Improvement Model and PDSA Cycles

Organ Donation

• The Service Improvement Model provides a framework to test, implement and sustain change ideas to overcome barriers to donation

Overview

Understand the problem and its causes

Define aim and measures

Collect change ideas

Test change idea with PDSA cycles

Implement changes that are improvements

Work with colleagues and value different perspectives

Link frontline changes with strategic objectives

Work towards sustainability as part of implementation

Tools for defining problem

• Stakeholder analysis• Process Mapping• Root Cause Analysis• Ishikawa Fishbone• Gathering data

- quantitative data- qualitative data

“If I had one hour to save the world, I would spend 59

minutes defining the problem and one minute finding a

solution.”

Albert Einstein

Stakeholder analysis

• Identify as many stakeholders as possible

• Understand the different roles along the donation pathway

• Enables appropriate use of resources

• Decide how people will be engaged

HighLow

Keep informedMay feel victims of change. Need to be consulted frequently if change is not to be resisted.

MonitorThis group is often ignored if resources are stretched

Low

Manage closelyKey stakeholders who should be fully engaged and involved.

Keep satisfiedOpinion leaders who should be satisfied with what is happening

High

HighLow

Keep informedMay feel victims of change. Need to be consulted frequently if change is not to be resisted.

MonitorThis group is often ignored if resources are stretched

Low

Manage closelyKey stakeholders who should be fully engaged and involved.

Keep satisfiedOpinion leaders who should be satisfied with what is happening

High

Impacted by the change

Po

wer over the

change

Why process map

• Visual representation of the organ donation pathway• Identify key stages of the pathway and who is involved• Avoids only one person’s perspective• Understand viewpoints and experiences of clinical

colleagues and families • Identify opportunities to improve organ donation

How to map a process

• Work with key stakeholders as a group• Define the scope (start and end of the process)• Start with a high level map• Proceed with a more detailed analysis once key

problems identified• Describes what really happens

Detailed Process Map Brain Death Testing

START FINISHintubated patient

identification referralbrain death

testingfamily

approach

Brain death testing

Meets clinical criteria Exclude reversible causesAppropriate personnel

Stabilise physiologyPerform Ancillary tests

Brain Injury

Approach Family

Root Cause Analysis

• Repeating the question ‘why’? can lead to the cause of a problem to be identified

• As a simple guide the question ‘why’? Should be asked at least 5 times

• By identifying the cause of a problem interventions can be developed to prevent reoccurrence

• Resources can be focussed to the correct area of a problem

Root cause analysisFishbone diagrams

Brain Death (BD) tests are not always carried out when patient meets pre-conditions

Family have declined

Resources

BD tests not a standard part of care

Donation will not happen

Lack of knowledge

Doubts/ concerns regarding the validity of testingNo clinical

interpretation of current BD testing policy

Can not/ will not test

Other patients considered to be higher priority for beds

Judicial/ Police refusal

Medical contra-indications

Patient choice not understood by family

Previous poor experience of care whilst in hospital

Approached prematurely Family refused

before a formal approach made

Biased due to adverse press/ TV

Poor approach from staff

Ancillary testing not available/ supported

Lack of suitable medical staff to perform tests

No transplant surgeon available

Lack of availability of expert opinion

Lack of available equipment for testing

Prevented by clinical condition (e.g. hypothermia)

Paediatric case

Doubts about time needed to wait

Lack of confidence / experience in performing tests• Useful for complex problems

with multiple causes• Group exercise• Brain storm possible causes

Ishikawa fishboneexample brain

death testing

Brain Death (BD) tests are not always carried out when patient meets pre-conditions

Family have declined

Resources

BD tests not a standard part of care

Donation will not happen

Lack of knowledge

Doubts/ concerns regarding the validity of testingNo clinical

interpretation of current BD testing policy

Can not/ will not test

Other patients considered to be higher priority for beds

Judicial/ Police refusal

Medical contra-indications

Patient choice not understood by family

Previous poor experience of care whilst in hospital

Approached prematurely Family refused

before a formal approach made

Biased due to adverse press/ TV

Poor approach from staff

Ancillary testing not available/ supported

Lack of suitable medical staff to perform tests

No transplant surgeon available

Lack of availability of expert opinion

Lack of available equipment for testing

Prevented by clinical condition (e.g. hypothermia)

Paediatric case

Doubts about time needed to wait

Lack of confidence / experience in performing tests

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

The aim should be clear, focussed and based upon real and important problems. It should measurable and, where relevant, in line with national targets.

Any intervention should be designed in such a way that its impact can be accurately measured. Monitoring arrangements need to be agreed before the change idea is introduced.

Change ideas may come from many sources, and are most likely when they concentrate on the patient rather than the various teams involved in the pathway.

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

The Model for Improvement

The Model for Improvement

• Define your measures• Collect baseline data before

implementing change• Make changes on a small

scale and ensure it is modifiable, measurable and realistic.

• May require multiple cycles• Can deliver rapid service

improvement

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

dostudy

planact

dostudy

planact

Model for Improvement

The PDSA cycle is a controlled test of a change idea that should provide a quick assessment of whether the idea will be effective or not.

Remember that a change idea is being tested, that not all will work and some might make things worse.

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

actplan

studydo

Model for Improvement

Plan: we will do this, in this location, with this expectation

Do: we did this, we made these measurements and observed these unexpected occurrences

Study: our data from the pilot compare with baseline data in this way. We also had the following problems

Act: as a result of our observations we will now extend the trial, adjust the change idea, trial more widely, implement into practice etc

What are we trying to achieve?

How will we know that change is an

improvement?

What changes can we make that will result in

improvement?

actplan

studydo

Data Collection

• Agree how the data will be collected

• Agree how the data will be analysed and presented

• Keep it simple

Tips

• Don’t think too big– make it manageable and realistic, break down big

changes into smaller interventions• Don’t be too vague

– need some detail, although to a practical, not obsessive, level

• Measure and monitor impact of change– qualitative data is important, but best if complemented

by quantitative• In practice more than 1 PDSA can be run at a time as

long as they are small and simple

Achieving strategic objectives

Driver diagrams

• Minimum of 3 levels

- Strategic aim

- Primary drivers what is causing the problem- Intervention or change idea being tested against each of the primary drivers

• Links specific interventions to overall aim

Steps to develop driver diagrams

• Define the strategic goal (vision or strategic objective).• Gather together a group of people who know about the

subject• Generate ideas to identify the key things which need to

be improved to achieve the outcome• Cluster the ideas to see if groups represent a common

driver• Generate the interventions (change ideas) linked to each

of the drivers

Increase conversion of

potential donors

Maximise each donation

Expand deceased

donor pools

Reduce incidence of graft failure

Reduce need for cadaveric

grafts

Improved preventative health measures to reduce organ

failure

Reduce family refusals

Reduce loss of donors through physiological instability

Improved donor optimisation

Improved immunomodulation / immunosuppression

More accurate cross-matching / organ sharing

Xenotransplantation and stem cell technologies

Novel technologies, e.g. ventricular assist devices

Achieve self-sustainability in

organ transplantation

Support organ donation from the Emergency Department

Establish DCD programmes

post-mortem interventions to reverse ischaemic injury

High quality outcome monitoring

Trained requestors in all neurosurgical centres

Review of legal framework for consent

Impactful and sustained public promotion

Strategic objective Primary driver Secondary driver Specific interventions

Implementation and Sustainability

• Consider during the implementation plan of how the change can be sustained.

• When a change idea is tested and led to an improvement then it should be considered for adoption into practice

• The most important factor when considering sustainability is staff engagement and effective leadership

• Measurement is vital to demonstrate sustainability

UK Example

• What were we trying to achieve? Increased consent rates by increasing SN-OD involvement

• How would we know the change was an improvement? Measure consent rates and SN-OD involvement rates in Phase 2 data collection of ACCORD, alongside UK PDA

• What changes could we make that would result in improvement? Improve nursing staff attitudes towards SN-OD involvement, peer review consultant performance against this metric, clear protocol for all clinical staff to follow explaining how families should be approached with evidence

UK Example

• Develop Mandatory Study Day• Peer review consultant performance • Development of Organ Donation Care Pathway by

CLOD & SNOD – all unit staff consulted, document piloted for 6 months and feedback invited

UK Example

• Phase 1 problem identified - consent rate (54%) collaborative approach 46%

• Phase 2 significant improvement – consent rate (76%)• Phase 2 consent rate when SNOD involved 79%

Thank you