The Model for Improvement and the Plan-Do-Study-Act cycle is a popular quality improvement (QI) tool for health care providers to successfully lead QI projects and redesign care processes. This tool has several distinct components that must be addressed in sequence to organize and critically evaluate improvement activities. Unlike other health sciences clinical research, QI projects and research are based on dynamic hypotheses that develop into observable, serial tests of change with continuous collection and feedback of performance data to stakeholders.
Key points
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The Model for Improvement is a popular, easy-to-use method of systematically and successfully implementing a quality improvement project.
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The problem is defined by scoping the current state and describing the existing quality gap. This may be accomplished by performing a literature review, using the 5 Whys tool, flowchart, fishbone diagram, root cause analysis, or failure modes effect analysis.
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The Plan-Do-Study-Act cycle is done successively with small tests of change until process improvement is accomplished; the final set of recommendations can then be implemented on a larger scale throughout the institution and health care system, resulting in greater gains.
Introduction
Since the publication of the Institute of Medicine (IOM) report To Err is Human 15 years ago, there has been substantial interest in improving patient safety and the quality of health care delivered in both medical and surgical fields, with many physicians and health care leaders devoting their careers to effecting positive change. With this interest has come the increased adoption of using process improvement tools initially designed in other industries and adapted for use in health care quality and process improvement. This article provides a general framework for neurosurgery providers who wish to embark on quality improvement (QI) projects using the Model for Improvement (MFI) and Plan-Do-Study-Act (PDSA) project cycles. Lean and Six Sigma are two other methods to approach QI work, and are not described in this article.
The Model for Improvement and Plan-Do-Study-Act
Because of its ease, logical approach, and emphasis on testing changes using a small-scale and rapid cycle approach, the MFI and the PDSA cycle is a popular framework that has been endorsed by the Institute for Healthcare Improvement as a tool for health care organizations to spearhead and accelerate QI efforts.
The MFI consists of 2 parts ( Fig. 1 ):
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Three questions must be addressed:
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What needs to be accomplished?
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How can a change be shown to be an improvement?
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What changes can be made that will result in improvement?
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Use the PDSA cycle to test changes in a real-work setting to ensure that the change results in improvement.
Defining the problem
The main goal of this phase is to address the first question of the MFI: what needs to be accomplished? Project teams must ask themselves what the problem is that they are trying to solve, and whether this is even a problem that is supported by current data. If clinicians suspect that there is a problem but do not have local data to support this or cannot specifically speak to how big the quality gap is, then a needs assessment should be conducted. The goal of the needs assessment is to develop a solid understanding of the current state, highlight how the current state does not meet the quality goal to show the quality gap that needs to be addressed, and explore potential areas for improvement.
Needs assessments can be done in several ways. As an example, consider the reduction of postoperative catheter-associated urinary tract infections (CA-UTI). One method of performing a needs assessment is to conduct a literature search to determine the general prevalence and incidence of the problem, and any evidence-based proven strategies that have been shown to reduce CA-UTI rates.
Another method of performing a needs assessment is to go to where the work is being done by providers. Nursing protocols and workflow for Foley catheter care should be observed and reviewed in addition to surgical provider workflow and order sets for placement and removal of Foley catheters. While performing workflow observations, the QI team may use the following tools to gather and organize their data:
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Five Whys tool
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Flowcharts
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Fishbone diagram
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Failure modes and effects analysis
Five Whys Tool
The 5 Whys tool ( Fig. 2 ) is a simple technique for determining the root cause of a problem. It was made popular by the Toyota Production System. Asking “Why?” no fewer than 5 times allows the answers to come from frontline providers who have direct experience with the process being examined. Continue the process of asking “Why?” until the root cause of the problem is identified. This process allows project team members to save time by devoting efforts to the underlying cause of the problem, rather than aimlessly pursuing other strategies that may have no effect on the outcome. The 5 Whys tool is best suited for simple to moderately difficult problems. More complex problems benefit from a more detailed needs assessment and scoping approach, although using the 5 Whys may still yield useful insights.
Flowcharts
A tool that may be used in more complex problems is the flowchart, which is a visual method of listing each separate step of a process in sequential order to help clarify steps in a complex process and allow team members to gain a shared understanding of the process of collecting data, identifying problems, and focusing improvement discussions. Fig. 3 shows an example of a flowchart describing the discharge process. Flowcharts may also be used to identify steps that do and do not add value to the customer, which is the patient in most health care QI projects. Flowcharts also allow teams to identify delays, unnecessary work, communication failures, and added expense. As a process analysis tool, flowcharts allow QI teams to have a consensus-built tool to drive the design of new process improvements.
Fishbone Diagram
The fishbone diagram ( Fig. 4 ), or cause-and-effect diagram, is another graphical process analysis tool that allows teams to understand that there are many causes that contribute to an effect, displays the relationship of the causes to each other and to the end effect, and identifies areas for improvement. The fishbone diagram is one method of graphically displaying the results of a root cause analysis (RCA), which is described in greater detail later in this article.
Failure Modes and Effects Analysis
A failure modes and effects analysis (FMEA) is a systematic, proactive method for evaluating a process to identify:
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Where the process may fail
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How the process may fail
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The relative impacts of the different failure points
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The higher-risk failure components of the process that are most in need of change to redesign the process and prevent harm
A multidisciplinary team selects a high-risk process to evaluate and begins by listing the steps in the process, similar to a flowchart. For each step in the process, the team lists the failure modes (things that can go wrong with the process) and failure causes. The team then assigns numeric values for each failure mode based on the likelihood of occurrence, likelihood of detection (with lower likelihood of detection rated as being higher risk for causing harm), and severity. Based on these numeric values, a risk priority number (RPN) is then assigned for each failure mode. Failure modes that have the highest RPN are then chosen for improvement efforts. Thus, an FMEA may be performed to better understand crucial processes that must be improved to avoid adverse events or errors ( Table 1 ).
Related posts:
Quality Improvement in Neurosurgery
The Relationship Between National Health Care Policies and Quality Improvement in Neurosurgery
Cost-Effectiveness Research in Neurosurgery
Electronic Medical Records and Quality Improvement
Using Clinical Registries to Improve the Quality of Neurosurgical Care
Comanagement Hospitalist Services for Neurosurgery
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