The Model for Improvement, developed by Associates in Process Improvement, is a prominent quality improvement approach in healthcare. The process establishes an aim and decides how to measure changes and what changes will achieve the aim. The model also tests changes to determine improvement through a Plan-Do-Study-Act (PDSA) cycle (IHI, n.d.). This article describes this approach, with one hospital’s experience using PDSA to improve an obstetric hemorrhage team response.
How does the Model for Improvement Work?
The Model for Improvement includes the following components:
Aim: What do we want to achieve? This step ensures the aim is measurable and defined, and answers the questions: How good? Who is this applicable to? What is the time period to achieve the aim by? The Institute of Medicine’s 6 domains of quality can be used as a guide in developing an aim statement: timely, effective, patient centered, efficient, safe and equitable.
Measures- what metrics can be used to reflect that the changes made are resulting in improvement? There are 3 types of measures that can be evaluated: outcome, process and balancing measures.
Changes- what interventions can be made to help achieve our aim? The following may assist with deciding what changes will work: best practice/research, national patient safety bundles, frontline staff suggestions, streamlining processes, reducing variation, and integrating human factors engineering, including modifying the work environment and optimizing electronic medical record systems.
PDSA cycles
Plan- develop a detailed plan for the changes, including data collection
Do- implement the changes on a small scale
Study- evaluate how well the changes are working
Act - make changes based on evaluations. Often this means making minor adjustments to processes or interventions to get it right, or best adapt it to the environment (IHI, n.d.)
Plan-Do-Study-Act
The concept of PDSA was developed by Dr. Edwards Deming, who integrated knowledge from engineering, management, and operations with cost reduction, safety and efficiency. PDSA cycles can be repeated as often as needed to continuously learn and improve. It is a useful strategy for small tests of change or for larger quality improvement implementation (Kelly et al., 2018). Audits or data collection tools can be used to evaluate during the study phase, however valuable information can also be gained by simply asking frontline staff how the process is working and if able, directly observing in real-time.
When integrating quality improvement work to the bedside, we often don’t get it right the first time. Processes usually must be modified once implemented in the clinical environment. Using the PDSA approach allows for identifying challenges or barriers and subsequent changes to be made which improve the process.
Case example
The following case example applies the IHI Model for Improvement to reducing the number of obstetric patients who require massive transfusions. Experts recommend a multifaceted approach, however, for the purposes of this example, we will focus on one intervention, the development of an obstetric hemorrhage rapid response team. Setting up a process in which the right people respond at the right time, with defined roles, helps to ensure timely treatment of hemorrhage and mitigation of further complications including progression to massive hemorrhage.
AIM- Within 6 months, the number of women who receive massive transfusions, defined as receiving 4 units or greater of packed red blood cells during their birth admission, will be reduced by 30%.
MEASURES
(Lyndon et.al., 2015)
Changes- A multidisciplinary team was pulled together to discuss who needed to be on the response team, when to activate and how best to reach the team members. Literature was reviewed and the team chose to integrate applicable lessons learned from other organizations.
PDSA- The plan included staff education on the new process, debriefings after the events to evaluate team performance including how the rapid response team was working, and completion of audits by charge nurses.
Once the plan was implemented, audits were used to study the effects. Audit results showed that in 20% of the cases, there was pushback regarding activating the hemorrhage response team from providers. This led to additional interventions to help remove this barrier: education for all staff that focused on empowering anyone to activate the response team and the mindset that if not needed, the team walks away and no harm is done but everyone is there if needed.
The importance of PDSA cannot be underestimated, as it demonstrates that this is not a “one and done” change. As mentioned, often these interventions are based on research or national safety bundles which serve as the overall structure, but the details and adaptation to the clinical environment and staff involve continuous evaluation in order to ensure the best fit.
ONQS practice questions
A quality improvement project involving the development of an obstetric hemorrhage response team is undertaken. An in-hospital app was used to notify designated nursing and physician staff. After implementation survey feedback showed additional care providers needed to be included in the notification response via this app. Additional roles were created for the app, allowing for these care providers to be included. Several tests were performed to ensure it was working correctly. This is an example of what quality improvement method?
a. Just Do It
b. Plan Do Study Act
c. Value Stream Mapping
PDSA is a valuable tool for small tests of change or for larger quality improvement implementation
True
False
Answers:
b
a
*If this article interests you, you can find more information like this in my book titled: Obstetric and Neonatal Quality and Safety (C-ONQS) Study Guide: A Practical Resource for Perinatal Nurses, available on amazon: Amazon_obneonatalstudyguide
Copyright by Jeanette Zocco RNC-OB, C-EFM, C-ONQS
References
Institute for Healthcare Improvement (n.d.). Science of Improvement: How to Improve. Retrieved from http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
Kelly, P., Vottero, B. A., & Christie-McAuliffe, C. A. (2018). Introduction to Quality and Safety Education for Nurses: Core Competencies for Nursing Leadership and Management. Springer Publishing Company
Lyndon A, Lagrew D, Shields L, Main E, Cape V. (2015). Improving Health Care Response to Obstetric Hemorrhage. (California Maternal Quality Care Collaborative Toolkit to Transform Maternity Care) Developed under contract #11-10006 with the California Department of Public Health; Maternal, Child and Adolescent Health Division; Published by the California Maternal Quality Care Collaborative.