You can use plan, do, study, act (PDSA) cycles to test an idea by temporarily trialling a change and assessing its impact. This approach is unusual in a healthcare setting because traditionally, new ideas are often introduced without sufficient testing.
The four stages of the PDSA cycle:
Plan - the change to be tested or implemented
Do - carry out the test or change
Study - data before and after the change and reflect on what was learned
Act - plan the next change cycle or full implementation
Using the PDSA cycle involves testing new change ideas on a small scale.
For example:
- Trying out a new way to make appointments for one consultant or one clinic
- Trying out a new patient information sheet with a selected group of patients before introducing the change to all clinics or patient groups
- By building on the learning from these test cycles in a structured way, you can put a new idea in place with greater chances of success
As with any change, ownership is key to implementing the improvement successfully. If you involve a range of colleagues in trying something out on a small scale before it is fully operational, you will reduce the barriers to change.
Why test change before implementing it?
It involves less time, money and risk
The process is a powerful tool for learning; from both ideas that work and those that don’t It is safer and less disruptive for patients and staff Because people have been involved in testing and developing the ideas, there is often less resistance How to test:
- Plan multiple cycles to test ideas. You can adapt these from the service improvement guide so there is already evidence that the change works
- Test on a really small scale. For example, start with one patient or one clinician at one afternoon clinic and increase the numbers as you refine the ideas
- Test the proposed change with people who believe in the improvement. Don’t try to convert people into accepting the change at this stage
- Only implement the idea when you're confident you have considered and tested all the possible ways of achieving the change
You may not get the results you expect, so it is safer, and more effective to test out improvements on a small scale before implementing them across the board.
Achieving the 18 week target is a significant challenge and you will need to make major changes to many working practices. It is crucial that the various stakeholders buy in to the change, so focus on proven changes.
Using PDSA cycles enables you to test out changes before wholesale implementation and gives stakeholders the opportunity to see if the proposed change will work.
PDSA cycles form part of the model for improvement, which provides a framework for developing, testing and implementing changes leading to improvement. The model is based in scientific method and moderates the impulse to take immediate action with the wisdom of careful study. The framework includes three key questions and a process for testing change ideas.
The three questions:
- What are we trying to accomplish? The aims statement
- How will we know if the change is an improvement?
- What changes can we make that will result in improvement?
What we trying to accomplish?
Teams need to set clear and focused goals. These goals require clinical leadership; they should focus on problems that cause concern, as well as patients and staff.
The aims statement should:
- Be consistent with the national goals of the 18 week pathway and be relevant to the length of the project
- Be bold in its aspirations
- Have clear, measurable targets
An example of an aims statement from cancer services:
Aims:
To improve access, speed of diagnosis, speed of starting treatment and patient care of people who are suspected of having bowel cancer.
This will be achieved by:
- Introducing booked admissions and appointments. Target: more than 95 per cent of patients
- Reducing the time from GP referral to first definitive treatment to less than 15 weeks
- Ensuring that over 80 per cent of patients are discussed by the multidisciplinary team
Concentrate efforts and measurements on key stages of care: GP referral, first out-patient appointment, first diagnostic test and first definitive treatment.
How do we know if the change is an improvement?
You will need to measure outcomes, such as reduction in the time a patient has to wait in order to answer this question. If we make a change, this should affect the measures and demonstrate over time whether the change has led to sustainable improvement. The measures in this model are tools for learning and demonstrating improvement, not for judgment.
Each project team should collect data in the following areas:
The number of days from referral to first definitive treatment. Use the PJA
The percentage of patients with booked admissions or appointments at three key stages of the patient journey: first out-patient appointment, first diagnostic test and first definitive treatment. Use the PJA The percentage of patients who are discussed by a multidisciplinary team Patient satisfaction or experience at several different stages along the patient journey. See getting patient perspectives You should report improvement progress monthly on time series graphs known as ‘run charts’ or statistical process control charts (SPC). See the PJA.
What changes can we make that will result in improvement?
There are many potential changes your team could make. However, evidence from scientific literature and previous improvement programmes suggests that there are a small number of changes that are most likely to result in improvement.
The Cancer Service Collaborative has identified twenty eight change principles which they have grouped into four areas that you may find helpful.
- Connect up the patient journey
- Develop the team around the patient journey
- Make the patient and care experience central to every stage of the journey
- Make sure there is capacity to meet patients’ needs at every stage of the journey
It is possible that there may be several PDSA cycles running sequentially (figure 3), or even simultaneously (figure 4). Sequential cycles are common when the study reveals results which suggest a different approach is needed.
Figure 3
Figure 4
Simultaneous cycles may occur when the changes are more complex, possibly involving several departments. It is important that you identify any interactions between simultaneous cycles, as a change in method in one cycle may alter the impact of another somewhere else. For example, you are making changes to the way that secretaries process letters, so that they are printed and stuffed into envelopes in a central department. As another part of the project, a PDSA cycle looks at when doctors sign their correspondence and concludes that is should be done in the secretary’s office. Obviously the two solutions conflict.
The cycles in use:
Produce a first draft. Check it against this guidance. Make changes. Is it easy to read? Produce another draft and check it with members of your team. Do rapid cycles of testing until it seems easy to read?
Is it right?
Produce another draft and check it with colleagues, clinicians, experts, patient support groups. Think about people like secretaries and booking staff. If you have to send it to someone, always give them a deadline.
Is it good for patients?
Produce another draft and check it with patients or people in the hospital who are unfamiliar with the topic area.