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If youve ever tried to lose weight, you know improvement is an uncertain road.

How much should you really eat?

Where are you going to find time to exercise? And honestly, how much difference does a Hersheys Kiss make?

If improving your silhouette is that complex, you can imagine how much more complex it is to improve some aspect of health care. One way to ensure your efforts wont go off track is to adopt a systematic approach to improvement.

This lesson will provide an overview of the Model for Improvement, a method you can use to improve everything from your tennis game to your hospitals rate of ventilatorassociated pneumonia.

Youll also start your own personal improvement projectand youll learn how a hospital system in Saudi Arabia successfully used the Model for Improvement to reduce infections to zero in its neonatal intensive care unit.

After completing this lesson, you will be able to:


the three fundamental questions that are the basis of the Model for Improvement. how a health care team has used the Model for Improvement to bring about significant improvements.



the processes that make up the PlanDo-Study-Act (PDSA) cycle. to use the Model for Improvement to plan and execute your own personal improvement project.


Three Questions + the Plan-Do-Study-Act Cycle = The Model for Improvement

Fasten your seatbeltsin this course, youre going to learn everything you need to begin designing and carrying out an improvement project. is to reduce central line infections in the neonatal intensive care unit or to get more sleep and exercise in your daily lifethe basic principles are the same.

Whether your goal

As you know, every system is perfectly designed to get the results it gets, and the only way to get different results is to change the system. Furthermore, because we know that the best way to learn something is by doing it yourself, youre not only going to learn how to carry out an improvement project, youre going to actually do it. Youll begin planning your personal improvement project in this lesson, and youll take it to the next step in each subsequent lesson in this course.

Where to begin? The Institute for Healthcare Improvement (IHI) uses a simple mantra to describe the essential elements for strategic improvement: Will, ideas, and execution.

You must have the will to improve, you must have ideas about alternatives to the status quo, and then you must make it realexecution.
When you put all three elements together, youre on your way to achieving unprecedented and sustained results at the system level.

The engine for the execution step is something we call the Model for Improvement. This lesson presents an overview of the Model for Improvement; subsequent lessons in this course will look at each component of the model in more depth.

The Model for Improvement has been used successfully by thousands of health care organizations in many countries to improve a variety of health care processes and outcomes.

There are other useful models to guide improvement out there:

Six Sigmas DMAIC, the 7-Step Problem-Solving Method, and more.

Studies have shown that it is more important for an organization to have a standard road map to conduct improvement projects rather than have any specific framework.

Voila! I Give You . . . the Model for Improvement


Model for Improvement, developed by a group called Associates in Process Improvement, is slender, but it packs a powerful punch.

When you combine the 3 questions with the..

.and The Model for Improvement PDSA cycle, you get


The Model for Improvement begins with three fundamental questions that can be addressed in any order. 1. The Aim: What are we trying to accomplish? 2. The Measures: How will we know a change is an improvement?

3. The Changes: What change can we make that will result in improvement?

Next comes a little dance with four steps: the PDSA cycle. The PDSA cycle was originally developed by our old friend Walter Shewhart as the Plan-DoCheck-Act (PDCA) cycle. Then Shewharts colleague W. Edwards Deming modified Shewhart's cycle to PDSA, replacing "check" with "study." Same idea, clearer word.

The PDSA cycle gives us a way to quickly test changes on a small scale in real work settings, observe what happens, tweak the changes as necessary, and then test againbefore implementing anything on a broad scale. Instead of spending weeks or months planning out a comprehensive change, then putting it into practice only to find that its fundamentally flawed, the PDSA cycle enables rapid testing and learning.

PDSA cycles can also be used for more complicated things like learning about the system, running complex, wide-scale tests, and implementing change.

You actually conduct PDSA cycles every day. We all test out new ideas constantly. Consider these tests, for example:

I ate breakfast this morning instead of skipping it like I usually do. That worked out pretty well for me.

I took the train to class this morning rather than ride the bus. It ended up taking longer on the train and was more expensive.
Instead of writing out notes while in class, I tried to type the notes into my laptop. That was a total bust! I missed half the lecture trying to type faster than my skills allowed.

Improving Care in the Neonatal Intensive Care Unit


see how the Model for Improvement works in real life. Remember SAMSOs NICU? how they used the Model for Improvement to cut their central line infections to zero.



improvement journey consisted of the following steps.

Form a Team

Including the right people is critical when youre changing a complex system. The team consisted of Dr. George Cheriyan, the head neonatologist; the nurse in charge of the unit; a data collection clerk; the infection control coordinator; and the units quality improvement coordinator.

Set an Aim

The aim should be time-specific and measurable, stating exactly How good? and By when? It should also define the specific population of patients who will be affected. A general aimWe will improve our infection ratewont cut it. The SAMSO teams aim was to decrease the infection rate in the NICU from 11 infections per 1,000 catheter days to less than 5 infections per 1,000 catheter days over a period of nine months.

Establish Measures

You need feedback to know if a specific change actually leads to an improvement, and quantitative measures can often provide the best feedback.
Dr. Cheriyans team measured the rate at which babies were getting bloodstream infections. They also measured how often staff members were actually doing the things they were asked to do to prevent infection.

Develop Changes

Dr. Cheriyans team decided to test several changes, including having staff implement a five-step bundlesuch as improving hand hygiene and checking the lines dailythat had been shown to reduce the rate of central line infections.
They also instituted a checklist that staff would review during a time-out before inserting the central line, and they required staff to place red tags on the beds of the babies with central lines, so everyone would remember to take extra precautions.

Test Changes

Heres where the PDSA cycle came in. Dr. Cheriyans team trained the units staff on all the changes and measured how well everyone stuck to the new protocol. Heres what they found.

The two process measures shown in the graph above indicate that the staff was doing a pretty good job complying with the use of the checklist (the blue line), but not as good a job on implementing the five-step central line bundle (the yellow line). This was the Study step of the PDSA cycle. In January and February of 2006, the team used this information to tweak the process so staff would comply more often. This was the Act step of the PDSA cycle.

The team also monitored an outcome measure: how often babies were getting bloodstream infections (BSIs). The solid blue line in the chart below shows BSIs. (Dont worry about the red line for nowits called the upper control limit, and it falls under the heading of advanced improvement statistics.) Note that the infection rate each month dropped rather dramatically after the team began testing new changes (as marked by PDSA 1, 2, and 3), and by November 2006 it had dropped to zero.

Implement Changes

After testing a change on a small scale, learning from each test, and refining the change through several PDSA cycles, the team created a new policy governing the placement and care of central lines.
They started training everyone who rotated through the unit on the new protocol. In other words, they made the new procedures part of everyday work life.

Spread Changes

After the team successfully changed the way the NICU handled central lines, SAMSO expanded the protocol to the pediatric intensive care unit.

Your Turn: A Personal Improvement Project

The first step in your personal improvement journey is to decide what youd like to improve. Think of something relatively simplesmall in scope, with obvious failure points in the process, and where you have the ability to try out new approaches. Its helpful to think of something thats a part of your regular workdaya source of nagging frustration or hassle.


you want to eat healthier food. Maybe you want to drink fewer cups of coffee. you want to exercise more often or compete better in tennis. you want to get more sleep. you want to call your mother more often.


Maybe Maybe

Take a minute to think of somethingsomething right in front of youthat youd like to improve. Any good improvement project starts with a general statement of the problem youre attempting to address, or the opportunity you hope to develop and take advantage of. Write down your personal opportunity statement.

This is your chance to take control of your persistent problems.

Post-Lesson Assessment : 1. The initial stage of the Model for Improvement is based on three questions designed to clarify the concepts of: a) Plan, do, act b) Mission, goal, strategy c) Aims, measures, changes d) Wills, ideas, and execution

Use the following scenario to answer questions 2-4: An orthopedic clinic in a busy metropolitan area would like to improve the way it schedules patients.

2. Applying the Model for Improvement to the clinics improvement goal, which of the following is the most reasonable aim statement? a) Implement two PDSA cycles within six months of beginning the project

b) Increase the number of patients reporting they are very satisfied with the clinics scheduling by 50 percent within six months
c) Modify the scheduling process to allow both front desk staff AND nurses to directly schedule appointments d) Create an efficient process for scheduling return appointments at the time of checkout

3. After assembling a team and working through the three questions of the Model for Improvement, the orthopedic clinic decides to assign one nurse per day to schedule all follow-up visits. This would be the nurses only responsibility for the day, and five nurses would rotate the task on a daily basis. By assigning the job of scheduling follow-ups to a specific staff member who can work without interruptions, the clinics improvement team hopes to improve the scheduling process. What is the team a) Take a well-deserved break b) Develop their project-level measures c) Test their change plan using the PDSA cycle d) Report their results to clinic leadership and prepare a poster for a national meeting e) Clarify their aim statement

4. The orthopedic clinic plans the staffing change to improve scheduling, and then it carries out a small test of change with one nurse and three patients on Tuesday morning. Whats the next thing the clinics improvement team should do? a) Change their measures b) Briefly survey the nurse and patients involved to see how the test went c) Report their results to the clinic leadership and prepare a poster for a national meeting d) Implement the new scheduling process based upon their initial impressions of how everything is working e) Implement a reward system for nurses who schedule the most appointments per day

5) When trying to improve a process, one reason to use PDSA cycles rather than a more traditional scientific method (such as a randomized, controlled trial) is that: a) PDSA cycles are much less expensive b) The results of PDSA cycles are more generalizable than other methods c) PDSA cycles are much simpler to use than other methods

d) PDSA cycles provide a mechanism to adjust methods as the project progresses

Lots of people make resolutions on New Years Eve. But how many people actually keep those promises? At the start of an improvement project, theres often a sense of energy and purpose. But its all too easy for that sense of purpose to wane as time goes on. A strong, measurable aim with a clear time frame will help keep your project on course.

This lesson focuses on crafting an effective aim statement and forming a team for an improvement project.

Youll apply what you learn by continuing to work on the personal improvement project you began in Lesson 1.

After completing this lesson, you will be able to:

State why its important to set an aim statement at the start of an improvement project.
Identify the key elements of an effective aim statement.

Critique sample aim statements from quality improvement projects.

Compose an effective improvement team.

Develop an effective aim statement for your own personal improvement project.

The Key Elements of an Effective Aim Statement

If improvement were simple, everyone would be at a healthy weight, speak many languages fluently, drive exceptionally safely, and conduct their work and relationships with brilliant ease. No one would be late. Nothing would be mislabeled. No one would wait for medical care.

Everyone would receive exactly the right care, every time.

Its a testament to the complexity of improvement that things generally dont work like this. An organizationor an individualjust wont improve without a clear and firm intention to do so. The first thing needed is usually an aim.

An aim statement is the answer to the question What are we trying to accomplish?

A good aim addresses an issue that is important to those involved; it is specific, measurable, and addresses these points:
How good? By when? For whom

(or for what system)?

Some aim statements also contain information about key strategies and other guidance for the improvement project. But the aim should be succinct and not contain extraneous background information or side issues. Heres an example of a good aim statement. Every member of our study group will increase his or her grade point average by 10 percent within eight months.

Heres another. I will weigh 160 pounds by February 1. And another. Im going to run 10 miles per week by July 4. All of these aims are specific about measure, time, and populationin other words, how good, by when, and for whom. This tells us exactly where were going and what we expect to accomplish.

x Here are a few examples of some not-so-useful aim

Well I

do better on tests.

will lose weight. going to exercise more often.


How good? By when? Who knows. We could try forever and never get there, because its not clear where there is.

Two Examples of Effective Aim Statements:

Here are examples

of effective aim statements in two different areas of work. that all of the sample aim statements contain specific numerical goals and a time frame for achieving them, describe the population served and the system to be improved, and give guidance on the approaches to improvement.


Improving Primary Care Clinic Access (sample aim statement)

We will

provide our primary care patients access to the provider of their choice when they want. begin with two providers who are most in demand. 12 months, we will have spread the changes that resulted in improvement to the other providers at our clinic.

We will


We will achieve the following results for all of our providers within 12 months.
Reduce days

to third next available appointment to less than one day time by 20 percent

Decrease office visit cycle Match

daily capacity to daily demand

Increase patients'

satisfaction with seeing their provider of choice by 25 percent (team member/patient continuity) no-shows by 50 percent

Decrease patient Increase

future capacity by 25 percent

Increase patient satisfaction

with "length of time waited" to get today's appointment to 80 percent excellent

Improving Specialty Care (sample aim statement)

We promise our patients

care in our adult outpatient oncology clinics that is safe, effective, patient-centered, efficient, and timely. addition, we promise that all patients, regardless of their background, race, ethnicity, or insurance status, will receive the same highquality care.


We will begin with our adult chemotherapy clinic. Within 12 months, we will have spread improvements to all adult oncology clinics. We will strive to achieve the following results for our adult oncology clinics within 12 months.

Decrease the number of exacerbations by 50 percent and adverse medication events to zero (Safe) Improve functional health status for daily activities, physical activities, overall health, and quality of life, as reported in the How's Your Health survey


patient satisfaction with access, explanations, received help needed and wanted, and clinician sensitivity from 75 percent to 90 percent excellent


test/procedure cycle times from two hours to one hour

to an initial visit following a referral from two weeks to two days

Provide access

Developing Effective Aim Statements: Start with the Institute of Medicine Aims Running 10 miles per week is a lot simpler than getting everyone to wash their hands in the intensive care unit. So how do you begin developing an aim statement in a complex clinical setting? Remember the six dimensions of health care systems from the Institute of Medicines (IOMs) Crossing the Quality Chasm report that we mentioned in QI 101, Lesson 3?

(By the way, a handy mnemonic device for remembering the six IOM dimensions is STEEEPSafe, Timely, Effective, Efficient, Equitable, and Patient-centered.)

They are a good guide for teams to use in developing organizational and project-based aims. First, health care must be safe. This means much more than the ancient maxim "First, do no harm," which makes it the individual caregivers responsibility to somehow try extra hard to be more careful (a requirement modern human factors theory has shown to be unproductive).

Instead, the aim means that safety must be a property of the system. No one should ever be harmed by health care again.

Second, health care must be effective.


should match science, with neither underuse nor overuse of the best available techniques every elderly heart patient who would benefit from beta-blockers should get them, and no child with a simple ear infection should get advanced antibiotics.

Third, health care should be patientcentered.


individual patients culture, social context, and specific needs deserve respect, and the patient should play an active role in making decisions about his or her own care. is especially vital today, as more people require chronic rather than acute care.

That concept

Fourth, care should be timely.

Unintended waiting that doesnt provide information or time to heal is a system defect. Prompt attention benefits both the patient and the caregiver.

Fifth, the health care system should be efficient, constantly seeking to reduce the wasteand hence the costof supplies, equipment, space, capital, ideas, time, and opportunities.

Sixth, health care should be equitable.


ethnicity, gender, and income should not prevent anyone in the world from receiving high-quality care. need advances in health care delivery to match the advances in medical science so the benefits of that science may reach everyone equally.


You Make the Call: Good, Bad, or Ugly?

Your local hospital is writing an aim statement to improve its safety and effectiveness. Youve been asked to join the improvement team. Today youre meeting with your fellow team members to review some possible aims. Check them out. Which ones are good? Bad? Ugly? Why?

Q We aim to reduce harm and improve patient safety for all of our internal and external customers. a) Good b) Bad

c) Ugly


is too broad.

The aim

It doesnt

say how good or by when.

Q By June of 2008, we will reduce the incidence of pressure ulcers in the critical care unit by 50 percent. a) Good b) Bad

c) Ugly


is specific.

This aim


tells us how good, by when, and for whom.

Q We will reduce all types of hospitalacquired infections. a) Good b) Bad

c) Ugly



is not an aim; its more like a mission statement.


needs to be turned into a how good, by when aim.

Q Our most recent data reveal that, on average, we reconcile the medications of only 35 percent of our discharged inpatients. We intend to increase this average system-wide to 50 percent by April 1, 2008, and to 75 percent by August, 31, 2008.

a) Good
b) Bad c) Ugly



This aim

is clear and specifies how good and by when, along with a staged goal (50 percent by one date and 75 percent by the next). is reasonable and could be suitable for a teams work and managements expectations.


Forming an Effective Team

Including the right people on an improvement team is critical to a projects success. Teams vary in size and composition. Each organization builds teams to suit its own needs.

First, review the aim.

Second, consider the system that relates to that aim: What processes will be affected by the improvement efforts? Third, be sure that the team includes members familiar with all the different parts of the processmanagers and administrators as well as those who work in the process, including physicians, pharmacists, nurses, and front-line workers.

Effective teams include members representing three different kinds of expertise within the organization: system leadership, technical expertise, and day-to-day leadership. There may be one or more individuals on the team with each kind of expertise, or one individual may have expertise in more than one area, but all three areas should be represented in order to drive improvement successfully.

System Leadership

Teams need someone with enough authority in the organization to institute a change that has been suggested and to overcome barriers that arise.
The team's system leader understands both the implications of the proposed change for various parts of the system and the more remote consequences that such a change might trigger. It is important that this person has authority in all of the areas affected by the change. This person must have the authority to allocate the time and resources the team needs to achieve its aim.

Clinical-Technical Expertise

technical expert is someone who knows the subject intimately and who understands the processes of care.


expert on improvement methods can provide additional technical support by helping the team determine what to measure, assisting in design of simple, effective measurement tools, and providing guidance on collection, interpretation, and display of data.

Day-to-Day Leadership

day-to-day leader is the driver of the project, assuring that tests are implemented and overseeing data collection. is important that this person understands not only the details of the system, but also the various effects of making change(s) in the system.


Examples of Effective Teams

Here are four examples of effective teams. Note that for each example, the team includes representatives of all processes affected by the aim of the improvement team.

Example 1: Improving Care in Office Practices

Aim: We will improve care for all patients with chronic diseases by making improvements in our clinic that impact the six dimensions of quality, as outlined in the IOM report Crossing the Quality Chasm: A New Health System for the 21st Century.
Team Team Leader: ____, MD, medical director for primary care clinic Technical Expert: ____, MD, physician at downtown primary care clinic

Day-to-Day Leader: ____, RN, manager of downtown primary care clinic

Additional Team Members: patient educator, medical assistant, clerk/scheduler, laboratory manager, quality expert

Example 2: Improving Patient Safety

Aim: Reduce adverse drug events on all medical and surgical units by 75 percent within 11 months.
Team Team Leader: ___, MD, chair, Pharmacy and Therapeutics Committee, and patient safety officer Technical Expert: ____, RPh, director, clinical pharmacist Day-to-Day Leader: ____, RN, manager, medical/surgical nursing

Additional Team Members: risk manager, quality improvement specialist, staff nurse, staff education, and information technology

Example 3: Improving Critical Care Aim: Redesign the leadership and care systems of our medical intensive care unit (MICU) in order to reduce harm and improve outcomes for patients. Team Team Leader: ____, MD, medical director, MICU Technical Expert: ____, MD, intensivist Day-to-Day Leader: ____, RN, MICU manager Additional Team Members: respiratory therapy, quality improvement specialist, staff nurse, clinical pharmacist, clinical nurse specialist

Example 4: Improving Flow

Aim: Ensure that patients receive timely access to appropriate care in our hospital and move through the system efficiently.
Emergency Department Team Team Leader: medical director or physician Technical Expert: director or nurse manager Day-to-Day Leader: front-line nurse Additional Team Members: Two "continuity staff" with a crossorganizational view of flow (e.g., operations engineer or vice president with management responsibilities across departments/services, who will be assigned to this work over time)

Intensive Care Unit Team Team Leader: intensivist or medical director Technical Expert: director or nurse manager Day-to-Day Leader: front-line nurse Additional Team Members: Two "continuity staff" with a cross-organizational view of flow (e.g., operations engineer or vice president with management responsibilities across departments/services, who will be assigned to this work over time)

Operating Room Team Team Leader: surgeon or anesthesiologist Technical Expert: director or manager of surgical services

Day-to-Day Leader: operating room nurse (circulating or scrub nurse)

Additional Team Members: surgery technician, one "continuity staff" with a cross-organizational view of flow (e.g., operations engineer or vice president with management responsibilities across departments/services, who will be assigned to this work over time)

Your Turn: Develop an Aim Statement for Your Personal Improvement Project

In Lesson 1, you selected your improvement project. You wrote your personal opportunity statementa general statement of the problem you are attempting to address (or the opportunity you hope to develop).

For this lesson, you need to develop a succinct yet complete aim statement. It needs to specify how good, by when, and for whom. Be sure to set specific goalssomething ambitious but realistic. Define a specific timeline, perhaps with a staged goal if that complexity is useful.

Now post your aim statement on the discussion board.

Institute for Healthcare Improvement Personal Improvement Project


inspire you and keep you company, heres our Institute for Healthcare Improvement staffer, back to develop her aim statement for her personal improvement project. Lesson 1, I developed my personal opportunity statement:


like to become a really good runner.

Now, heres my aim statement for my planned work to improve my performance as a runner:
Five weeks

from today, I will be able to run 5.3 miles in 50 minutes without stopping and run one mile in less than 8.8 minutes without injuring myself.

Post-Lesson Assessment

1. Having a clear aim statement is important in quality improvement work because:

a) aim statements provide a clear and specific goal for the organization to reach.

b) grant agencies require clear aim statements when they are considering funding requests.
c) aim statements make the change process move along more quickly. d) the leaders of most organizations expect to see these types of goals.

2. An aim statement should include the following: a) Specific time frame, team membership, numeric goals b) Numeric goals, specific time frame, patient population or system affected

c) Patient population or system affected, estimated cost of improvement, numeric goals

Use the following scenario to answer questions 3-5: Brenda, an emergency room nurse, notes that there seems to be a significant delay between the ordering and the administration of pain medications in her department. She decides to conduct a small improvement project to reduce this delay and obtains the support of the charge nurse (head nurse). 3. Which of the following is the most effective aim statement for this project? a) Within one month, 95 percent of physicians will tell nurses when a pain medication is ordered on emergency room patients. b) Within three months, the emergency department will administer all pain medications within 45 minutes of order time. c) Within two months, improve the timeliness of pain medication delivery by allowing nurses to stock the most commonly used medications in the emergency unit d) Within three months, the emergency department will improve the timeliness of pain medication delivery to 100 percent of patients.

4. The charge nurse in the emergency room asks Brenda to assemble a team to improve the delivery of pain medication. As she considers who to place on the team, Brenda should: a) review the aim statement.

b) create a team of volunteers.

c) create a team of managers and administrators.

d) make sure only nurses are on the team, as they are the most likely to help her achieve her aim.

5. During Brendas first group meeting, the members ask to review the aim statement to make sure they agree it addresses the current problem. With Brendas approval, they all decide to rewrite it. However, when they meet to consider what would be a better aim statement, the group loses direction. In order to help them, Brenda might want to:

a) reconsider who should be on the improvement team.

b) move the meeting to a later date, so that she can come better prepared. c) explain to the group that the aim is set, as both she and the charge nurse have already agreed upon the wording. d) remind the team of the Institute of Medicines dimensions of health care quality.

Youve been measuring your whole life. In elementary school, you learned to measure a cup of flour. In middle school, you measured your heart rate. And in high school, you measured the acceleration of falling objects. But when it comes to improvement, you need to measure things a little differently than you did in high school physics.

This lesson outlines the distinctive process of measuring for improvement and explains the three kinds of measures youll need as you continue your own personal improvement project.

After completing this lesson, you will be able to:

Explain why measurement is important in improvement.

Identify three kinds of measures: process measures, outcome measures, and balancing measures. List some of the differences between measurement for improvement and measurement for academic research. Explain the basics of displaying data for improvement. Develop effective measures for your own personal improvement project.

Why is measurement important?

Measurement helps answers the second question in the Model for Improvement: How will we know a change is an improvement? Without some type of feedback, we have no way of knowing whether the changes we are making are leading to improvement. In health care system environments, measures usually provide the most useful form of feedback.

Consider two examples.

Lets say the aim of your personal improvement project is to improve your punctuality: to arrive on time for work, class, meetings, and appointments 100 percent of the time within three months. In pursuit of that aim, youre now getting out of bed an hour earlier.
Youve bought a PDA that beeps an hour before appointments. And youve advanced all the clocks in your house by 20 minutes to fool yourself into leaving on time.

Those all

seem like good changesbut are they actually getting you where you want to go? to tell is to look at your outcome measure: percent of the time you arrive punctually to work, class, meetings, and appointments. Has that number increased? Thats how you know if a change is an improvement.

The only way


lets say the aim in your clinic is to decrease the average hemoglobin A1c (HbA1c) level of your population of patients with diabetes to less than 7.0 within 12 months. have identified everyone in your patient population who has diabetes, and you have set up a reminder system to automatically notify everyone with diabetes that they need their HbA1c level (an indication of blood sugar control) measured twice a year.


But are

those changes leading to improvement?

The only way

to tell is to look at your outcome measure: average HbA1c for our patients with diabetes. Has that number decreased? Thats how you know if a change is an improvement.

Measurement for Research versus Measurement for Learning and Improvement

Measurement is a critical part of testing and implementing changes; measurements tell a team whether the changes they are making actually lead to improvement. Measurement for improvement should not be confused with measurement for research. The following chart outlines, at a basic level, some of the differences between the two approaches.

As you can see, measurement for research and measurement for learning and process improvement are very different. Measurement for improvement is based on keeping track of a few simple measures to see if the changes youre trying out are working. Its purpose is to help your team and other teams learn from changes.

It is for learning, not judging, as improvement is an ongoing processit's not so much about where you are now, but where youre going.

Process, Outcome, and Balancing Measures

Improvement teams typically use three types of measures: outcome measures, process measures, and balancing measures. Outcome Measures = Where are we ultimately trying to go?

Outcome measures tell you whether changes you are making are actually leading to improvement.

These are the measures you ultimately want to move. They tell you how the system is performingwhat is the ultimate result?

Examples of outcome measures

For diabetes: average HbA1c level for population of patients with diabetes

For critical care: ICU mortality

For medication systems: adverse drug events per 1,000 doses For your personal improvement project: percent of the time you arrive punctually

Process Measures = Are we doing the right things to get there?

To affect the outcome measure, you have to improve your processes. Measuring the results of these process changes will tell you if theyre leading to improvement.

Are the parts/steps in the system performing as planned?

Examples of process measures

For diabetes: percentage of patients with HbA1c level measured twice in the past year

For critical care: use of adverse drug event chart review

For your personal improvement project: number of days per week you wake up early for work

Balancing Measures = Are the changes we are making to one part of the system causing problems in other parts of the system?

Balancing measures tell you if changes designed to improve one part of the system are causing new problems in other parts of the system. They are often measures that are not directly related to the aim.

Examples of balancing measures

For reducing time patients spend on a ventilator after surgery: reintubation rates (make sure theyre not increasing) For reducing patients' length of stay in the hospital: readmission rates (make sure theyre not increasing) For your personal improvement project: level of fatigue (make sure youre not sleep-deprived because of your early wake-up time)

Using a Family of Measures

For any improvement project, youll want to identify a family of measures, including outcome measures, process measures, and balancing measures.
Each kind of measure will give you important information about how the changes you are testing are affecting the system. Heres an example of a balanced set of measures for a project to reduce waiting time (and, therefore, improve patient satisfaction) in the emergency department (ED).

You Make the Call

Youre the vice president for quality in a large health system, and youre reviewing several improvement projects already underway.
Based on the aim of each project, indicate whether each of the following measures is an outcome measure, a process measure, or a balancing measure.

AIM: Reduce the incidence of ventilator-associated pneumonia by reducing the number of ventilator days in the ICU by 20 percent within five months.

Q Average number of days on mechanical ventilation a) Outcome measure b) Process measure

c) Balancing measure

The correct answer is


Q Percent of patients with ventilatorassociated pneumonia a) Outcome measure b) Process measure

c) Balancing measure

The correct answer is A.

Q Readmission of ventilated patients within 30 days a) Outcome measure b) Process measure c) Balancing measure

The correct answer is


AIM: Reduce the incidence of catheter-induced bloodstream infections in the ICU by 80 percent within one year. Q Percent of patients with catheter-induced bloodstream infections a) Outcome measure b) Process measure c) Balancing measure

The correct answer is A.

Q Rate of staff compliance with recommended steps to reduce bloodstream infections a) Outcome measure b) Process measure c) Balancing measure

The correct answer is


Q Compliance with central line bundle a) Outcome measure

b) Process measure
c) Balancing measure

The correct answer is


AIM: By June 2009, lower the average HbA1c (blood sugar) level for all diabetes patients by 10 percent by delivering evidence-based care 100 percent of the time. Q Percent of patients with HbA1c level measured twice in the past year

a) Outcome measure
b) Process measure c) Balancing measure

The correct answer is


Q Percent of patients with documented selfmanagement goals a) Outcome measure b) Process measure c) Balancing measure

The correct answer is


Q Average HbA1c level for population of patients with diabetes a) Outcome measure b) Process measure c) Balancing measure

The correct answer is A.

Q Percent of patients with documented foot exam in the past year a) Outcome measure b) Process measure c) Balancing measure

The correct answer is


AIM: Within four months, reduce the number of adverse drug events from 5 per 1,000 doses to 0.5 per 1000 doses. Q Adverse drug events per 1,000 doses

a) Outcome measure
b) Process measure c) Balancing measure

The correct answer is A.

Q Percent of staff reporting a positive safety climate a) Outcome measure b) Process measure c) Balancing measure

The correct answer is


Displaying Data over Time

Youre working on an improvement team in a doctors office that is trying to reduce waiting times for patients.
For the past month, your team members have dutifully gathered process data, such as the percent of the time nurses arrive for their shifts early and patient cycle times (cycle time simply means the amount of time it takes to complete a processfor instance, how much time elapses from the moment the patient arrives to when shes seen by the doctor). Youve gathered outcome data, such as the number of minutes patients are waiting. Youve also collected balancing data, such as the percent of staff reporting theyre satisfied at work.

Now that youve got all those numbers, what do you do with them? How do you take all that data and use it to understand how youre doing? Plotting data over time is a simple and effective way to determine whether the changes you are making are leading to improvement. The graph below, which deals with office cycle time, is a simple annotated time series. This graph shows the minimum standard for data analysis using the Model for Improvement.

These are the basic ingredients.

X axis shows time (month/day)

Y axis shows number of minutes in an office cycle time (i.e., from time patient arrives to time patient is seen by the doctor)

Goal line indicates desired cycle time

Annotations show when specific process changes were made

Blue line clearly connecting the data points (diamonds) shows the variation in office cycle time from June through November

Q Youre meeting with your improvement team to review this graph. Upon studying it, would you say the changes being tested are leading to improvement? a) Yes b) No

Yes. Although

cycle time increased initially, it decreased steadily between September 10 and November 9.

Your Turn: Define the Measures for Your Personal Improvement Project

In Lesson 1, you selected your improvement project and wrote a personal opportunity statement. In Lesson 2, you developed an aim statement.

In this lesson, its time to identify the things you will measure. Choose a balanced set of measures, including the following:
One or Two

two outcome measures

to four process measures two balancing measures

One or

In Lesson 2, I wrote an aim statement:

Five weeks

from today, I will be able to run 5.3 miles in 50 minutes without stopping and run one mile in less than 8.8 minutes without injuring myself.

Now, here are the measures Im going to track to see if the changes Im making are leading to improvement.

have two outcome measures.

far I can run without stopping in 50 minutes at which I can run one mile without injuring




Ill have three process measures

Minutes Minutes

run per week spent strength training per week


slept per night

And Ill have one balancing measure 1) Hours spent relaxing or hanging out with friends (I dont want this measure to go to zero!)

Post-Lesson Assessment

Use the following scenario to answer questions 1-4:

As a nurse manager of a medicine unit in an academic hospital, youre aware that your unit has a high rate of patient readmissions.

In fact, 36 percent of the patients discharged from your unit are readmitted to the hospital within 30 days.
After reviewing the literature, you become aware that this rate is quite high compared to national standards. Working with other members of your unit, you develop a plan to call patients on the phone within 48 hours of discharge, with the aim of cutting readmission rates to 18 percent.

1. You are hoping to publish and present the results of your work at a large national research meeting. Which of the following measurement strategies is therefore likely to be part of your plan? a) Identify a control unit to use as a comparison. b) Review the data weekly as it comes back. c) Adjust the process youre testing while gathering data. d) Obtain external grant funding.

2. Which of the following is an example of a process measure that you may collect as part of this improvement effort? a) The rate of patients being readmitted within 30 days b) The reasons for readmission to the hospital c) The percent of patients receiving a call within 48 hours of discharge d) The cost of the labor associated with the calls

3. Why might you consider collecting balancing measures? a) To show that you met your aim b) To make sure you are able to publish your study c) To demonstrate to your hospital board that you were justified in using resources for this project d) To make sure you did not unintentionally damage other aspects of the units work

Use the following information to answer question 4: After six months of data collection and four linked PDSA cycles, you are preparing to present the results of your units readmissions project to the hospital board.

The graph looks like this so far:

4. What else should you add to the graph to best explain the work your unit has done? a) The cost of the improvement effort

b) Annotations to show when specific changes were tested

c) Explanation of what a PDSA cycle is d) P-values showing statistical significance

Institute for Healthcare Improvement Personal Improvement Project


help you along, heres our friendly Institute for Healthcare Improvement staff member again. Lesson 1, I came up with a personal opportunity statement: Id like to become a really good runner.


5. Gathering and reviewing data during an improvement project that is, measuring helps you answer which of the three questions of the Model for Improvement?

a) How will we know that a change is an improvement?

b) What are we trying to accomplish? c) What changes can we make that will result in improvement?

Your kickball team can barely kick. Everyone wants to get better and win the league championship.

But what are you going to do to get there?

Your score on your last anatomy test was lower than the temperature on a chilly day in Moscow.

Youve got to do better to pass the course. But how? This lesson will discuss a range of methods for developing good ideas for changes. Youll also use these techniques to start developing ideas for your personal improvement project.

After completing this lesson, you will be able to:

State and

use the five approaches to coming up with a change. how to use change concepts to come up with good ideas to test. changes to test for your own personal improvement project.


Identify some good

Developing Changes: Getting People to Show Up

Youre a second-year public health student. At the beginning of the fall semester, you organized a group of your fellow students to hand out flyers about hepatitis B vaccination at festivals and fairs. Your first planning meetings went pretty well, drawing more than 25 people. But now volunteers are skipping the weekly meetings, leaving you and five other die-hard volunteers to scramble around doing all the work.

So you turn to the Model for Improvement. First, you meet with your core team and draft an aim statement: Within six weeks, we will triple our current attendance at volunteer meetings, resulting in a turnout of at least 18 people.

Then you come up with an outcome measure: Number of volunteers attending meetings. So now the question is, how are you going to achieve your aim? Y our next team meeting is Monday evening, so you have the whole weekend to think about changes that could help boost attendance. But on Monday afternoon, youre still tapping your pencil and staring out the window.

Its not that you have no ideas. To the contraryyou have too many. Move the volunteer meetings to a different night. Move them to a different location. Make them shorter. Provide food and play music.

Review everyones accomplishments publicly. Send out a reminder email.

Where to start?
How do you even begin to think about the host of changes that could have an effect on attendance rates?

In terms of the Model for Improvement, youre now struggling with the third question:

What changes can we make that will result in improvement?

Five Useful Ways to Develop Changes

Here are some basic techniques to come up with good ideas for changes.

thinking about the current system*


simply reflecting on problems within a system can generate some good ideas for change.


you make a flow chart of your current process say, your morning routine that inevitably makes you late for workit may be possible to identify parts of the system that arent working or are needlessly complex. Another way to go about critical thinking is to gather and analyze data on the way your system currently workswhich can then help you identify problems and develop changes to address them.


Comparing your own process to best practice can help you identify where your own system falls short. Based on that analysis, you can develop ideas for improving your performance. This is known as benchmarking. (Note: Benchmarking is not a numberas in, I have a number that is the benchmark. Benchmark is a verb, not a noun.)

Using technology

If youre trying to reduce medication errors in your clinic, you might consider bar-coding medicines. This is just one example of how technologysuch as automation, new equipment, or new information systemscan lead to improvement. But be carefultechnology that isnt reliable, or that simply makes a bad system more accessible via the Internet, isnt necessarily the fix youre looking for.

Creative thinking

Where do new ideas come from?

You can spark creative thinking in various ways, including simply taking the time to do this sort of thinking; exposing yourself to situations (such as taking the role of a patient) that can spark new ideas; identifying the boundaries that limit the changes you can make and then finding ways to dismantle those boundaries; and temporarily considering unrealistic goals (I will get an A+ on every single paper for four semesters) that can prompt you to break out of your old way of thinking.

Using change concepts


Change Concepts to Come Up with Ideas

change concept is a general notion or approach to change that has been found to be useful in developing specific ideas for changes that lead to improvement. these change concepts with knowledge about specific subjects can help generate ideas for tests of change.

Creatively combining

After generating

ideas, run Plan-Do-Study-Act (PDSA) cycles to test a change or group of changes on a small scale to see if they result in improvement. they do, expand the tests and gradually incorporate larger and larger samples until you are confident that the changes should be adopted more widely.


Here are nine general categories that are useful buckets for a total of some 70 change concepts. 1) Eliminate WasteCan you think of an activity or resource that doesnt add value?

2) Improve Work FlowIs there some aspect of your processes where the work doesnt happen as smoothly as it should?
3) Optimize InventoryDo you have too much or too little of the items you use or provide? Is your work held up because items are poorly organized or not available?

4) Change the Work EnvironmentChanging the work environment itself can make all other process changes more effective. Does the culture resist or embrace new ideas? 5) Producer/Customer InterfaceWhat are the needs of the people you serve? Do they understand the value of your services? Do they have ideas for ways you can improve? 6) Manage TimeCan you cut down on the time it takes to do anything in the organizationwhether its waiting times or the time to develop a new idea or product?

7) Focus on VariationWhat aspects of your systems vary and make your outcomes unpredictable? 8) Focus on Error ProofingCan you make it harder for people in your system to make mistakes? For instance, can you make the information necessary to perform a task available in, say, a checklistrather than in ones memory?

9) Focus on the Product or ServiceIs the service or product you provide a good one? Can it be better?

Change Ideas Galore

For each

one of those categories, you can use several change concepts to come up with ideas.


an example, here are some of the related change concepts for Eliminate Waste, with a health care example for each.

Change Concept: Change Targets


Energy is wasted when lights are left on in unoccupied rooms. hospital had this problem with its recycling closets. team eliminated this problem by arranging to have the light turn on automatically when the door is opened and turn off automatically when the door is closed.



Change Concept: Recycle or Reuse


At one hospital, a team discovered that x-ray technicians were generating excess waste because they were not able to recycle the canisters that contained the x-ray film. team persuaded a major producer of x-ray film to let the hospital return the canisters for refills.


Change Concept: Reduce Classifications to Remove Complexity

Example: Having a lot of appointment types actually increases total delay in the system because each appointment type creates its own differential delay and queue. For example, if a physician takes physicals only on Tuesday afternoons, a patient needing a physical may have to wait several weeks until a Tuesday afternoon slot is available. The more criteria, the more time it takes to put people in the line.

Change Concept: Reduce Controls on the System

Example: Organizations can benefit from allowing staff to come up with innovative solutions to problems. For example, one organization gave its smokingcessation team the flexibility to decide who would do what tasks as long as the job was accomplished. The team soon learned that on one team, the nurse was better at counseling, while on another team it was the doctor. The team assigned roles based on skill and availability.

Change Concept: Eliminate Multiple Entry


Many hospitals have implemented a computerized medication administration record system.

Change Concept: Match the Amount to the Need

Example: Medical supplies come in standard packages of six units.

When physicians want to give a week's supply (seven units), they are forced to give two packs of six, and five of the units often end up being wasted. After study of this application and other uses of the supplies, the manufacturer developed three standard package sizes: four, seven, and ten units.

Change Concept: Use Sampling

Example: An infection control group estimated the infection rate in their hospital by following up on every positive culture to see if it was an infection.
They used the concept of sampling to change the process, taking a sample of 20 positive cultures each day and then estimating the infection rate from the samples.

They were able to cut one laboratory technician position because of the reduction in the number of tests required and data handled.

Change Concept: Remove Intermediaries


One hospital identified 31 steps involved in completing a patient transfer from the emergency department to the inpatient unit. identifying these steps, the team removed intermediaries by asking the emergency department clerks to call the admitting unit directly, bypassing their own admitting staff, which eliminated two of the 31 steps.


Change Concept: Use Substitution

Example: An organization working on improving access to its rheumatology department tested a change by having the physicians type all consult responses directly into the computer system at the time the patient is seen, instead of writing in a patients chart.
Several efficiencies are gained: less use of paper materials, immediate access to lab results and old notes, ability to review what other consults have been requesting and the outcome, ability to examine x-rays, and ability to reread the physicians own notes prior to writing the assessment and plan.

Your Turn: Come Up with Some Good Changes to Test

In Lesson 1, you selected your improvement project. In Lesson 2, you created an aim statement.

In Lesson 3, you developed a balanced set of measures, including the following:

One or two outcome measures

Two to four process measures

One or two balancing measures

In this lesson, its time to come up with some good ideas of changes to test. Use the methods youve learned in this lesson to generate your list of ideas. Then share your list with other students on our discussion board.

Institute for Healthcare Improvement Personal Improvement Project

Heres our Institute for Healthcare Improvement staff member, back to develop her project. Ill apply creative thinking to this problem. Specifically, Im going to think about the boundaries that keep me from running as much as Id like. The main boundary, as far as I can see, is that I leave work much too late7 PM, sometimes even 8 PMto go to the gym and still get home at a reasonable time.

What can I do to remove this boundary? Well, this ones simple. I can just leave earlier. I dont strictly need to stay so late. Its just a bad habit Ive developed. In fact, I dont even get that much extra work done in those last few hours. So heres a specific idea for a change I can try: Leave work by 6:30 PM.

Post-Lesson Assessment

1. Youre a medical assistant at a community health clinic. Sometimes, patients with unresolved problems need to come in for follow-up appointments. However, you notice that its a real challenge to schedule these follow-ups within a week of the initial appointments. Which of the following techniques might be most useful as you search for a good idea for change?
a) Review the process for scheduling these appointments with colleagues to identify opportunities for improvement. b) Quit and start working in a new clinic that functions more effectively. c) Research possible upgrades to the appointment scheduling software.

d) Tell a member of the office staff that it would be great if follow-ups were scheduled more quickly.

2. Whats the main benefit of using change concepts to come up with improvement ideas? a) Using change concepts makes PDSA cycles unnecessary. b) Using change concepts makes it much more likely that the implementation will go smoothly. c) Using change concepts will lead you to focus on quantifiable technological improvements.

d) Using change concepts can help you develop specific improvement ideas that might not have occurred to you initially.

3. Which of the following is NOT a basic technique to come up with good ideas for changes? a) Benchmarking

b) Using technology
c) Making resolutions d) Critical thinking about the current system

4. Which of the following changes falls under the heading of eliminating waste? a) Physicians type all consult responses directly into a computer rather than writing them in a patients chart, thus saving paper b) Dispensers full of hand sanitizer are placed throughout a floor, thus improving compliance with hand hygiene protocols c) A clinic starts tracking the number of foot exams that diabetic patients receive each year, thus ensuring they receive evidencebased care d) A hospital invites patients to participate in the redesign of one of its centers, thus making them feel like valued members of a care team

5. As you recall, the IHI staff members change idea involves leaving work by 6:30 PM each workday. Which of the following is an example of using technology to help her do so? a) Comparing the time she leaves to that of the person who seems to go home earliest each day. b) Cancelling two meetings every day. c) Scheduling a reminder into her work calendar that pops up daily at 6:15 PM with the message, Leave! d) Taking work home each night on a laptop computer.

Its one thing to make a change to a system. Its another thing to know whether that change is making a difference.

By testing changes on a small scale and tracking your results as you go, you can see how your changes are affecting the process and how they might be revised for better results.

This lesson will explain the reasoning behind the Plan-Do-Study-Act (PDSA) cycle and demonstrate how its used to test changes sequentially. In this lesson, you will also conduct the first testing cycle of your own improvement project.

After completing this lesson, you will be able to:

Develop tests of change on a small scale, using the PDSA cycle. Explain how to link PDSA cycles for iterative testing and refinement of a change. State how to test several changes at the same time. Propose and operate a small test of changethe first PDSAfor your own personal improvement project.

Now that youve got some good ideas . . . its time to test them.

Once a team has set an aim (Lesson 2), developed measures to determine whether a change leads to an improvement (Lesson 3), and come up with some good ideas for changes (Lesson 4), the next step is to test a change in the real work setting. The PDSA cycle is a great way to test a changeby planning it, trying the plan, observing the results, and acting on what is learned.

Why is it important to test changes? The angel on one shoulder (the one whos always in a hurry) is telling you that you could just follow common sense and go ahead and make the obvious changesno testing needed, just do it! Meanwhile, the angel on the other shoulder (the cautious one) is telling you to take some time and carefully plan out the new systemand not be in a rush to test small changes that would be part of that system.

Dont listen to either one of them.

The changes that you think are obvious might not in fact help you get closer to your goal; they might work well in one setting, but not at all in another.
The only way youll know for sure is if you test them and measure to see if theyre having the desired effect. And on the other hand, that new system that you could plan out so carefullyand over such a long timemight turn out to be deeply flawed in a way that a simple test of change, early on, would have made clear.

Instead, consider this simple maxim. All improvement will require change, but not all change will result in improvement.

You know that youve got to change the system to get better results; your challenge now is to come up with some good predictionsto identify changes with a high likelihood of resulting in improvement and then test them in real settings ASAP to find out if your hunches are correct.

Why test changes that are already proven?

To increase your belief that the change will result in improvement in your setting To learn how to adapt the change to the particular conditions in your setting To evaluate the costs and side effects of changes

To minimize resistance when implementing the change in the organization

There are four simple steps in the PDSA cycle. Lets see how they play out for your group of student volunteers. Youll recall that you developed this aim. Within six weeks, we will triple our current attendance at volunteer meetings, resulting in a turnout of at least 18 people. So heres how you plan out your first PDSA cycle.

Step 1: Plan

the test or observation, including a plan for collecting data.

State State

the objective of the test.

the questions you want to answer and make predictions about what will happen and why.

Develop a

plan to test the change. (Who? What? When? Where? What data need to be collected?)

The objective of your test is to increase attendance at your meetings. The question you want to answer is Will making small changes to have more fun increase attendance? Youve discussed a lot of changes with your team, but for this first test you decide to keep it simple.

You predict that if you simply offer Guitar Hero and food at two consecutive meetings, attendance will double as people enjoy themselves and ask their friends along to the next event. For this first, simple test, youll document two things: 1) whether you provide food and Guitar Hero or not at each meeting and 2) how many people show up to your meetings.

Step 2: Do

out the test on a small scale.

the test.

Carry out


problems and unexpected observations.

analysis of the data.

You and your team hold two weekly meetings, incorporating the two changes. Your student volunteers are rocking out after the work portion of the meeting and stuffing their mouths with Doritos. So far, things are looking pretty good.

Step 3: Study

aside time to analyze the data and study the results.

Complete Compare

the analysis of the data.

the data to your predictions. reflect on what was learned.

Summarize and

Based on the data you collected, there were six people at the first meetingand 11 at the second.

Your attendance did indeed go up, almost doubling as predicted.

It looks like this change in meeting format might be helping you get to your projects aim.

Step 4: Act

the change, based on what was learned from the test.

Determine what Prepare a

modifications should be made.

plan for the next PDSA.

Now that youre somewhat confident in your changes, you plan to try them for two more meetings, and you also add one new change.

For the next PDSA cycle, you and your team plan to post flyers all over campus advertising the weekly Guitar Hero study breaks.

Decreasing Surgical Site Infections: A PDSA Cycle in the Health Care Setting

the PDSA cycle, youre well on your way to getting 18 people to attend your weekly meeting. But how might a PDSA cycle work in the much more complex setting of a health care facility? example showing how a team starts with a small-scale test in their quest to decrease the number of surgical site infections.

Heres an

Aim: Decrease surgical site infections by 30 percent within four months.

Test of

Change (PDSA Cycle): Determine the feasibility and effect of asking the anesthesiologist to administer the first dose of prophylactic antibiotic within an hour of the first incision.

Objective of

the test: Test a way to ensure that the first dose of antibiotic is administered within one hour of incision time.


The anesthesiologist will best be able to ensure that the first dose of antibiotic is administered within one hour of incision time. plan: We will test this change on four patients next Tuesday.

Develop a

The charge

nurse will notify the pharmacy, which will deliver the antibiotics to the perioperative area before each patient arrives. Emerald will ask Dr. Violet, the anesthesiologist, to administer antibiotic within one hour of the incision. Violet will administer the first dose of antibiotic and will document the administration time and the incision time.




The day before the test, we discussed the plan with Dr. Violet, who agreed to the small test. The day of the test, we selected four patients from the operating schedule and notified the pharmacy. Dr. Violet administered the antibiotic in three of the four cases, due to the late arrival of one dose.

Dr. Violet did not record the incision time twice out of the four times, due to intervening priorities.


We checked into why that single antibiotic dose arrived late, and found that the patient's surgery was moved up due to an emergency case requiring a special room.

Do we need a better communication system with the pharmacy?

We also discovered that the reason Dr. Violet could not document the incision time twice was that he was working with the patient's airway and the anesthesia settings at the time, and did not witness the actual incision.

Should someone else document the incision time?

In the cases where both incision time and antibiotic dosage time were documented, we found that the antibiotic was administered within an hour of the incision time, verifying our prediction.


team decided that, because it was difficult for the anesthesiologist to document incision time because of the other activities occurring at that time, another member of the surgical team will have to document the incision time.

The team thought that the circulating nurse could document the incision time more easily than the anesthesiologist, so for the next test they will ask the circulating nurse to document the time of incision. For the next test, the anesthesiologist will continue to administer the antibiotic and document the time. The team will work on a new method of communicating changes in the surgery schedule with the pharmacy, and they will test that communication plan by next week.

Youre the chief of surgery in this hospital. Youre trying to think about how you and your team should conduct the next PDSA cycle. Q When testing changes, you should be sure to gain consensus and buy-in. a) True b) False

The answer is


to choose changes that do not require a long process of approval or buy-in. use the test itself, if successful, to gain consensus and buy-in.


Q You and your team should reflect on the results of every change. a) True b) False

The answer is
After testing


a change, a team should address several issues, including reconciling the prediction to what actually happened, identifying unintended consequences, and understanding the best and worst aspect of the change.

Q You should never end a test of change. a) True

b) False

The answer is


the test if it is not leading to improvement or if things are not safe. However, much can be learned from a failed test of change, so be sure to study it thoroughly.

Linking Tests of Change

When you finish one PDSA cycle, you plunge right into the next one.
Thats what we call linking your PDSA cycles. Why not stop at just one? Because each test generates lots of useful informationwhat worked and what didn't?that tells you what you should do differently next time. But often new questions are raised.

Over the course of a few linked PDSA cycles, all of the kinks in making the change work in your system get smoothed out until youre ready to implement the change in one location. Heres what linking PDSA cycles looks like.

Running a series of tests, by the way, also helps overcome the resistance people often feel to change. Think about how you felt when you were 15 years old and your parents said you had to be home by 11 PM every night for the rest of the year. You probably screamed and yelled and periodically violated your curfew just to make a point.

Now imagine your parents had instead said, Lets try this new curfew for one week. At the end of the week, well talk about how it went and what changes we can make.

You still might not have liked itbut youd have been much more likely to try it, knowing your input would count for something at the end. Linking small tests of change helps ensure buyin from all the people involved.

Linking PDSA Cycles - Tips for Doing It Right

Think Ahead

already know youll want to do multiple tests. make your life easier by planning for it. Think a couple of cycles ahead, testing over a wide range of conditions and collecting useful data from each test to guide the next one.


Start Small

it simple at the beginning.

Scale down

the size of the test (for instance, start with just a few patients in one location). dont try to get consensus from everyone in the organization before starting.

Test with volunteers and

Get Started

wait around! Ask, What change can we test by next Tuesday?

Decreasing Surgical Site Infections: Linked Tests of Change

So what do linked PDSA cycles actually look like in a clinical setting?

Lets go back to the team that was working on reducing surgical site infections.
The team knew that one way to do this was to make sure that all patients received the first dose of prophylactic antibiotic within one hour of incision.

Their first PDSA cycle was designed to test the change of having the anesthesiologist administer the first dose of prophylactic. Not everything went perfectly: The anesthesiologist wasnt able to document the incision time consistently. So what did the team do next?

Heres how they tested and implemented the change through several linked PDSA cycles.


In the first cycle, Dr. Violet, the anesthesiologist, administers the first dose of antibiotic while documenting the administration and incision time for four patients. Turns out Dr. Violet doesnt document the incision time 50 percent of the time. Is that a failure of the test? Nope. Just useful information for the next test. In the second cycle, the team asks Dr. Violet to administer the first dose of antibiotic again and document the administration time for four patients. But this time, the circulating nurse documents the incision time. That works 100 percent of the time. Looking good!



In the third cycle, Dr. Violet and the circulating nurse work together the same way as beforebut this time, they try the change on all of Dr. Violets patients for one week. Again, the change seems robust. n the fourth cycle, Dr. Violet, excited about the change, presents his results to the anesthesia department. They all agree to try it for one week.



In the fifth cycle, the chair of the anesthesia department presents the results to the operating room committee, which includes representation from all surgical specialties. In the sixth cycle, the whole anesthesia department implements the change. All staff are trained on the new procedure.


Testing Several Changes at the Same Time

Now, how do you run a test of change when you're dealing with several changes at once? Here's an example. Your hospital is looking for ways to cut costs without lowering the quality of care. One promising place to start, your team decides, is in the area of elective coronary artery bypass graft (CABG)a procedure in which a new route is created around blocked arteries so blood can flow freely to the heart.

Your team wants to cut down on the time it takes to remove the breathing tubes from patients whove undergone this procedure.

This measureknown as early extubation could save many thousands of dollars a year.

Your team realizes, however, that more than one change is required. For instance, the tube cant be removed if a patient is still heavily sedated. So you need to test two changes.

Instead of using the traditional high dose of morphine, you want to test the use of smaller, more frequent doses. In this way, patients' pain can managed adequately, yet patients will be awake enough to be extubated safely.

You want to ask anesthesiologists to use lower doses of sedatives during the operation, so patients wont remain heavily sedated long after the surgery is over.

Q How does your team test these two changes? a) Run several PDSA cycles for reducing the general anesthesia dosage first. Once youve got all the kinks worked out and the change is implemented, start on the PDSA cycles for the morphine. b) Start the PDSA cycles for the general anesthesia and the PDSA cycles for the morphine at different times, but run them concurrently. That way you can see how the changes work together.


The answer is B.

You start the tests at different times but run them concurrently. That way you can see how all the required changes work together. Remember, your goal is to bring knowledge into actionnot to discover the single change that works best. If you are trying to see which changes corresponded to which outcomes, there are other experimental designs you might try for example, a factorial design that looks at the four combinations defined by the two changesbut well save this for a more advanced lesson. Subject matter knowledge about the changes and how they might interact will determine the best design.

Implementing Changes

After developing an idea for a change, testing that change on a small scale, learning from each test, and refining the change through several PDSA cycles, the change is ready for implementation.
During an implementation PDSA, the change is hard-wired into the system and made a permanent part of how the process of interest is done.

A Word About Spreading Changes

Improvement teams usually do not implement the change in other places.

Each time you expand the change to a new place or a different (or larger) population, an improvement team at that location should run a PDSA test cycle. You never know if the changes that worked so well in one setting will fall flat somewhere else. The methodology for spreading changes is distinct from the Model for Improvement, and will be the subject of a more advanced Quality Improvement course.

Using the Model for Improvement: Improving Your Tennis Game

In a few minutes, youll start the first Plan-Do-Study-Act cycle for your own personal improvement project. But first, heres an example of how you can use the Model for Improvement, from start to finish, to tackle personal problems. In 2004, Greg Randolph, a professor in the Department of Pediatrics at the University of North Carolina at Chapel Hill, wanted to become a better tennis player.

So he crafted an aim, a set of measures, and a group of changes:


To improve my enjoyment of tennis and the breadth of my game by learning to hit an effective topspin backhand. I will do this by undertaking a series of training and practice activities over the next 9 months to achieve the following goals:

my backhand effectiveness rating to 75 Increase my average tennis game satisfaction rating to 4.5


my ball machine or wall sessions to 4/month Attend one tennis lesson per month focused on backhand Hit 100% of backhands with continental grip


Backhand effectiveness rating will be rated weekly by me with input from partner after matches (scale 0=1st-time beginner; 20=very weak shot; 40=weak shot; 60=strong shot; 80=strong weapon; 100=professional (Federer)) Satisfaction with my tennis game will be rated weekly by me (1-5 scale from very dissatisfied to very satisfied) Number of ball machine or wall sessions/month

Number of %

tennis lessons/month

backhands hit with continental grip measured weekly by me measure: forehand effectiveness rating will be rated monthly by me with input from partner after matches (same scale as backhand effectiveness)


Key changes:

ball machine and/or wall to practice topspin backhands lessons with tennis pro focused on topspin backhand tennis partners in hitting primarily to backhand during matches shift to continental grip for backhand



Make gradual

Then Randolph conducted several PDSA cycles, tracking his results over time. Heres how he graphed his data:

In November of that year, Randolph reflected on the changes he had made so far:

Have taken several lesson with tennis pro, and scheduled 2/month through Dec.

Have gathered information on signing up for ball machine with tennis pro
Have regularly engaged tennis partner in hitting primarily to backhand during matches Have done a few wall sessions focused on topspin backhand

And it turned out he was pretty happy hed attempted this improvement project hed made a lot of progress. But he still had work to do in future PDSA cycles:

Im still amazed at the rapid progress Ive made in this short period of time more than Ive made in 20 years of playing tennis and wanting to improve my backhand.
An unanticipated effect of this improvement project is that has improved my forehand, too.

lot of the tips Im getting during tennis lessons apply to my forehand as well. I am falling short on ball/wall sessions thus far. this is due to competing demands on time (training for a 5-mile run, taxiing daughter to swim practice, etc.). may try doing ball or wall sessions after tennis lessons in coming weeks.


Off You Go!

In this course, youve been introduced to many of the things you need to know to run an improvement project. By now, this figure should look like a sturdy, reliable engine for getting you wherever you want to go:

When you combine the 3 questions with the..

.and The Model for Improvement PDSA cycle, you get

Your Turn: Conduct Your First Plan-DoStudy-Act Cycle

In Lesson 1, you selected your improvement project. In Lesson 2, you created an aim statement.

In Lesson 3, you developed a balanced set of measures, including the following:

One or Two

two outcome measures

to four process measures

two balancing measures

One or

In Lesson 4, you came up with some good ideas for changes. In this lesson, its time to design and carry out your first PDSA. Once youve picked a good change to test from your list of changes, use this worksheet to plan your first PDSA.

Post-Lesson Assessment

Use the following scenario to answer questions 1-3:

You are working on shortening the time it takes patients with chest pain to get to the cardiac catheterization lab in your hospital. Your aim is to have 90 percent of patients brought to the lab within 45 minutes of arrival to the hospital. You decide to try a care protocol that another hospital in the area implemented with great success.

1. The care protocol was successful at the other hospital. Why would it be important to test this proven change at your hospital? a) Because the last success may have been a fluke. b) So that you can publish your results. c) Because this change may not be as effective in your hospital. d) In order to demonstrate the ability of this protocol to improve care in other hospitals for those that created it.

2. After several tests, you decide to try implementing a modified version of the protocol at your institution. Which of the following might you do within the S portion of your next PDSA cycle? a) Develop the final plan for the protocol implementation. b) Document unexpected observations. c) Analyze information collected. d) Strategize how to move this to another hospital in the system.

3. After implementing the new protocol, you observe that patients are getting to the lab more quickly than before, but not as quickly as you had predicted. You examine the data and realize that there are really multiple issues delaying patients arrival to the catheterization lab. Specifically, the emergency department needs to notify the lab staff in advance, but this communication rarely happens. Further, the schedule that the emergency department uses to contact the lab staff is riddled with a) Focus on fixing the schedule. b) Discipline the emergency department staff who have failed to contact the catheterization lab in the past. c) Focus on improving the communication between the emergency staff and the catheterization staff. d) Work on improving both the schedule and communication at the same time.

4. PDSA stands for:

a) Prime-Design-Study-Adjust
b) Plan-Do-Study-Act c) Plan-Design-Stabilize-Adjust

d) Prime-Do-Stabilize-Adjust

5. Linking small tests of change:

a) Allows you to start testing on a larger scale than would otherwise be possible
b) Improves the likelihood of buy-in from opinion leaders c) Reduces the amount of planning you need to do before each test

d) Should be done only with the consent of opinion leaders

6. Which of the following statements is true? a) All changes lead to improvement; therefore, all improvement requires change.

b) While all changes do not lead to improvement, all improvement requires change. c) The changes that are known to lead to improvement should be implemented before testing.