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Description
Use
Examples
Further
Reading
The Ramp of
Improvement
The PDCA (or PDSA) Cycle was originally conceived by Walter Shewhart in 1930's, and later adopted by W. Edwards Deming. The model provides a framework for the improvement of a process or system. It can be used to guide the entire improvement project, or to develop specific projects once target improvement areas have been identified.
The PDCA cycle is designed to be used as a dynamic model. The completion of one turn of the cycle flows into the beginning of the next. Following in the spirit of continuous quality improvement, the process can always be reanalyzed and a new test of change can begin. This continual cycle of change is represented in the ramp of improvement. Using what we learn in one PDCA trial, we can begin another, more complex trial.
(Bold from Deming p.132, Plain from
BPC p.52)
Plan - a change or a test, aimed at
improvement.
In this phase, analyze what you inted to improve, looking for areas that hold opportunities for change. The first step is to choose areas that offer the most return for the effort you put in-the biggest bang for your buck. To identify these areas for change consider using a Flow chart<link> or Pareto chart<link>.
Do - Carry out the change or test (preferably on a small scale).
Implement the change you decided on in the plan phase.
Check or Study - the results. What was learned? What went wrong?
This is a crucial step in the PDCA cycle. After you have implemented the change for a short time, you must determine how well it is working. Is it really leading to improvement in the way you had hoped? You must decide on several measures with which you can monitor the level of improvement. Run Charts can be helpful with this measurement.
Act - Adopt the change, abandon it, or run through the cycle again.
After planning a change, implementing and then monitoring it, you must decide whether it is worth continuing that particular change. If it consumed too much of your time, was difficult to adhere to, or even led to no improvement, you may consider aborting the change and planning a new one. However, if the change led to a desirable improvement or outcome, you may consider expanding the trial to a different area, or slightly increasing your complexity. This sends you back into the Plan phase and can be the beginning of the ramp of improvement.
Examples
Personal
Improvement
Example
1: The student with poor grades
Improving
Patient Compliance in Personal Health Maintenance
Example
2: The businesswoman who wants to lose weight
Student
Section: Improving Your History-Taking Skills
Example
3: Feedback for the medical student
Clinician
Section: Improving Your Office
Example
4: The Medical Student who made a difference
The PDCA cycle is a
valuable process that can be applied to practically anything. In this
chapter, we discuss cases related to patient care and medical student
performance, but the PDCA cycle can be used in everything from making
a meal to walking your dog. An immediate concern of yours may be
improving your study skills.
Example 1: The Student with
Poor Grades
Isabel is a first-year medical
student who has just taken her first set of examinations and is very
unhappy with the results.
Cycle 1
Plan: Isabel decides to add an additional
thirty hours per week to her already busy schedule. She resolves that
she must socialize less, get up earlier, and stay up later. At the
end of the week she will take an old exam to see how she is
progressing.
Do: By the end of the week, Isabel
finds that she was able to add only fifteen hours of studying. When
she takes the exam she is dismayed to find that she does no
better.
Check: The fifteen extra hours of studying
has made Isabel feel fatigued. In addition, she finds that her
ability to concentrate during those hours is rather limited. She has
not exercised all week and has not seen any of her friends. This
forced isolation is discouraging her.
Act: Isabel knows that there must be
another way. She needs to design a better, more efficient way to
study that will allow her time to exercise and socialize.
Cycle 2
Plan: Isabel contacts all her medical
school friends who she knows are doing well yet still have time for
outside lives. Many of these friends have similar advice that Isabel
thinks she can use. Based on her findings, she decides to always
attend lectures, to rewrite her class notes in a format she can
understand and based on what the professor has emphasized, and to use
the assigned text only as a reference.
Do: Isabel returns to her original
schedule of studying. However, instead of spending a majority of her
time poring over the text, she rewrites and studies her notes. She
goes to the text only when she does not understand her notes. When
Isabel takes one of the old exams, she finds that she has done
better, but she still sees room for improvement.
Check: Isabel now realizes that she had
been spending too much time reading unimportant information in the
required text. She knows that her new approach works much better, yet
she still feels that she needs more studying time. She is unsure what
to do, because she doesn't want to take away from her social and
physically active life.
Act: Isabel decides to continue with her
new studying approach while attempting to find time in her busy day
to study more.
Cycle 3
Plan: In her search for more time to
study, Isabel realizes that there are many places that she can
combine exercising and socializing with studying. First, she decides
to study her rewritten notes while she is exercising on the
Stairmaster. Next, she intends to spend part of her socializing time
studying with her friends.
Do: Isabel's friends are excited about
studying together, and their sessions turn into a fun and helpful use
of everyone's time. Isabel has found that she enjoys studying while
she exercises. In fact, she discovers that she remains on the
Stairmaster longer when she's reading over her notes. When Isabel
takes her exams this week, she is happy to find that her grades are
significantly higher.
Check: Isabel now knows that studying does
not mean being locked up in her room reading hundreds of pages of
text. She realizes that she can gain a lot by studying in different
environments while focusing on the most important points.
Act: Isabel chooses to continue with the
changes she has made in her studying habits.
What Isabel initially thought
would be an improvement turned out to only discourage her further.
Many people who are in Isabel's place do not take the time to study
their changes and continue them even though they lead down a
disheartening path. By using the PDCA cycle, Isabel was able to see
that her initial change did not work and that she had to find one
that would better suit her. With perseverance and the willingness to
learn, Isabel was able to turn a negative outcome into a positive
improvement experience.
Designing and implementing a patient's plan for health care is a dynamic process. Therefore, it is not uncommon for even the best-intentioned care plans to fail on the first attempt. When this happens, the provider and patient must carefully reconsider, reevaluate, and redesign the health improvement plan to make it more compatible with the patient's lifestyle and needs. The PDCA cycle aids in this reevaluation process by providing a systematic approach to improvement.
Example 2: The Business Woman
Who Wants to Lose Weight
Mrs. T is a 55-year-old white
woman, a successful buyer. She is 10 pounds overweight, suffers from
high blood pressure, and lacks muscle tone.
Cycle 1
Plan: Ride an exercise bike four days a
week for twenty minutes. To continue her exercise program while
traveling, Mrs. T will make reservations only at hotels equipped with
gyms. She will also lease an exercise bike for her home.
Do: Mrs. T tries to exercise four days
a week for twenty minutes. The patient finds that the exercise bike
is too difficult and makes her back sore. She can ride for only three
minutes before she gets dizzy and has to stop. Mrs. T finds that at
hotels, it is hard to get time on the bike, since there are usually
many people who want to use it.
Check: Mrs. T exercised only one day a
week and could go for only three minutes. The patient is not
motivated to use the exercise bike because she doesnÌt enjoy
it. Also, the hassle about using bikes at hotels is a big hindrance.
Mrs. T needs to find an exercise that permits her to set her own pace
and her own hours.
Act: Mrs. T and her doctor decide to
find a different program.
Cycle 2
Plan: Mrs. T will try a treadmill instead
of the exercise bike.
Do: Mrs. T tries to exercise four days
a week for twenty minutes, but can go for only about five minutes
before she gets bored. Also, she feels sick after getting off the
treadmill. There was no problem finding an available treadmill at the
hotels.
Check: Mrs. T exercised twice a week for
five minutes. However, the patient did not enjoy it. She enjoys the
walking but has trouble with motion sickness.
Act: Mrs. T will continue to walk but
will walk outside to avoid inconvenient gym hours and the motion
sickness. The patient considers purchasing a dog, knowing that this
will provide greater motivation to walk and make it more
enjoyable.
Cycle 3
Plan: Mrs. T will get a dog and walk it
every morning she is home. When she is away, she will try to take a
short sight-seeing trip on foot, while her husband takes care of
their dog at home.
Do: Mrs. T exercises as frequently as
possible. She finds walking her dog very enjoyable and does it every
day she is home (approximately three days a week) for about
forty-five minutes. When she is away, she tries to take a walking
tour of the city. This isn't always possible but occurs about 50
percent of the time.
Check: Mrs. T exercises three to six days
a week for at least twenty minutes. She finds walking the dog most
enjoyable because of the early-morning fresh air. Her blood pressure
has become less elevated as well.
Act: Now that she has found a program
she enjoys, Mrs. T decides to commit herself to this new exercise
regimen: walking the dog and sight-seeing by foot.
By directly considering Mrs.
T's needs as well as Mrs. T's likes and dislikes, the physician and
the patient were able to design and implement an unconventional but
highly effective exercise program that improved both the physical and
the emotional wellness of the patient.
In the first year of medical school, many students are taught to take histories from patients. Some students are comfortable with this process, but others feel like they're barely keeping their heads above water. Whether you are the former or the latter, it would be beneficial to get feedback on your strengths and weaknesses so that you can become a better history taker. The PDCA cycle does just that. It allows medical students to gather knowledge about their interviewing skills and then walks them through different tests of change to see whether the desired improvement really works.
Example 3: Feedback for the
Medical Student
Jake is a first-year medical
student at Dartmouth Medical School (DMS). He visits a local primary
care provider's office twice a month, where he works on interviewing
different patients. Although he is comfortable talking to patients,
he is unsure whether he's asking them the right questions. Sometimes
he is at a loss for things to ask, and there are moments of awkward
silence. The provider that Jake works with, Dr. Eastman, is a kind
man who teaches Jake a lot about medicine but never gives Jake
feedback on how he is doing.
Cycle 1
Plan: Jake asks Dr. Eastman to sit in on
at least two interviews so that he can receive immediate feedback. On
any interview that Dr. Eastman doesn't sit in on, Jake will see the
patient first and report all his findings.
Do: Dr. Eastman is very busy the next
time Jake visits him, and he sits in on only one interview. However,
he has his nurse practitioner, Ms. Irvine, observe Jake for two
additional interviews. Because Dr. Eastman is so busy, Jake doesn't
have time to report his findings to him.
Check: The feedback that Dr. Eastman and
Ms. Irvine gave Jake was very different. Dr. Eastman told Jake that
he was doing a good job but that he forgot to ask a couple of
questions in the HPI. Ms. Irvine said that Jake needed to work on
asking open-ended questions and pausing to let the patient think. In
addition, she mentioned that he completely left out the social
history.
Act: Jake decides to make some changes
that will affect both his history taking and the feedback he is
receiving. He needs more feedback from both Dr. Eastman and Ms.
Irvine, in addition to other sources such as his classmates and the
doctors he works with at school.
Cycle 2
Plan: Jake decides to continue receiving
regular feedback from both Dr. Eastman and Ms. Irvine. He
specifically asks Dr. Eastman what questions he may have missed while
interviewing and what the doctor thinks of his interviewing style.
Jake also works with other medical students at mock interviewing. He
tries to find a group of four so that two can watch and critique
while Jake interviews the fourth student. Finally, DMS tests its
students' interviewing skills twice a year during observed structural
clinical encounters (OSCEs). In this process, medical students are
videotaped while they interview patients (paid actors). Jake just
went through his first OSCE a month ago. He received feedback from
the mock patient he interviewed, but he also wants feedback from some
of the physicians who run the OSCE program. He sets up a time to meet
with them to watch his video.
Do: It takes only two weeks for Jake to
receive more feedback. Dr. Eastman seems more comfortable criticizing
Jake now that he knows what he wants. Also, Jake and his fellow
classmates have a lot of fun doing the mock interviews.
Check: Jake receives a lot more feedback
from Dr. Eastman, who notes that Jake tends to rush patients and ask
closed-ended (yes or no) questions. "Take the time to let them tell
their story," Ms. Irvine tells him. In the OSCE videotape, Jake and
the physician who watched it with him notice that he needs to work on
his skills taking blood pressures, that he missed the social history,
and that he didnÌt ask any questions regarding the patient's
habits. In addition, the videotape reveals Jake's poor habit of
rushing the patient and asking closed-ended questions. In the mock
interviews with his peers, Jake notices that he is slowing down and
does a better job covering the social history aspect of the
interview.
Act: Jake decides to continue receiving
regular feedback from Dr. Eastman and Ms. Irvine. He also continues
to meet with his peers to work on his interviewing skills and receive
criticism from them. Jake works on all the weaknesses he discovers in
these learning sessions when he sees real patients in Dr. Eastman's
office.
Jake's major improvements came
from his ability to study his changes in the check phase of the PDCA
cycle. In this phase, Jake was able to recognize that Dr. Eastman and
Ms. Irvine provided different kinds of feedback. This knowledge led
him to a second PDCA cycle in which he experimented with using more
and different health care professionals to test his history-taking
performance. As Jake proceeds with each cycle, he will gain more
knowledge and continue to improve his history-taking skills.
As a first-year medical student, your role can extend far beyond just practicing your history-taking skills. You have an untainted perspective that attacks problems with a freshness that your office is probably unaccustomed to and will probably treasure. But simply throwing out ideas for change every time one pops into your head is not the way to effect change; instead, use the PDCA cycle. LetÌs see how it works in an office setting like yours.
Example 4: The Medical Student Who
Made a Difference
Tucker is a first-year medical
student who follows a preceptor in a small family practice office. At
a recent lunch break at this office, Tucker listened in as the four
physicians complained about the high volume of patients they were
referring to specialists.
What are they trying to
accomplish?
Improvement is certainly needed in this referral process.
How will they know that a
change is an improvement? The major measure that this practice is
interested in is the number and type of referrals. Another metric the
practice is concerned about is financial productivity.
What changes can they make
that will result in improvement? Tucker knew that there were opportunities for
improvement here, so he decided to apply the PDCA cycle.
Cycle 1
Plan: Tucker asked his preceptor for all
her referrals in the past six months. After stratifying the referrals
by specialty, Tucker realized that 70 percent of the patients went to
the orthopedics department at the local tertiary care center, mostly
for sprained ankles and knee trauma. He also noted that a number of
the initial calls to the family practice came when the office was
closed, on weekends and after 5 p.m. Tucker presented this
information to his preceptor, and together they realized that the
practice might benefit from a change in its delivery of orthopedic
care. Their plan was simple: have the orthopedics department at the
local hospital train the four physicians in the practice how to treat
sprained ankles and some knee trauma. Since the local hospital
physicians are on a salaried status, not fee-for-service, there is no
disincentive for this training.
Do: The family practitioners arranged
for a one-week, after-hours training session in these two areas of
high-volume injuries. They decided that they would test this change
for two months to determine whether they would be able to reduce the
number of referrals and maintain their patients' continuum of care at
the practice. They also decided to stay open until 9 p.m. every
Wednesday and from 10 a.m. to 1 p.m. every Sunday as an open clinic.
One physician, one nurse, and one administrator would staff each open
clinic.
Check: The practice is interested in the
number and type of referrals, as well as financial productivity.
After two months of implementing this change, the number of
orthopedic referrals fell by 30 percent compared with the same period
in previous years. By staying open longer, treating more patients,
and referring less, the profits at the practice were 18 percent
higher than they were during those two months in any previous year.
Further, although they had no formal metric for patient satisfaction,
all four physicians received positive feedback for the orthopedic
care they were delivering and for their new convenient open
clinic.
Act: Clearly, this change resulted in
major improvement. The physicians decided to institute this change
permanently. Because of its success, the physicians are considering
applying this technique to other specialties to which they refer
patients.
As demonstrated by this
case study, the PDCA cycle can be applied to any situation. By
employing the PDCA cycle, the family practice first carefully
assessed what needed to be changed and then implemented an effective
improvement plan. Implementing an improvement plan that is hastily
selected rarely leads to effective change. This family practice did
not fall into the trap of shooting without properly
aiming.
Further Reading
Deming, WE "The New Economics: for
industry, government, education." 1994 MIT CAES, Cambridge
Walton, M "The Deming Management Model."
1986 Perigee Books, NY, NY
"The Medical Student's Guide to Better
Patient Care" pp51-64
This is a schematic represenation of the use of the PDCA cycle in the improvement process. As each full PDCA cycle comes to completion, a new and slightly more complex project can be undertaken. This rolling over feature is integral to the continual improvement process.
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