Friday, 26 December 2014

The Problem with PDSA in healthcare

In healthcare it is now generally understood that using the PDSA cycle is a good and valid method to try to achieve improvement. The PDSA is very widely known in healthcare and often used, though it is thought it ought to be used even more. Yet, when we look at health organisations that are using the PDSA we do not find the improvement at a range or scale or impact that is very often found in other industries who use PDSA.


To resolve the angst around this we need to know what comes before and after any particular individual PDSA cycle.

Before a PDSA

How is the specific individual PDSA cycle conceived? Why was this particular PDSA chosen over many possible PDSAs that could have been done?

Before choosing to do any one particular PDSA there are at least five prior major detailed outlining steps to be completed that involves objective and subjective methods, data analysis, prioritisation, setting aims, measures and interventions. Only after this a PDSA ought to be done by a very small team which has mostly understood the prior steps as a matter of overall context – i.e. the how and the why, the logic that validates your activity, the reason that requires your engagement and the rationale that demands your time and energy.

If you are currently doing a PDSA or soon planning to do a PDSA it is important for you to consider how it was chosen. If you chose it out of an impulse, hunch, suggestion, obligation, instruction that is great for your personal learning of the tool which is of course very important. It may (or may not) show an improvement on that particular cycle or cycles, but you or your organisation should not be under the illusion that this PDSA effort is going to contribute to sustained or widespread improvement. It is important to prove to yourself on where the PDSA fits in within a broader department, division, directorate, organisation context.

One of the ways to identify whether there is any link to anywhere other than to you is to observe if your boss or your boss’ boss is as keen and enthusiastic about your PDSA not because they support you but because your PDSA has an important link to moving the dots in the right direction that they are supposed to move and they can prove it. They should be able to stop further PDSAs that is not working and you should be happy with it.

After a PDSA

What happens to your PDSA after you have completed and you think it shows some positive result? Are you in a position to pilot it further in repeatedly larger areas/scales? Do you have the support for it? Have your bosses confirmed your PDSA cycles have proved as shown by a series of linked organisation wide data that it has led to wider improvement? Eventually after a series of such PDSAs does your intervention, process and outcome become official standard protocol for the area?

The problem with PDSAs as we do it in healthcare right now

Every empowered person does PDSA based improvement activity but there is usually no one to track all of these, guide the people doing PDSA projects, help them do the run or SPC charts, identify where these projects are in the overall organisational improvement effort (say by using a driver diagram), capture and roll out good ideas for the whole organisation's benefit.
I would say that we should stop healthcare employees from doing unsupported PDSAs for at least two reasons a) it wastes individual staff time which could be usefully spent on something more useful b) if the unsupported PDSAs are successful then it leads to small individual areas shining which is usually a drain on resources and general emotion (technically known as sub-optimisation). In theory it is possible to even cause harm by such poorly designed activity.

The issue is Tools vs Philosophy

PDSA has great history and comes from the times of superior masters like Shewhart Juran and Deming. It is a part of an overall philosophy that can be called the QI movement or which after adaptation now more familiarly known as the ‘Lean’ (though some purists, even non-purists will be able to differentiate between the two).

To understand this better, we need to ask ourselves whether the PDSA is used as a tool for individuals or as a part of a philosophy for organisations. Similar to the issue whether Lean is used as a method or philosophy. If you or your organisation are using PDSA (or Lean) as a mere tool or a method – you are designing is poor and destined to fail.

We are at a point in history of improvement healthcare that we are training a large number of people on ‘quality improvement’ and letting them do unsupported PDSAs. We do that under the guise that we do not want to interfere with the freedom of senior and experienced healthcare staff. When these ‘trained’ ‘senior’ people do not see the improvement that the lean system claims that it offers, they then become committed disbelievers in the philosophy while at the same time being obliged to follow the tools and the methods.

We are at the risk of defiling and debunking a well established validated healthcare improvement philosophy because of our unwillingness to adopt it as a philosophy. It will be to the eternal shame of us in healthcare. We are creating proof that lean healthcare does not work, instead of accepting that we do not know how to do lean healthcare properly and we are not doing it as we are supposed to do. We need to act swiftly to avoid this - there is life and limb at risk.


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1 comment:

Abhishek Bhartia said...

Great to see a doctor write so passionately about doing quality improvement in the right way. We need to guard against blaming the method or philosophy when we haven'the invested the effort to learn it well.