Performing a Test of Change using the Model for Improvement

In the previous newsletter, we discussed how to engage with stakeholders, including both patients and healthcare staff, conduct a baseline assessment, and select the appropriate quality improvement (QI) methodology. This issue will focus on how to perform a test of change using the practical components of the Model for Improvement.

The Model for Improvement, also known as the PDSA (Plan-Do-Study-Act) methodology, is a powerful tool for implementing and testing changes across various sectors, particularly in healthcare and engineering. It is among the improvement tools discussed in the context of Quality Improvement Models. The Model for Improvement employs a cyclical process that offers a structured approach to problem-solving and continuous improvement by allowing teams to test small-scale changes in a controlled setting before wider implementation. The Model for Improvement comprises two main components: three fundamental questions and the PDSA cycle. By addressing these questions and adhering to the PDSA cycle, organisations can ensure that changes achieve the desired outcomes, mitigate risks, and cultivate a culture of continuous improvement.

The three key questions that guide this process are: What are we trying to accomplish? How will we know that a change is an improvement? What change can we make that will result in an improvement?

What are we trying to accomplish?

To answer this question, it is essential to establish a SMART aim statement. An effective aim must be Specific, Measurable, Attainable, Relevant, and Time-bound (SMART). For further guidance on setting SMART aims, please refer to my article on Setting SMART Aims. For example, a SMART aim for reducing hospital-acquired infections could be: "To reduce the incidence of surgical site infections in the paediatric surgery theatre by 30% by December 31, 2025." This aim is Specific, as it clearly defines the focus area (surgical site infections in the paediatric surgery theatre); Measurable, as it specifies a 30% reduction from the baseline; Attainable, as a 30% reduction is considered achievable; Relevant, as reducing surgical site infections aligns with the organisation's goal of promoting patient safety; and Time-bound, with a deadline set for December 31, 2025. For more insights on selecting focus areas, refer to my articles Identifying Areas for Improvement and Impact of Quality Improvement on Patient Safety.

How will we know that a change is an improvement?

This question pertains to the use of measures and data in healthcare improvement. To accurately assess the impact of changes and move beyond subjective perceptions of improvement, it is vital for improvement practitioners to utilise metrics. These metrics could range from simple tools like tally charts for data collection to more complex methods such as Excel sheets and KPI trackers on dashboards. Regardless of the complexity, every improvement project must be measured to validate its outcomes; otherwise, the effort is rendered ineffective. For more comprehensive guidance on measures and the importance of data, please refer to my articles Understanding Measures and The Importance of Data in Healthcare Improvement.

What change can we make that will result in an improvement?

This is often the most frequently asked question in the context of improvement within healthcare organisations, as the answer is usually evident: change ideas. Individuals involved in a project typically understand what needs to change and often have initial ideas for potential tests. However, despite the apparent simplicity of this question, determining the right change ideas can be complex. These ideas can range from straightforward, low-cost solutions, such as implementing checklists to enhance task completion or improve medication administration, to more elaborate, cost-intensive interventions, such as introducing a new electronic IT system to reduce medication errors, which may require significant financial investment. Whatever the change ideas are, several factors must be considered. These ideas should be agreed upon by a significant majority of stakeholders, be easy to understand and implement, be largely reversible, and have measurable effects that can be directly attributed to the specific change. 

In the next newsletter, we will delve into how to use the PDSA cycle to test a change idea, as well as how organisations can effectively trial new concepts, minimise risks, and promote continuous improvement.