Directions: Use thisPlan-Do-Study-Act(PDSA)tool toplan anddocumentyourprogresswithtestsof changeconductedaspartofcharteredperformanceimprovementprojects(PIPs). Whilethecharterwillhaveclearlyestablishedthegoals,scope,timing,milestonesandteamrolesand responsibilitiesforaproject,thePIPteamasked tocarryouttheproject willneedtodeterminehowtocomplete thework. Thistool shouldbecompletedbytheproject leader/manager/coordinatorwithreviewandinputbytheprojectteam. Answerthefirsttwoquestionsbelowfor your PIP. Thenas youplantotestchangesto meetyour aim,answerquestion 3belowandplan,conductanddocumentyourPDSAcycles. Rememberthat aPIP willusuallyinvolve multiplePDSA cycles in ordertoachieve your aim. UseasmanyformsasyouneedtotrackyourPDSAcycles.
Once you have completed filling out this form, save a copy for your records and email a copy of the completed form to Krystal Hays at .
ModelforImprovement: Threequestionsforimprovement
1.Whatarewetryingtoaccomplish (aim)?Stateyouraim (reviewyourPIP charter– andincludeyourbold aimthatwill improveresidenthealthoutcomesandqualityofcare).
2.Howwillweknowthat changeis animprovement (measures)?
Describethemeasureableoutcome(s)youwanttosee.
3.Whatchangecanwemakethatwillresultinanimprovement?
Definetheprocessescurrentlyinplace;useprocessmappingorflowcharting.
Identifyopportunitiesforimprovementthatexist(lookforcausesofproblemsthathaveoccurred–seeGuidanceforPerformingRootCauseAnalysiswithPerformanceImprovementProjects;oridentifypotentialproblemsbeforetheyoccur–seeGuidanceforPerformingFailureModeEffectsAnalysiswithPerformanceImprovementProjects)(seerootcauseanalysistool):
- Pointswherebreakdownsoccur
- “Work-a-rounds”thathavebeendeveloped
- Variationthat occurs
- Duplicateorunnecessarysteps
- Identifybetterwaystodo thingsthat addresstherootcausesoftheproblem
- Learn whathasworkedatotherorganizations(copy)
- Reviewthebestavailableevidenceforwhat works(literature,studies,experts,guidelines)
- Rememberthatsolutiondoesn’thavetobeperfect thefirsttime
Plan
What changeareyoutestingwiththePDSAcycle(s)?
Whatdoyoupredictwillhappenandwhy?
Who willbe involvedinthisPDSA?(e.g.,onestaff memberorresident,oneshift?) Wheneverfeasible,itwillbehelpfultoinvolvedirect carestaff.
Plan asmalltestofchange.
Howlongwillthechangetaketoimplement?
Whatresourceswilltheyneed?
Whatdataneedtobecollected? / Listyouractionstepsalongwithperson(s)responsibleandtimeline.
Do
Carryouttheteston a small scale.
Documentobservations,includinganyproblemsandunexpectedfindings.
Collect data you identified asneededduringthe“plan”stage. / Describewhatactuallyhappenedwhenyouranthetest.
Study
Studyandanalyzethedata.Determineifthechangeresulted intheexpectedoutcome.
Werethereimplementationlessons?
Summarizewhatwaslearned. Lookfor:unintendedconsequences,surprises,successes,failures. / Describethemeasuredresultsandhowtheycomparedtothepredictions.
Act
Basedonwhatwaslearnedfromthetest:
- Adapt –modifythechangesandrepeatPDSAcycle
- Adopt –considerexpandingthechanges inyourorganizationtoadditionalresidents, staff andunits
- Abandon– changeyourapproachandrepeatPDSAcycle
Story Author: / Title:
Email: / Phone:
Facility Name: / City:
We grant permission to the Great Plains Quality Innovation Network/ Nebraska to share, as appropriate, this success story with other Nursing Home Quality Care Collaborative teams. / Yes
No
Maybe
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This material was prepared by the Great Plains Quality Innovation Network, the Medicare Quality Improvement Organization for Kansas, Nebraska, North Dakota and South Dakota, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents presented do not necessarily reflect CMS policy. 11SOW-GPQIN-NE-C2-36/0715
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.