This month’s column is the second in a series of three articles written by a group from Toronto and Houston. The series imagined that a community of gastroenterologists set out to improve the adenoma detection rates of physicians in their practice. The first article described the design and launch of the project. This month, Dr. Bollegala and her colleagues explain the plan-do-study-act (PDSA) cycle of improvement within a small practice. The PDSA cycle is a fundamental component of successful quality improvement initiatives; it allows a group to systematically analyze what works and what doesn’t. The focus of this article is squarely on small community practices (still the majority of gastrointestinal practices nationally), so its relevance is high. PDSA cycles are small, narrowly focused projects that can be accomplished by all as we strive to improve our care of the patients we serve. Next month, we will learn how to embed a quality initiative within our practices so sustained improvement can be seen.
John I. Allen, MD, MBA, AGAF
Editor in Chief
Article 1 of our series focused on the emergence of the adenoma detection rate (ADR) as a quality indicator for colonoscopy-based colorectal cancer screening programs.1 A target ADR of 25% has been established by several national gastroenterology societies and serves as a focus area for those seeking to develop quality improvement (QI) initiatives aimed at reducing the interval incidence of colorectal cancer.2 In this series, you are a community-based urban general gastroenterologist interested in improving your current group ADR of 19% to the established target of 25% for each individual endoscopist within the group over a 12-month period.
This article focuses on a clinician-friendly description of the plan-do-study-act (PDSA) cycle, a key construct within the Model for Improvement framework for QI initiatives. It also describes the importance and key elements of QI data reporting, including the run chart. All core concepts will be framed within the series example of the development of an institutional QI initiative for ADR improvement.
Plan-Do-Study-Act cycle
Conventional scientific research in health care generally is based on large-scale projects, performed over long periods of time and producing aggregate data analyzed through summary statistics. QI-related research, as it relates to PDSA, in contrast, is characterized by smaller-scale projects performed over shorter periods of time, with iterative protocols to accommodate local context and therefore optimize intervention success. As such, the framework for their development, implementation, and continual modification requires a conceptual and methodologic shift.
The PDSA cycle is characterized by four key steps. The first step is to plan. This step involves addressing the following questions: 1) what are we trying to accomplish? (aim); 2) how will we know that a change is an improvement? (measure); and 3) what changes can we make that will lead to improvement? (change). Additional considerations include ensuring that the stated goal is attainable, relevant, and that the timeline is feasible. An important aspect of the plan stage is gaining an understanding for the current local context, key participants and their roles, and areas in which performance is excelling or is challenged. This understanding is critical to conceptually linking the identified problem with its proposed solution. Formulating an impact prediction allows subsequent learning and adaptation.
The second step is to do. This step involves execution of the identified plan over a specified period of time. It also involves rigorous qualitative and quantitative data collection, allowing the research team to assess change and document unexpected events. The identification of an implementation leader or champion to ensure protocol adherence, effective communication among team members, and coordinate accurate data collection can be critical for overall success.
The third step is to study. This step requires evaluating whether a change in the outcome measure has occurred, which intervention was successful, and whether an identified change is sustained over time. It also requires interpretation of change within the local context, specifically with respect to unintended consequences, unanticipated events, and the sustainability of any gains. To interpret study findings appropriately, feedback with involved process members, endoscopists, and/or other stakeholder groups may be necessary. This can be important for explaining the results of each cycle, identifying protocol modifications for future cycles, and optimizing the opportunity for success. Studying the data generated by a QI initiative requires clear and accurate data display and rules for interpretation.
The fourth step is to act. This final step allows team members to reflect on the results generated and decide whether the same intervention should be continued, modified, or changed, thereby incorporating lessons learned from previous PDSA cycles (Figure 1).3
AGA Institute
Figure 1
Despite these challenges, the PDSA framework allows for small-scale and fast-paced initiative testing that reduces patient and institutional risk while minimizing the commitment of resources.4,7 Successful cycles improve stakeholder confidence in the probability for success with larger-scale implementation.
In our series example, step 1 of the PDSA cycle, plan, can be described as follows: Aim: increase the ADR of all group endoscopists to 25% over a 12-month period. Measure: Outcome: the proportion of endoscopists at your institution with an ADR greater than 25%; process – withdrawal time; balancing – staff satisfaction, patient satisfaction, and procedure time. Change: Successive cycles will institute the following: audible timers to ensure adequate withdrawal time, publication of an endoscopist-specific composite score, and training to improve inspection technique.8
In step 2 of the PDSA cycle, do, a physician member of the gastroenterology division incorporates QI into their job description and leads a change team charged with PDSA cycle 1. An administrative assistant calculates the endoscopist-specific ADRs for that month. Documentation of related events for this cycle such as unexpected physician absence, delays in polyp histology reporting, and so forth, is performed.
In step 3 of the PDSA cycle, study, the data generated will be represented on a run chart plotting the proportion of endoscopists with an ADR greater than 25% on the y-axis, and time (in monthly intervals) on the x-axis. This will be described in further detail in a later section.
In the final step of the PDSA cycle, act, continuation and modification of the tested changes can be represented as follows.
