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JRCERT Update

innovation. Understanding the social norms in an summarizing conclusions from the data. Act begins
organization, where the opinion leaders stand, and who the process of reiterating the project by determining
the change agents will be is vital to the diffusion of what changes are needed and how the next cycle will
innovation. Most health care systems are hierarchical, proceed. The Model for Improvement (Associates
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and new ideas and processes are brought in from the in Process Improvement) is used as a precursor loop
top down. However, the informal social structure in an before the PDSA cycle (see Figure 2). This model
organization should not be discounted, and often has interjects 3 questions before the cycle is initiated: What
more power for implementing sustained change. The are we trying to accomplish? How will we know that a
structure of the social system can facilitate or impede change is an improvement? and what changes can we
the diffusion of an innovation. 16 make that will result in improvement? 22
Diffusion of innovation is a more informal and A systematic review of the PDSA cycle was published
unplanned process (let it happen), while dissemination in 2013 in which the authors analyzed the success of
of innovation is more structured and managerial (make the PDSA framework implementation in the United
it happen). Both require a strong social network of lead- States, United Kingdom, Canada, Australia, and the
ers and change agents. Often, the dissemination of new Netherlands. In this review, less than 20% of health
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innovations in the form of technology, efficiency mea- care institutions documented a sequence of iterative
sures, and guidelines is slow in the health care space. cycles, and 15% reported the use of quantitative data
Berwick gave several recommendations to health care at frequent intervals to inform progress. This review
executives on how to accelerate change, including : concluded that although the PDSA model has been
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ƒ create slack for change implemented throughout health care, there is a broad
ƒ find sound innovations lack of adherence to key principles in the method, espe-
ƒ find and support innovators cially around data collection and reporting. Because of
ƒ invest in early adopters
ƒ lead by example
ƒ make early adopter activity observable A
ƒ trust and enable reinvention What are we trying to accomplish?

Plan-Do-Study-Act How will we know that a change is an improvement?
The PDSA model is used widely in health care quali-
ty improvement. PDSA is a systematic cycle for building
knowledge and implementing a continual improvement What changes can we make that will result in improvement?
process. The PDSA cycle evolved from earlier models
developed by Walter Shewhart and Dr William Edwards B
Deming, including the Deming wheel. The strength • What changes • Identify
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objective
are needed?
of the PDSA cycle is its foundation in the scientific • How will the next • Identify
method such as hypothesis formation, data collec- cycle proceed? Act Plan resources
tion, analysis, and results interpretation. This model
was originally created for industry, but was translated
into health care in 1996 by Gerald Langley. In this • Data analysis • Execute plan
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adaptation, plan is characterized by identifying the • Comparing data Study Do • Document
objective and resources to carry out the cycle (includ- to hypothesis issues and
• Summarizing data
unexpected
ing financial, human, structural, and system resources). conclusions observations
Do entails executing the plan and documenting issues
and unexpected observations. Study involves analyzing Figure 2. A. Model for improvement framework. B. Plan-Do-Study-
the data, comparing data to the initial hypothesis, and Act cycle. Figure courtesy of the authors.

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