Welcome to this section on the model for improvement. I'm excited that you've joined me. I'm Melody Malone, Quality Improvement Consultant with TMF Health Quality Institute. The model for improvement is a message to adapt, implement, and spread change through something we call the PDSA, the Plan, Do, Study, Act Cycle. This will sound very familiar to clinicians in the audience as we do this with our clinical process. We fully assess the resident. In Quality Improvement, we call that root cause analysis. We identify their issues or problems sort of working our clinical diagnosis. That would be our opportunist for change. And then we develop a plan, implement the plan and evaluate the plan for effectiveness. So, this is going to sound familiar but let's walk through it together. And as we begin working through the model for improvement, we use data in our quality improvement, but let us remember that there are many people that could've been hurt through our clinical errors and errors in our business practices. So even though we speak about data a lot, every piece of data may actually have hurt a human being. Every resident matters, every staff member matters, every guest and visitor matters. If you've already reviewed the Root Cause Analysis section, then good for you. But don't forget the human factors and the just culture sessions as well. And you will know that it takes a team to discover the real reason or set of circumstances that allow the event you're wanting to improve to even happen. Once you have the root cause analysis, that's the most fundamental reason a problem occurred, you are now ready to move on to identifying the one test of change that you may want to make in your process. This is the assessment component in the clinical process. When we move on to the model for improvement, I want to welcome you to this. By answering these three questions and working through the plan, do, study, act cycle or the PDSA, this is a systematic method for going through quality improvement in a thoughtful way. It starts with three questions. And once we'd asked and answered the three, we're ready to move on to more work. So, let's start by reviewing the three questions. First question, what are we trying to accomplish? Have you ever tried to take a trip without asking where you're going? Well, that's what we're trying to ask in our quality improvement. So, in our root cause analysis, we identified a problem. So that's what we're going to put here. So, we're going to come up with our problem statement and maybe even a goal statement because that way, we have an idea of where we want to go. Our goal statement should be where we want to head with regard to our specific population, our numerical goal, and a description of our spread strategy. We'll be talking about spread in another session. This goal statement will help guide your team and keep you on track. So for example, a goal statement might be we want to decrease falls on unit one within 30 days and spread this change throughout each unit within a quarter. The team that develops this goal statement is pretty clear and they know exactly what their goal is, who they're going to work with, and what the measurable outcomes they hope to achieve and spread. Our second question is what change--how would we know that a change is an improvement versus a setback because are all changes an improvement? No, not so much. We've all experienced this scenario, right? We've put a change in place but it didn't work. Having a failure on a small scale is much less damaging than having one on a big scale. So, if you're going to work a quality improvement project, then we got to work on the systematic changes that we're going to make but we don't want to add anything that's going to increase the risk for our residents and our staff. So, how would we know that it changes an improvement? Well, we're going to be tracking data and we're going to be understanding our data so that we could know our measurement. So every time we do a plan, do, study, act cycle, we want to check that against our goal statement and ensure that we have our right data that we're measuring whether it's daily, weekly, or monthly and whatever our spread measure might be. The third question is what change can we make that will result in an improvement? Well, this is really what you've identified in your root cause analysis. You've done your root cause analysis, you've considered just human factors. This is your idea. It doesn't have to be some big rocket science thing. And you may pull ideas for changes from variety of ideas. There might be a change package that you want to look at. There might be satisfaction, survey ideas, your brain storming efforts, your root cause analysis. You may have come up with opportunities for test of change, their variety of effort and you want to embrace all in your quality improvement efforts. So don't forget the residents, the staff, as well as the long-term community at large, long-term care community at large that may have other resources in standard that you could work with. As outcomes improve and as you move closer to quality improvement, the lives of your residents and your staff will improve. They work all closely together. So this is a great opportunity to include everybody. So now that we've figured out our three questions, we have to move to the plan, do, study, act cycle. This is our way that helps us test and adapt change, implement an improvement on a small scale, then spread the improvement throughout your organization. There are some details in the plan, do, study, act cycle. And I want to talk about each areas. So within the plan, you're going to evaluate that plan by giving you an objective, some questions or predictions, what do we think is going to happen when we carry out the plan and then the plan it out. Who's going to do what and what are we going to get it done by. Then we go out and actually do the plan. Don't get stuck in the planning mode. You can't plan and--and for every possible outcome. So don't get stuck just in planning. Make sure you get out there and actually work your plan and collect your data, but we've got to make sure we're always collecting the right data. And then in your study, you're going to go and look at your hypothesis again. Did what we think happened, really happen? And then in your act phase, you're going to decide. What changes need to be made? Are we going to adapt to this test of change, it works great so we're going to adapt it and it worked okay but we want to abandon it a little bit. I mean, adapt it a little bit and maybe make a few little tweaks or changes or maybe we need to abandon the idea altogether. And if we abandon the idea, let's not throw out the lessons learned. We want to ensure that we learned from those lessons, even a failure has lesson. But we want to document why it failed and then move that learning forward. This helps us build our PDSA skills. Celebrate those failures and gold mine them in your quality improvement efforts. Share with your team and in the facility and with those at the QIO. It's a great learning that happens in plan, do, study, act cycle. We call this PDSA cycle a rapid cycle or small scale cycle. And the reason is you want to do something on a small scale. So here is a great idea. So, our purpose is to increase protein in the resident's diet. So our plan is to add protein powder to all dessert recipes. But in order to do that, in order to work our plans, we're going to have to collect data, we've got to educate staff, we got to experiment with recipes and of course we have to purchase protein better. So, this might be a great plan, do, study, act protein that's working on increasing protein in the resident's diet. And you know, you could even include the residents by letting them help sample the desserts that you're going to experimenting recipes. I'm sure they could enjoy that. So, you want to try it even if you think the solution might fail 'cause we want to learn from every thing. Remember, no idea is too crazy to trial. Once you move on, we actually do our test of change then we study those results. And when we study those results, we decide. Are we going to adopt, adapt, or abandon that test of change? Remember these are small test of change. So we may be trialing this just with one resident or one staff member. Then we're going to trial it with the larger group after we work through the study and the act phase. Now, we've taken the model for improvement and we've pushed it out onto a piece of paper called the worksheet for testing change. So, when you're learning organization, we trap our quality improvement efforts. This worksheet for testing change is one way of documenting our efforts and our learning in quality improvement. The only thing not documented on this tool is the root cause analysis. That would be a companion piece to this. But, as you work through your worksheet for testing change, don't make this harder than it has to be. You can always just flip it over and update it for more tests of change. And why did we test? Well, we test to answer question. We want to know how all of this is going to work 'cause ideas are great but it's the how that's really on trial. So, will the change result in an improvement such as a [inaudible] to prevention idea might be to put cushions in all wheelchairs that caught--but what we found is this caused an increase in fall. But why? 'Cause the chair is no longer for the resident. So they learned that rehab needed to be involved for proper fit, better cushion selection, perhaps the different programs such as wheelchair push-ups or walking program. And they also learned they bought too many cushions that they couldn't use and not enough for the ones that they did need. So, depending upon how all of these works as you go through your quality improvement process and your plan, do, study, act cycle and you will learn much. You'll had much learning but be sure to share any failing with others and remember the how is what's up for trial. This will let you build a business case for your quality improvement. So, here's your next step. Start small. Determine what your first test of change is and go do it. And what can you do by it tomorrow? We're just willing to test with one. So how fast that can you pull together a plan, do, study, act cycle and get it done? And then learn from that and then the next day, do two or three or more. Try that on two or three more people and so on, so you could build your learning. The secret to being successful in quality improvement is a good root cause analysis but being quickly getting to your test of change and work you through the model for improvement. If you need any help, feel free to contact us. We'll be happy to try and help you out. Good luck.