Strategies for local quality improvement.

Quality Improvement Using Plan-Do-Study-Act

  • Laura Lee Hall, PhD American College of Physicians
AMA in partnership with
CME Credits: 0.5
Quality Improvement Using Plan-Do-Study-Act

How will this module help me successfully make changes in my practice?

  1. Four STEPS to quality improvement using the PDSA method
  2. Answers to common questions about this method
  3. Downloadable toolkit with samples and templates

CME accreditation information 

Increasing administrative responsibilities—due to regulatory pressures and evolving payment and care delivery models—reduce the amount of time physicians spend delivering direct patient care. A structured approach to quality improvement can help practices successfully implement the change they want to make. Plan-Do-Study-Act (PDSA) cycles provide a straightforward approach to implementing a change in practices and continuing to make improvements. This approach works on many changes from improving a patient care process to executing a new workflow.

Plan-Do-Study-Act
Release Date: March 2016
End Date: March 2019

Objectives

At the end of this activity, participants will be able to:

  1. Select a quality improvement initiative
  2. Implement an improvement initiative
  3. Evaluate the success of the improvement initiative
  4. Adjust the improvement initiative based on the results

Target Audience

This activity is designed to meet the educational needs of practicing physicians.

Statement of Need

Engaging practices in quality improvement is “essential to achieving the triple aim of improving the health of the population, enhancing patient experiences and outcomes, and reducing the per capita cost of care, and to improving provider experience.” (AHRQ Quality Improvement in Primary Care) Quality improvement initiatives are also essential for setting priorities for areas to improve: if there is no specific plan for measurement, there can be no improvement. This module will guide practices in planning these measurement cycles for true improvements in their practices.

Statement of Competency

This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Accreditation Statement

The American Medical Association is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.

Credit Designation Statement

The American Medical Association designates this enduring material for a maximum of 0.5 AMA PRA Category 1 Credit™. Physicians should claim only the credit commensurate with the extent of their participation in the activity.

Claiming Your CME Credit

To claim AMA PRA Category 1 Credit™, you must 1) view the module content in its entirety, 2) successfully complete the quiz answering 4 out of 5 questions correctly and 3) complete the evaluation.

Planning Committee

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA
  • Rita LePard, CME Program Committee, AMA
  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA
  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

Author(s)

  • Laura Lee Hall, PhD, Director, Center for Quality and Office of Grants, American College of Physicians

Faculty

  • Marie Brown, MD, FACP, Associate Professor, Rush University Medical Center
  • Bernard M. Rosof, MD, MACP, Chief Executive Officer, Quality in Healthcare Advisory Group
  • Doron Schneider, MD, FACP, Chief Patient Safety and Quality Officer, Abington Health
  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA
  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA
  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

About the Professional Satisfaction, Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement

The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

Media Types

This activity is available to learners through Internet and Print.

Hardware/software Requirements

Adobe Flash 9.0.115 or above
Audio speakers or headphones
Screen resolution of 800X600 or higher
MS Internet Explorer 8.0 or higher, Firefox, Opera, Safari, etc.
Adobe Reader 5.0 or higher

References

  1. The W. Edwards Deming Institute. The Plan-Do-Study-Act (PDSA) Cycle. https://www.deming.org/theman/theories/pdsacycle. Accessed November 30, 2015.
  2. American Medical Association. Small changes, big impact: creating thriving physician practices [video]. https://www.youtube.com/watch?v=XDNDq76sMfw. Updated December 11, 2015. Accessed January 4, 2016.
  3. Institute for Healthcare Improvement. Science of improvement: how to improve. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx. Accessed November 30, 2015.
  4. Institute for Healthcare Improvement. Science of improvement: forming the team. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx. Accessed November 30, 2015.
  5. Institute for Healthcare Improvement. Science of improvement: testing changes. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed November 30, 2015.
  6. Institute for Healthcare Improvement. Run chart tool. http://www.ihi.org/resources/Pages/Tools/RunChart.aspx. Accessed November 30, 2015.
  7. Agency for Healthcare Research and Quality. Workflow assessment for health IT toolkit. https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit. Accessed November 30, 2015.
  8. American College of Physicians Immunization Portal. Practice improvement tool. http://static.acponline.org.s3.amazonaws.com/media/immunization/acp_adult_immunization_section1.pdf. Updated August 2011. Accessed November 30, 2015.
  9. National Diabetes Education Program. Improve practice quality. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-practice-quality/index.aspx. Accessed November 30, 2015.
  10. Centers for Medicare & Medicaid Services. The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs): delivery system reform, Medicare payment reform, & the MACRA. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed November 30, 2015.
  11. American College of Cardiology. Quality programs. http://www.acc.org/tools-and-practice-support/quality-programs?w_nav=FN. Accessed November 30, 2015.
  12. American Society of Clinical Oncology (ASCO) Institute for Quality (iQ). http://www.instituteforquality.org. Accessed November 30, 2015.
  13. Agency for Healthcare Research and Quality. Quality improvement in primary care. http://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html. Updated June 2014. Accessed November 30, 2015.
  14. Agency for Healthcare Research and Quality. Building quality improvement capacity in primary care. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/capacity-building/pcmhqi2.html. Updated April 2013. Accessed November 30, 2015.
  15. DuBosar R. Chronic pain program provides model for small practices. ACP Internist. http://www.acpinternist.org/archives/2015/11/success.htm. November/December 2015 issue. Accessed November 30, 2015.
  16. American College of Physicians. ACP Practice Advisor: Improving clinical care. https://www.practiceadvisor.org/Modules/improving-clinical-care. Accessed November 30, 2015.

  17. National Committee for Quality Assurance. Patient-centered medical home recognition. http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed November 30, 2015.
  18. National Diabetes Education Program. Examples of PDSA cycles for quality improvement activities to address elements of the chronic care model. http://ndep.nih.gov/media/Table_1-Examples_of_PDSA_Cycles_for_Quality_Improvment_Activities.pdf. Accessed November 30, 2015.
  19. Stratis Health. Goal setting. https://www.stratishealth.org/expertise/index.html. Accessed February 1, 2016.

Introduction

Quality improvement using Plan-Do-Study-Act

PDSA provides a straightforward, iterative approach to quality improvement in your practice. The framework is easy to adopt regardless of practice size or resources. As ongoing quality improvement becomes part of your practice’s culture, your team will continue to find opportunities to make existing and “improved” processes better.

Intensive Primary introduction
Plan-do-study-Act

Institute for Healthcare Improvement. Science of Improvement: How to Improve. 2016.

Four STEPS to use PDSA

  1. Plan: develop the initiative
  2. Do: implement your plan
  3. Study: check the results
  4. Act: make further improvements
  1. 1

    Plan: develop the initiative

    Select your improvement initiative

    Involve your team in selecting the quality improvement initiative. Most good ideas for improvement come from the people doing the work, so consider the perspectives of the clinical team members as well as the clerical staff. Patient surveys can also be used to identify areas for improvement.

    To identify areas for improvement, consider asking these questions:

    • Where does your practice need to improve patient care?
    • Where is your practice less efficient than it should be?
      • Staff may be able to identify bottlenecks in the workflow. Prioritize those areas that you have some control over and that the team thinks will be most impactful. Use a “go and see” approach of respectfully observing the work and then asking “why?” A team member can help identify key areas for workflow improvement within the bottleneck.
    • What about the day is most frustrating for your team and/or patients?
      • Ask patients and staff. This will generate a list from which you can prioritize areas for improvement.

    Reference the module on selecting sustainable change initiatives for more guidance on choosing areas for improvement in your practice.

  1. Identify your PDSA team

    The people doing the work should be the ones planning and guiding the process improvement initiative. Your PDSA team should thus include representatives from all areas of your practice that will be affected by the improvement. Set expectations for the time commitment to the PDSA team early in the cycle and plan to continue working together through implementation. You may also choose to have a core quality improvement team that rotates in specialized representatives based on the initiative. Most teams work best with a maximum of 10 people. Practice members who are not on your PDSA team should receive regular updates about the initiative’s progress.

  • What is an example of a PDSA team?

    Your team could include physicians, practice leadership, nurses, medical assistants, receptionists, potentially patients, IT and coding and/or compliance staff. For example, if your practice’s first PDSA project is to increase rates of adult pneumococcal vaccinations, your team may consist of the following representatives:

    • A physician champion or leader can provide clinical expertise and secure support from providers as well as practice and/or system leadership.
    • The front desk lead can distribute information about vaccines to appropriate patients upon check-in or before their appointments through email or a patient portal.
    • A practice manager or supervisor can work directly with the electronic health record (EHR) or IT representative to develop a daily report of patients over the age of 65 who do not have a documented pneumococcal vaccination. The practice manager could also serve as the project manager and administrative lead for the initiative.
    • A nurse or medical assistant can offer insight about current workflows and the most effective way to reshape the practice’s current workflow to reflect the new process. He or she will likely be the one administering the vaccine, so his or her input is particularly important.
    • An IT representative can program a clinical decision support reminder to administer and record vaccinations.
    Project management 101 Download See all downloadable tools
  • Why is leadership support important?

    Keeping your leaders informed will help you gain their support and could help your team obtain the resources needed to make the desired change. For larger-scale initiatives, senior-level support is essential. Communicate with leaders about the potential for improved performance measures, workflow efficiencies and/or cost savings. See the Starting Lean module for more information about identifying a champion for your quality improvement work.

  • How can I include patients in my practice’s PDSA effort?

    It is important to design care with patients, instead of designing care for patients. Towards this end, your practice could include one or two trusted patients on the quality improvement team. If your practice does not use patient advisors regularly, start with a simple survey to find out what patients value in the process that you are focused on improving.

  1. Develop your plan

    Your quality improvement team should work together to develop a plan. Using the framework of Lean – the plan is an experiment that will help you identify what you do not yet know about the work. A Lean A3 worksheet is a useful tool to help guide this plan. In addition, the following questions can help you formulate your plan:

    • What does my practice want to accomplish?
    • Why is this a priority? (Of all the possible areas for improvement, why is my practice focused on this one in particular?)
    • What current process is my practice changing?
    • What does the new process look like?
    • How will the new process become hardwired into the practice?
    • Who will enact the changes?
    • When will the changes be made?
    • Where will the changes take place?
    • What team training and preparation are required?
    • Will patients be affected? How? Which patients will be affected?
    • What results do you expect?
    • How will you measure the impact of the changes? What process and outcome measures will you use?
    • How and when will you inform the team about progress?
    ACP Quality Connect: PDSA planning worksheet Download See all downloadable tools
  1. 2

    Do: implement your plan

    With a committed team and a specific plan, you are ready to implement your quality improvement initiative. Communicate with the team about the new process to keep your practice on track, and share any inspiring stories to keep the team excited about the change. Conduct regular audits to ensure the new process is hardwired into the practice by the team. Discuss adoption of the new process regularly at huddles and meetings.

    My practice benefited from making changes, especially in team-based care. I have felt empowered through education and have been able to provide better care through better staff engagement that involves everyone in practice improvement.

    Brenda Vozza-Zeid, MD, FACP; Henderson, TX
  • What is the best approach to rolling out the change in my practice?

    Start small by piloting the improvement with one physician or in one pod. This can help the initiative gain traction, and it can help the PDSA team and pilot team work together to successfully implement the new process. Team leaders can communicate with the rest of the practice and practice leadership about the initiative’s progress and promote its importance.

  • Are there any support networks that can help my practice improve?

    Organizations that provide support to practices implementing quality improvement initiatives include:

    • Area Health Education Centers (AHECs)
    • Health Information Technology Regional extension centers (RECs)
    • Quality Improvement Organizations (QIOs)
    • Quality Innovation Network QIOs (QIN-QIOs)
    • Practice-based Research Networks (PBRNs)
    • Local or regional Practice Transformation Networks (PTNs)
  1. 3

    Study: check the results

    This step may also be referred to as “Check.” Use the process or outcome measures the PDSA team chose during the planning phase to evaluate the success of the process change. A classic technique to visualize changes over time is a run chart, which can be displayed in a team area or shared regularly at meetings.

    At this stage of the PDSA cycle, your team can review the results of the process change implementation. Compare your actual results to your expected results (as well as to previous outcomes or process measures, if available), and consider the factors that might have contributed to the findings. You may discover that your team has been very successful or that you are not seeing the improvement you anticipated. You can work together with your team to identify why the observed results were achieved.

    Simplified practice assessment Download See all downloadable tools
    ACP quality connect: setting your QI goals worksheet Download See all downloadable tools
    Robert Dobbin Chow, MD, MBA, MACP; Baltimore, MD

    I thought I had a good handle on managing my diabetic patients but I learned about facilitating good decision-making by my patients, coaching behavioral changes and gaining insight into patient compliance. I also learned about how to engage my office staff into optimizing OUR care of OUR diabetic patients.

    Robert Dobbin Chow, MD, MBA, MACP; Baltimore, MD
  • What are some examples of process and outcome measures that we can monitor?

    Process measures assess the actions undertaken by the clinical team. Examples include:

    • Percentage of patients with diabetes who have a current A1c documented
    • Percentage of patients who have their blood pressure checked at their visit
    • Percentage of patients who have pre-visit labs obtained

    Outcome measures assess results. Examples include:

    • Percentage of patients who have an A1c less than 7.0
    • Percentage of patients with blood pressure at goal
    • Patient, physician and team satisfaction ratings
  1. 4

    Act: make further improvements

    This phase may also be referred to as “Adjust.” During this final stage of the PDSA cycle, your team can take the following courses of action:

    Action Rationale
    Restart the cycle at the planning phase The plan is not achieving the desired results. Based on your analysis, define failures in the plan or execution and correct them.
    The plan is meeting or surpassing the desired results, and the team sees opportunity for even better outcomes. Based on your analysis, refine the current process in the next planning phase. Look for other areas in your practice to expand your successful improvement.
    Discontinue the plan The plan did not work or is better suited for another time or environment. Go back to the planning phase to overhaul the existing plan or develop a new one.

    AMA. Practice transformation series: Plan-Do-Study-Act. 2016.

    The PDSA cycle is meant to be continuous; even your best processes can be improved and become more consistent. You can further refine your processes by repeating the cycle.

  • What are some real-world examples of PDSA analyses and follow-up actions?

    The table below provides some examples of analyses and follow-up actions from real practices.

    Table 1. PDSA examples

    Plan Do Study/Act
    Quality improvement goal Identified area of improvement Process change to be implemented Process/outcomes measured
    Increase removal of shoes and socks of patients with diabetes upon rooming Lack of consistency in removal of shoes and socks, resulting in low percentage of foot exam completion. Signage for patients, updated checklists and training for staff
    1. Number of foot exams completed
    2. Increased percentage of patients with foot exams
    Increase documented foot exams in the EHR Different members of the team document foot exams in different places in the EHR, giving the appearance that the exams are not being completed in a consistent manner.
    1. Program the EHR to support consistent entry of foot exam documentation
    2. Train staff on data entry
    1. Number of staff trained
    2. Increased percent of foot exam documentation completed correctly
    Decrease amount of physician time spent on documentation after clinic hours Physicians are documenting many elements of the visit that could be completed by MAs or nurses.
    1. Share responsibilities during the patient rooming process
    2. Train MAs or nurses to document the patient visit
    1. Number of MA or nurses trained
    2. Decrease in after-hours documentation time
    Increase depression screening for patients with chronic pain and/or substance abuse Patient surveys revealed that they felt uncomfortable completing a depression assessment in the waiting room.
    1. Conduct the screening in the exam room prior to being seen by the physician
    2. Train the rooming staff to conduct the PHQ-2 and PHQ-9 as appropriate
    1. Percent of screening completed in the exam room vs. waiting room
    2. Improvement in patient feedback about screening process
    Increase pneumococcal immunization among older patients A consistent process for identifying appropriate patients for pneumococcal vaccine does not exist. Surveys revealed that some patients seem concerned about receiving vaccines.
    1. Work with EHR vendor to build a flag for appropriate immunizations based on clinical guidelines
    2. Implement a pre-visit planning process to anticipate immunization and screening needs for all patients
    3. Educate the clinical team to communicate more effectively about the need for the immunization of appropriate patients
    1. Correct vs. incorrect identification of patients in EHR
    2. Number of patients identified during pre-visit planning
    3. Increased number of pneumococcal immunizations received by older patients

    AMA. Practice transformation series: Plan-Do-Study-Act. 2016

  • What methods should I use to communicate the results of the PDSA cycle?

    Your team, stakeholders and patients will be eager to learn more about your successes. Write up a brief summary of the quality improvement initiative and its results. Present a summary of the report during a lunch time meeting and celebrate your successes. Post a summary of the effort, with photos, on a bulletin board in a common area. Consider making a data wall or dashboard that tracks every initiative and displays practice goals. Continue to prominently display regular updates of run charts. This kind of positive reinforcement through communication and recognition can drive greater teamwork and continued quality improvement in your practice.

  • How should I communicate the results to patients?

    Patients and their caregivers can be an integral part of your quality improvement efforts. Surveys that gather outcomes data can help you monitor the patient experience in your practice. Summarize your results and report them to patient advisory groups, through your patient portal or by email.

Start small

Try using the PDSA framework on a simple initiative first so you can gain familiarity and comfort with the methodology. For example, if you want to increase rates of flu vaccinations in your practice, use PDSA to develop and implement a communications strategy during the upcoming flu season. Take what you learn to make improvements to your approach during next year's flu season.

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Use other analysis tools to approach improvement

This module provides the framework for making local changes in your practice. If you are taking on a larger quality improvement effort, try these tools:

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Set SMART goals for your PDSA quality improvement initiative

Help your team stay focused and efficient through impactful goal setting. For example, one practice goal may be to increase depression screening among patients with a diagnosed substance use disorder. Using the SMART approach, your goal would look like this:

  • Specific: Your practice will increase depression screening from 20 to 50 percent of patients with diagnosed substance use disorders.
  • Measurable: You will use manual or electronic chart audits to document depression screenings.
  • Achievable: You've set a reasonable goal of 50 percent rather than 100 percent. You want to set an attainable goal; the bar can always be raised if your change is successful.
  • Relevant: There is a clear gap in care because only 20 percent of your target population is being screened for depression.
  • Time-bound: The goal will be achieved over the next three months. A reassessment (the "study" step of PDSA) will occur three months from now.
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Conclusion

Any practice team can accomplish quality improvement if they use straightforward, small steps. Foster your internal capabilities and expertise to develop more reliable systems to improve care. With careful thought given to each aspect of the PDSA cycle, ongoing communication between team members, practice staff and patients, and careful attention to metrics, your practice can successfully reach its goals.

Intensive primary care conclusion

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References

  1. The W. Edwards Deming Institute. The Plan-Do-Study-Act (PDSA) Cycle. https://www.deming.org/theman/theories/pdsacycle. Accessed November 30, 2015.
  2. American Medical Association. Small changes, big impact: creating thriving physician practices [video]. https://www.youtube.com/watch?v=XDNDq76sMfw. Updated December 11, 2015. Accessed January 4, 2016.
  3. Institute for Healthcare Improvement. Science of improvement: how to improve. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx. Accessed November 30, 2015.
  4. Institute for Healthcare Improvement. Science of improvement: forming the team. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx. Accessed November 30, 2015.
  5. Institute for Healthcare Improvement. Science of improvement: testing changes. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed November 30, 2015.
  6. Institute for Healthcare Improvement. Run chart tool. http://www.ihi.org/resources/Pages/Tools/RunChart.aspx. Accessed November 30, 2015.
  7. Agency for Healthcare Research and Quality. Workflow assessment for health IT toolkit. https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit. Accessed November 30, 2015.
  8. American College of Physicians Immunization Portal. Practice improvement tool. http://static.acponline.org.s3.amazonaws.com/media/immunization/acp_adult_immunization_section1.pdf. Updated August 2011. Accessed November 30, 2015.
  9. National Diabetes Education Program. Improve practice quality. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-practice-quality/index.aspx. Accessed November 30, 2015.
  10. Centers for Medicare & Medicaid Services. The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs): delivery system reform, Medicare payment reform, & the MACRA. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed November 30, 2015.
  11. American College of Cardiology. Quality programs. http://www.acc.org/tools-and-practice-support/quality-programs?w_nav=FN. Accessed November 30, 2015.
  12. American Society of Clinical Oncology (ASCO) Institute for Quality (iQ). http://www.instituteforquality.org. Accessed November 30, 2015.
  13. Agency for Healthcare Research and Quality. Quality improvement in primary care. http://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html. Updated June 2014. Accessed November 30, 2015.
  14. Agency for Healthcare Research and Quality. Building quality improvement capacity in primary care. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/capacity-building/pcmhqi2.html. Updated April 2013. Accessed November 30, 2015.
  15. DuBosar R. Chronic pain program provides model for small practices. ACP Internist. http://www.acpinternist.org/archives/2015/11/success.htm. November/December 2015 issue. Accessed November 30, 2015.
  16. American College of Physicians. ACP Practice Advisor: Improving clinical care. https://www.practiceadvisor.org/Modules/improving-clinical-care. Accessed November 30, 2015.
  17. National Committee for Quality Assurance. Patient-centered medical home recognition. http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed November 30, 2015.
  18. National Diabetes Education Program. Examples of PDSA cycles for quality improvement activities to address elements of the chronic care model. http://ndep.nih.gov/media/Table_1-Examples_of_PDSA_Cycles_for_Quality_Improvment_Activities.pdf. Accessed November 30, 2015.
  19. Stratis Health. Goal setting. https://www.stratishealth.org/expertise/index.html. Accessed February 1, 2016.

STEPS in practice

Case 1

How’s it working in Brooklyn, NY?

University Physicians Group is a multi-specialty, 65-physician medical practice with offices in Staten Island and Brooklyn, NY.

The group started their first PDSA cycle in 2014 to address what they viewed as suboptimal diabetes outcomes during the previous year. They thought communication and educational processes might be improved to help their patients achieve better outcomes.

They began with a simple questionnaire that asked patients what they understood about diabetes and their care plans before each visit. This questionnaire covered the purpose of tests for diabetes, what the test results mean, and terminology related to diabetes care. The survey revealed a gap in what the doctors believed their patients understood about their disease and their care plan and what patients actually understood.

Patients with diabetes did not consistently have the information necessary to properly manage their own care. The survey results also indicated that the patients did not feel comfortable asking questions even when they did not comprehend the physician’s instructions. For example, 21 percent of the patients surveyed did not know the difference between fasting and non-fasting glucose measures, but they were afraid to ask their doctor to clarify what the measures meant.

Armed with this information, University Physicians Group developed a plan to accomplish two things:

  1. Improve communication with patients so that they understand their disease and the care plan that they created with their physician
  2. Improve outcomes for patients with diabetes

The plan that University Physicians Group created relied on the medical assistants (MAs)—who have the most hands-on time with patients—to educate and coach patients with diabetes. The practice disseminated the plan from the executive level to the office managers and then to the MAs. Getting buy-in from the group’s physicians was easy; diabetes is prevalent among the group’s patient population and improving communication is something that interested the physicians on both a personal and professional level.

No additional staff needed to be hired; instead, the current MAs were trained to ask patients the following:

  • Do you have a glucometer and if so, do you know how to properly use it?
  • Do you know the difference between fasting and non-fasting glucose?
  • Do you know what HbA1c is and do you know your most recent HbA1c test result?
  • Do you have insurance and if so, what kind?

Gathering this information helped the MAs tailor the educational material and coaching intensity for each patient. Approximately 150 patients were enrolled in a pilot program, which was implemented in the group’s two offices in mid-2015.

After three months of the pilot program, the practice resurveyed patients to check the initial impact. Results were favorable. Data is being collected on an ongoing basis and the group intends to start the "study" step of their PDSA cycle soon. Based on the findings, they will decide if they need to adjust their plan. One aspect of the plan that they already know they’d like to refine during the next PDSA cycle is to use the EHR more effectively for data collection.

The PDSA process was well-received, in part because the initiative selected was equally important to all of the group’s care team members. University Physician’s Group is excited to start on the next cycle.

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Downloadable tools

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Complete Plan-Do-Study-Act toolkit

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Module Completion

Individual tools

  • Starting Plan-Do-Study-Act module

    Download a printable PDF version of this module.

    Download

    PDF, 609 KB

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  • Quality improvement using Plan-Do-Study-Act PowerPoint

    Use this PowerPoint presentation to review this module with your team.

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    PPT, 799 KB

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  • ACP Quality Connect: Setting your QI goals worksheet

    Use this worksheet to set your practice's quality improvement goals.

    Download

    PDF, 267 KB

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  • ACP Quality Connect: PDSA planning worksheet

    Use this worksheet to plan out your practice's PDSA cycles.

    Download

    PDF, 271 KB

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  • Gap analysis worksheet

    This tool will help the team identify what influences are causing a problem in the practice.

    Download

    MS WORD, 49 KB

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  • PDSA evaluation worksheet

    Use this worksheet during the Act step of the PDSA cycle to help you evaluate each phase of your improvement effort before starting the next PDSA cycle.

    Download

    MS WORD, 51 KB

    Preview
  • Practical tips for a real-life PDSA

    Use this worksheet to pair with PDSA cycles to get useful tips and advice throughout the process.

    Download

    MS WORD, 42 KB

    Preview
  • Practice assessment tool

    Use this simple practice assessment checklist to gauge the overall health of your practice through these five key areas.

    Download

    MS WORD, 34 KB

    Preview
  • Run chart

    Use this tool to track and display your initiative's progress over time.

    Download

    MS EXCEL, 21 KB

    Preview
  • Process-map-tool kit

    Use this tool to customize a process flow map that fits your practice.

    Download

    PPT, 2,130 KB

    Preview
  • A3 template

    This tool provides a snapshot of your improvement activity to keep all stakeholders and supporting leadership informed.

    Download

    PPT, 92 KB

    Preview
  • Project management 101

    Manage projects from start to finish with this simple and effective tool.

    Download

    MS WORD, 34 KB

    Preview

Implementation support

The AMA is committed to helping you implement the solutions presented in this module.

If you would like to learn about available resources for implementing the strategies presented in this module, please call us at (800) 987‑1106 or send us a message.

Implementation Support

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Obtaining CME credits with STEPS Forward

AMA PRA Category 1 Credit™ will be available for the activity. Physicians should claim only the credit commensurate with the extent of their participation in the activity. In order to claim AMA PRA Category 1 Credit™, you must: 1) view the module in its entirety, 2) successfully complete the quiz by answering 4 out of 5 questions correctly and 3) complete the evaluation.

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If you have already completed this module, you can claim AMA PRA Category 1 Credit™ or receive a certificate of participation through the AMA Education Center.

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