Brenda West is the CNO and quality director at Mark Reed Health Care District in McCleary, Wash.
The author has disclosed that she has no financial relationships related to this article.
In the rapid cycle improvement model, a facilitator guides the team through four steps known as PDSA (Plan, Do, Study, Act). The team quickly moves through the steps to better understand the problem and then develop and implement a plan of action. This model works well for small, focused projects on a nursing unit because solutions are developed quickly and implementation can be almost immediate. However, there are pitfalls and challenges that can derail successful outcomes. Let's take a look at some common pitfalls and recommendations for successfully navigating them.
Common pitfalls and recommendations
The first step in the rapid cycle improvement model is the creation of a charter or blueprint to provide direction and focus for the project. The charter includes a problem statement, objectives, goals, and who'll participate on the improvement team. Through brainstorming, the team develops solutions and an action plan.
* Pitfall: The problem is too complex to use the rapid cycle model. Recommendation: Instead of attempting to solve the entire problem, it's better to focus on one section at a time. Ask the question: “Can we implement a solution within 90 days or less?” Map out the current process step by step. This will help you visualize the complexity of the process.
* Pitfall: You don't have the right people on the improvement team. Recommendation: The team should represent staff members who are affected by the problem. Keep the number of team participant small—no more than six to eight people who can represent their peers.
* Pitfall: The participants don't feel the problem is worth solving. Recommendation: Utilize the current process map and ask staff members to brainstorm barriers within each step and/or between each step. Ask unit staff: “What frustrates you about...?” Write all the ideas on a flip chart for all team members to see to help validate their importance. This technique is quick and can be completed during a staff meeting. Staff members can then vote for which idea they wish to work on. This technique will begin to create the buy-in you need for a successful project. When staff members have control and ownership in the project, they're more likely to accept the changes that are made.
* Pitfall: Your supervisor doesn't support the project. Recommendation: Share the charter with your supervisor and ask him or her to sponsor the project. Depending on the complexity of the project, the sponsor may be called on to remove barriers or promote the project to other departments. Every project needs a sponsor to champion the work. Invite the sponsor to the first team meeting and allow him or her to articulate the problems and goals to the team.
After the planning step has been completed, the team moves on to “do.” This step allows the team to try out and test specific changes. It also gives the team a chance to energize peers by helping them see for themselves the future state.
* Pitfall: The team is unable to visualize the future state. Recommendation: Help team members envision what success will look like by having them map out step by step the new and improved process. You can also have team members brainstorm what differences they expect to see after the change is successfully implemented. This will also help the team stay focused on the end goal.
* Pitfall: The tryout or pilot of the solution failed. Recommendation: Explain to the team that just because the change looks good on paper, doesn't mean it will go as planned in the work setting. There will always be details that were overlooked, and it's okay if something didn't work as planned. Team members will need to physically walk through the process and discuss the challenges to help them identify nuances and make changes before implementing the solution.
* Pitfall: The team hasn't developed a way to measure success. Recommendation: It's very difficult to know if the solution was successful if the process hasn't been measured. Measuring before and after can be by observations, surveys, or another form of data collection such as chart reviews.
* Pitfall: Peers haven't bought into the solution. Recommendation: Team members have the opportunity to work through their anxiety about change during improvement meetings, whereas their peers don't have this advantage. Team members need to bring their peers along on the improvement journey through regular updates and allowing their peers to ask questions, as well as providing feedback about the change. Remember, it's normal to be unsettled about change.
* Pitfall: Team member have tried the solution. It doesn't work, so they want to give up. Recommendation: Start small and realize it doesn't need to be perfect. There are always changes that will need to be made along the way. Take the team through a brainstorming session by asking the following question: “What went well?” “What didn't work?” “What do we need to change?” Always start with the positive to help team members realize that they're making progress.
During this step, the team will evaluate the tryouts and review peer feedback. Team members will compare data with previous findings. They may make changes to the process or decide they can move forward to a full implementation.
* Pitfall: The measurement system doesn't measure the change. Recommendation: Unfortunately, this issue can happen in the best of circumstances. Try to prevent this from happening by checking the measurement system during the planning step. If the team uses software, such as a patient-tracking system, it's important to validate the patient-tracking data by comparison with actual observations. The team may need to collect more data or survey more staff with different questions.
* Pitfall: The team and staff are uncomfortable with full implementation. Recommendation: You'll need to find out the cause of the concern. This can be accomplished with a brainstorming session by asking, “What are the barriers that are preventing full implementation?” After these thoughts are written on the flip chart, ask, “What's the plan of action to eliminate the barriers?”
In the final step, the team decides to move the full implementation forward. The implementation plan is communicated to all staff members who'll be affected. The plan of action and implementation are completed.
* Pitfall: The change wasn't sustained. Recommendation: In healthcare, there's a tendency to stop at implementation. We make the assumption that after a change is implemented, we can move onto the next project. We don't take into consideration human nature. Change can only succeed if the people who do the work feel that the improvement is better than what they were doing before the change, and they have the confidence to carry it out. Meet with the team the first week after implementation or sooner if necessary. These meetings shouldn't take more than 30 to 60 minutes and can decrease in time and/or frequency as the team feels more confident. The three agenda items should be: “What went well?” “What didn't work?” “What do we need to change?” Asking for the positive first helps team members realize how much they were able to accomplish.
* Pitfall: Other departments have been affected by the changes made. Recommendation: It's best to attempt solving this problem during the plan and do steps. After the solution has been developed, part of the plan of action should include a review with departments that may potentially be affected by the changes.
* Pitfall: The team doesn't have the opportunity to share the win. Recommendations: This can be accomplished through a report sent out to other departments, executives, or board members. Allow team members to present their work. It's a proud moment for a nurse manager to see growth in his or her staff members who now have the tools to move forward with another project.
Take the QI journey
The PDSA rapid cycle improvement model works at the nursing unit level and takes little training to understand the concepts. The tools are simple and the model is flexible enough to be completed in one 8-hour session or several half hour- to hour-long sessions. Rapid cycle improvement allows staff members to own the process and will help open their eyes to other possibilities. The more control you allow staff members to have, the less time it will take to complete a successful improvement project and the need for reimplementation of an initiative or the start of disciplinary action will be decreased. Quality improvement is a journey that we're all on together, and our ultimate goal is to help our staff provide the very best care for our patients.
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Zidel T. A Lean Guide to Transforming Healthcare: How to Implement Lean Principles in Hospitals, Medical Offices, Clinics, and Other Healthcare Organizations. Milwaukee, WI: ASQ Quality Press; 2006.
© 2012 by Lippincott Williams & Wilkins, Inc.