model for improvement. “the definition of insanity is doing the same thing again and again and...

Model for Improvement

“The definition of insanity is doing the same thing again and again and expecting a different result”

Albert Einstein

Scientific Method

• Analytic in nature with the focus on the development/discovery of new knowledge

What are we trying toaccomplish?

How will we know that a change is an improvement?

What change can we make that will result in improvement?

Model for Improvement

Act Plan

Study Do

Langley, et al.

Langley et. al

PDSA Learning Cycle:

Most important part of any PDSA cycle is the Prediction as it represents current knowledge about how a process or system will behave in the future.

When predictions are compared with actual outcomes they can reveal gaps in our current understanding of why a process or system behaves the way it does

This comparison/examination generates knew knowledge about what change might work or what modification is needed

Inductive learning begins here

6

Langley et al

Scoping PDSA cycles

• Learn/Develop change ideas

• Test under multiple conditions

• Implement/make permanent

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DS

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PD

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D S

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PD

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© Improvement Science Consulting

Appropriate Scope for a PDSA Cycle

Current Situation Resistant Indifferent Ready

Low Confidence that change idea will lead to Improvement

Cost of failure large

Very Small Scale Test

Very Small Scale Test

Very Small Scale Test

Cost of failure small

Very Small Scale Test

Very Small Scale Test

Small Scale Test

High Confidence that change idea will lead to Improvement

Cost of failure large

Very Small Scale Test

Small Scale Test

Large Scale Test

Cost of failure small

Small Scale Test

Large Scale Test Implement

Staff Readiness to Make Change

Langley et. al

Final Thoughts on PDSA

• The opportunities for learning about many aspects of the change from testing are expected to be significant, including learning from failures. Some percentage of tests—perhaps 25 to 50 percent—is expected to result in no improvement, to “fail,” but to result in substantial learning nevertheless.

9

Langley et al

Let’s try it out

10

Mr Potato Head

Please decide at your table

• Who will be:–Time Keeper

–Quality Assurance Officer

–Data Analyst

PDSA Simulation

PDSA Measures

Accuracy

• 3 – All pieces on Mr. P & positioned correctly

• 2 – All pieces on Mr. P, but one or more is out of place

• 1 – One or more pieces are not on Mr. P.

Time

• Start: When time keeper says go.

• Stop: When Assembly indicates last piece is in place AND removes hand.

Plan Do Study Act

PDSA Cycle #

Level Test Cycle Aim

Test Cycle Measures/Learning Questions

Predicted Cycle Outcomes

Capture Relevant Data

Observations expected/unexpected Results

Test Cycle Learning

Test Cycle successful Yes/No

Action Taken

Alternate Pathways Uncovered

Test Cycle completed Yes/No

If No, reason

1 2

 Start with feet and work to top

 Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy

 Time = 120secAccuracy = 3                  

2                         

Plan Do Study Act

PDSA Cycle #

Level

Test Cycle Aim

Test Cycle Measures/Learning Questions

Predicted Cycle Outcomes

Capture Relevant Data

Observations expected/unexpected Results

Test Cycle Learning

Test Cycle successful Yes/No

Action Taken

Alternate Pathways Uncovered

Test Cycle completed Yes/No

If No, reason

1 2

 Start with feet and work to top

 Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy

 Time = 120secAccuracy = 3

 Time = 2.37Accuracy = 3

 Struggled to get pieces organized in order.              

2                         

Plan Do Study Act

PDSA Cycle #

Level

Test Cycle Aim

Test Cycle Measures/Learning Questions

Predicted Cycle Outcomes

Capture Relevant Data

Observations expected/unexpected Results

Test Cycle Learning

Test Cycle successful Yes/No

Action Taken

Alternate Pathways Uncovered

Test Cycle completed Yes/No

If No, reason

1 2

 Start with feet and work to top

 Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy

 Time = 120secAccuracy = 3

 Time = 2.37Accuracy = 3

 Struggled to get pieces organized in order.

 Time improved by 20 sec. Accuracy improved from 2 to 3

 Organization of parts helps time & accuracy.  Yes        

2                         

Plan Do Study Act

PDSA Cycle #

Level

Test Cycle Aim

Test Cycle Measures/Learning Questions

Predicted Cycle Outcomes

Capture Relevant Data

Observations expected/unexpected Results

Test Cycle Learning

Test Cycle successful Yes/No

Action Taken

Alternate Pathways Uncovered

Test Cycle completed Yes/No

If No, reason

1 2

 Start with feet and work to top

 Can we build Mr P. faster than the demonstrated benchmark and with perfect accuracy

 Time = 120secAccuracy = 3

 Time = 2.37Accuracy = 3

 Struggled to get pieces organized in order.

 Time improved by 20 sec. Accuracy improved from 2 to 3

 Organization of parts helps time & accuracy.  Yes

 Next test to include ordering pieces. Need to set order before test.  None  Yes  N/A

3 – All pieces on Mr P & positioned correctly

2 – All pieces on Mr P, but one or more is out of place

1 – One or more pieces are not on Mr P.

PDSA Simulation

• Accuracy• 3 – All pieces on Mr. P &

positioned correctly• 2 – All pieces on Mr. P, but one

or more is out of place• 1 – One or more pieces are not

on Mr. P.• Time

• Start: When time keeper says go.

• Stop: When Assembly indicates last piece is in place AND removes hand

Mr. P must look exactly like this

3 – All pieces on Mr P & positioned correctly

2 – All pieces on Mr P, but one or more is out of place

1 – One or more pieces are not on Mr P.