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• Cindy Lewis, MSN, RN

We are all aware that quality health care is a high priority. In November 2001, the Department of Health and Human Services announced the Quality Initiative to ensure quality health care for all Americans through accountability and public disclosure. The Initiative is intended to empower consumers with quality of care information to make more informed decisions about their heath care and to encourage providers and clinicians to improve health care. In addition, the Centers for Medicare and Medicaid Services have been working in conjunction with the Hospital Quality Alliance, a public-private collaboration, on hospital measurement and reporting. Twenty hospital quality measures are endorsed for the following conditions: acute myocardial infarction, heart failure, pneumonia, and surgical infection prevention.¹

To be effective in improving health care outcomes, a truly collaborative approach is required. Nurses play an integral role in communicating, expanding knowledge and resources, and partnering with our physicians and other disciplines to achieve greater and immediate improvements in the quality of care we provide. The changes developed need to be approached in a strategic and coherent fashion. It requires shared vision to bring about improvements that are beneficial to our patients. It also requires a team approach to develop guideline implementation action plans.

The Plan Do Study Act (PDSA) cycle is a process model for quality improvement that has been used extensively in the health care field, especially for working with clinical practice guidelines.² It can provide a shorthand way to test a change: by planning it, trying it, observing the results, and acting on what is learned. This provides a scientific method for action-oriented learning. As each of you carry out action plans in your practice settings, treat each action item as material for a PDSA cycle. Although the cycle may appear more readily applicable to practice change actions, educational interventions can also be improved by testing them through PDSA cycles.

The Plan stage involves clearly defining the tasks or activities that will be undertaken to achieve your objective. Identify the people who will be involved, and define the time period and location for the practice change. State what you think will happen as a result of your planned actions. You will need to compare what actually happened with what you thought would happen to identify “gaps” in your planning. You will need to identify what data to collect to determine the outcome of change and demonstrate improvement.

During the Do stage, carry out a small-scale test of the planned action. You can test almost any type of action, ranging from small (eg, a training class) to large (eg, a redesign of patient flow procedures). During this test, you observe and document any problems or unexpected events and collect data that will help you determine the impact of your test. During the Study stage, analyze the data you have collected and the observations you have made. Compare what you have found with what you expected to happen, and summarize what you learned from testing the action item. During the Act stage, use what you have learned to improve your planned action. At this point you may decide either to test the change again with the modifications or to proceed to full-scale implementation.

PDSA cycles consist of small-scale tests of planned actions, followed by assessment and improvement of the initial plan. The PDSA cycle is an effective way to implement change. Testing changes on a small scale improves staff buy-in and focus attention on changing clinical processes. Some actions may even require more than one PDSA cycle. Whether you are challenged with implementing new changes, policies, standards, or new initiatives, the PDSA cycle can provide the template to test and implement a change.

We are all under increased pressure to improve patient safety and care, and contribute to improved overall quality of care. Share with us your practice changes. Share with us the processes or models you have used to implement new guidelines. There is such power in sharing our knowledge and our stories. We can learn from each other’s challenges and successes. I hope to hear from you soon!

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References 

1. http://www.CMShhs.gov/quality/hospital
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2. Marino J , Haggerty Raines A . Quality across the curriculum (integrating quality tools and PDSA with standards) . Milwaukee, WI: American Society for Quality (ASQ), Quality Press; 2004;
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