexts
  • Weak leadership
  • Securing sustainability
  • Risk of unintended consequences.
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Retinopathy of Prematurity: Practical Approaches to Prevent Blindness

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