Description



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.



Use



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.



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.



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.





Personal Improvement



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.



What is she trying to accomplish? Isabel knows that she needs to improve her studying skills in order to gain a better understanding of the material.

How will she know that a change is an improvement? Isabel considers the most important measure of her study skills to be her exam grades. However, she does not want to risk another exam period just to find out that her skills are still not good. She decides that a better way to measure improvement is by taking old exams.

What changes can she make that will result in improvement? Isabel thinks that she has spent too little time studying. She feels that the best way to improve her study skills is by putting in more hours.

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.





Improving Patient Compliance in Personal Health Maintenance



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.



What is she trying to accomplish? Mrs T. and her doctor are trying to find and implement a viable exercise regimen for her. The goal is to design an exercise schedule that the patient can maintain despite traveling four days a week on business.

How will she know that a change is an improvement? Improvement will be measured by how frequently she exercises and for how long, and whether her blood pressure decreases.

What changes can she make that will result in improvement? The doctor and patient need to design a plan that she enjoys as well as one that she can (and will) follow, even when she is traveling.

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.









Student Section: Improving Your History-Taking Skills



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.



What is he trying to accomplish? Jake would like to improve his history-taking skills.

How will he know that a change is an improvement? Jake knows that he needs more information concerning his history-taking skills. The only way he can get that information is through feedback from others in the medical field. He decides that the most important measure of his performance should come from Dr. Eastman.

What changes can he make that will result in improvement? Jake is unsure how to answer this question. He feels confident in his ability to take a patient history. The only weakness he feels is a lack of questions to ask.

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.





Clinician Section: Improving Your Office



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







The Ramp of Improvement



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.