By Helen Mawdsley, EdD and Eleftherios K. Soleas, PhD
Quality improvement and patient safety (QIPS) projects in healthcare often use a Plan-Do-Check-Act (PDCA) or Plan-Do-Study-Act (PDSA) cycle, such as taught by the Institute for Healthcare Improvement Open School virtual QI curriculum and described in the AMA PI-CME accredited activity process. While many clinicians and faculty members may be familiar with developing or leading a QI project within a healthcare setting using a PDSA structure, we would like to draw attention to QI projects focused on health professions education. QI projects in this space represent a coupling of the healthcare system and the education system, which means that we have more data sources to explore; however, we also have more relationships and interactions to account for. We maintain that there is a strategic benefit to conceptualizing QI projects in this coupled space, as many faculty members have a requirement to perform as leaders in QI projects and teach others about the QI process.
We would like to initiate this new column by providing a foundational review to guide your QI journey. We recognize that some readers of this column are seasoned QI experts and are prepared to engage in conducting a QI project within the health professions education context. We hope you will consider reaching out to us and sharing your own experiences in future issues.
The PDSA cycle is the typical structure for a QI project. These cycles have shown to be useful in healthcare settings, as long as the implementation is compliant with the principles underlying these cycles (Taylor, 2014). Given the importance of these principles, let’s explore where PDSA cycles originated. Following this, we will discuss how the PDSA can be applied in a health professions education and CPD context.
In the 1950s, Deming, an engineer and statistician, used the Shewhart cycle, which has developed over time to be known as the PDCA cycle (Noguchi, 1995). While PDCA and PDSA have become almost interchangeable terms currently, we can see why PDCA was used first, as Deming’s work was founded in an industrial context where the purpose was to detect variation outside of pre-determined parameters. Over time, an emphasis on exploring why variation exists may explain the multiple terms used, yet the nuanced difference between these terms remains.
The purpose of a PDSA cycle is to provide opportunities for learning and informed action, with the intent to make something better. PDSA cycles are intended to capture small, incremental, and iterative steps. This is important because this intention helps to:
- provide a sustainable scope to a QI project through multiple, manageable phases,
- provide multiple opportunities for learning and unlearning through multiple feedback loops, and
- enable navigation of complex environments without overt reductionism.
Let’s focus on that third point for a moment. As we mentioned earlier, QI projects in a CPD context represent the coupling of the healthcare system and education system, recognized as complex systems. It is important to understand what this complexity means for your QI project. In order to proceed with a QI project, we need to reduce complexity to a point where we can move forward with our QI project; however, we also need to understand that reducing a part of a larger complex system discards some of the meaning in the system. In this way, any QI project is an exercise in reduction, but this can be mitigated through project design. A series of smaller scoped QI projects can provide a sustainable momentum to see progress, multiple opportunities for feedback to the QI process and the project’s final outcome, and can reduce some of the assumptions placed on the amount of prediction that can reasonably occur while working within complexity.
How to facilitate designing a meaningful project
As you are about to embark on a QI project, it is important to define the problem of practice (PoP). The PoP is the gap in theory, knowledge, or practice creating barriers to desired performance. While a PoP may not be commonly seen in a healthcare setting, it is a common term in educational research. In the health professions education and CPD context, the PoP provides the tangible link between how we identify, teach, and learn about clinical issues in a meaningful and relevant manner (Olsen, 2019). When designing a QI project in health professions education, it is important to explore and define why the PoP exists, who is impacted by the PoP, and engage in viewing the PoP from multiple positionalities to explore the impact of the PoP. Some of these positionalities may include perspectives from patients/clients, clinicians, learners, healthcare staff and administrators, educational staff and administrators, regulatory bodies, and even current political mandates. Taking time to explore and articulate the PoP through multiple lenses can ensure that your project is meaningful and valuable to you, your practice, and your larger community. Another reason to firmly establish a PoP is that it may help offset criticisms of QI. QI projects have been accused of lacking academic rigour and legitimacy, which can be attributed to a poorly designed QI project, as well as the hidden curriculum (Brown et al., 2020). The process of developing a clear and robust PoP, as well as the defined PoP itself, can help mitigate some of these issues.
When you are leading a QI project in health professions education or teaching others about how to do their own QI project, the mandate of the QI is the quality improvement in question, but it should also consider placing some emphasis on upskilling others to be able to implement QI. For instance, improving the cultural safety of a program of CPD would be a perfect topic for a QI project. This project would only be enhanced by imparting the skills and documenting strategies to do QI elsewhere. In this way, you can facilitate a successful QI project and support teaching and learning how to design and implement a meaningful and relevant QI project elsewhere.
After the PoP is defined, as best as is possible at this stage, it is time to plan how to address the PoP. One way to do this is to develop some research questions that form the basis of identifying relevant data sources to inform your project. At this point, the data sources which would best respond to your question may or may not exist. That’s okay – move forward how you can, and note these gaps as limitations in your study, as well as offer these gaps as opportunities for future research or data infrastructure development. It is important at this stage to also think about the iterative phases of your project, what will be explored in this iteration, and what will be in a subsequent iteration. For example, a full PDSA cycle can be completed to gather baseline data only, or your first PDSA cycle may already include an intervention to a previously defined PoP. Consider the available data sources, such as referral data, previous knowledge test outcomes from other programming, performance evaluations from a learning management system, multisource feedback forms, or the last peer assessment that a person completed.
During this planning stage, it is also time to consider who and how the data will be analyzed. For example, are you employing quantitative, qualitative, or mixed methods in how you will respond to your research questions? If so, do you need to build a team to help analyze this data? It is important to include this expertise during the planning phase, as how data is collected can limit what type of analysis can be done. Including this expertise sooner than later will help your project succeed and add to your QI project’s credibility
How to document and disseminate
Now that planning and team-building have been done, it is time to proceed with baseline data or implement an intervention (get ethics clearance if needed). As you move forward, gather data to respond to your research questions, study the data, situate it within the context of your PoP, and determine what future actions would be meaningful to those impacted by the PoP. This work will inform the conclusion of this specific PDSA cycle and provide momentum for the next cycle. It is important to share these learnings, as your findings may be helpful to others. Some options include presenting your work at committees within your organization, writing white papers, presenting at conferences, and in peer-reviewed journals. Another option is to write us and tell us about your work! We would like to dedicate space in upcoming issues to share our experiences in QI in the health professions education and CPD context.
How to incorporate sustainability
QI projects are usually comprised of an iterative series of PDSA cycles. The PoP which inspired this work in the first place is important to address, and so finding a way to maintain momentum can help to add value to your project. There are a few things to consider when facilitating sustainability in a QI project:
- Chasing perfection vs. striving for improvement.
QI projects require us to find our weaknesses and talk about failures. Even if the QI project focuses on the successful improvement of something down the road, the PoP at the centre is about an authentic struggle in our practice. This requires courage and awareness to accurately describe and assess the PoP throughout the QI project and a space for this conversation.
- Consider scaffolding or phasing of the project
When defining the PDSA cycles, opt for creating numerous smaller cycles, which build over time. This can be hard, as each PDSA cycle will have less to show at first; however, this provides an opportunity to provide results sooner.
- Use feedback to inform future PDSA cycles
A QI project with numerous iterative cycles provides more opportunities to build on system feedback. Incorporating feedback frequently will help refine the research questions and PDSA cycle development to ensure that the findings are relevant and reliable. In contrast, limiting options for system feedback will reduce any possible refinements, encouraging the project to deviate from its intended outcomes.
We hope that this article has inspired you to explore QI projects, and we encourage you to share your tips on approaching a QI project by commenting on this article or emailing us. Also, if you have a QI project you would like to share, we would happily consider highlighting it in a future column. Please contact us at Helen.Mawdsley@umanitoba.caor email@example.com.
Helen Mawdsley, EdD is Director of Research, Office of Continuing Competency and Assessment, at Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Canada. Helen.Mawdsley@umanitoba.ca
Eleftherios K. Soleas, PhD, OCT, BScH, BEd is Director of Continuing Professional Development, Professional Development & Educational Scholarship, Faculty of Health Sciences, Queen’s University, Canada. firstname.lastname@example.org
- American Medical Association PRA Credit System. Performance Improvement Continuing Medical Education (PI-CME). https://www.ama-assn.org/education/ama-pra-credit-system/performance-improvement-continuing-medical-education-pi-cme.
- Brown, A., et al. (2020). “A Tale of Four Programs: How Residents Learn About Quality Improvement during Postgraduate Medical Education at the University of Calgary.” Teach Learn Med: 1-17. DOI: 10.1080/10401334.2020.1847652
- Cleghorn, G. D. and L. A. Headrick (1996). “The PDSA cycle at the core of learning in health professions education.” The Joint Commission journal on quality improvement 22(3): 206-212.DOI: 10.1016/s1070-3241(16)30223-1
- Institute for Healthcare Improvement Open School. PDSA Cycles (Parts 1 & 2). http://www.ihi.org/education/IHIOpenSchool/resources/Pages/AudioandVideo/Whiteboard6.aspx
- Noguchi, J. (1995). The legacy of W. Edwards Deming. Quality Progress. Milwaukee, American Society for Quality. 28: 35. https://uml.idm.oclc.org/login?url=https://www.proquest.com/magazines/legacy-w- edwards-deming/docview/214740392/se-2?accountid=14569
- Olson, C. A. (2019). “What is an Educational Problem? Guidance for Authors Submitting to JCEHP.” The Journal of continuing education in the health professions 39(4): 225-227. DOI: 10.1097/CEH.0000000000000273
- Taylor, M. J., et al. (2014). “Systematic review of the application of the plan–do–study–act method to improve quality in healthcare.” BMJ Quality & Safety 23(4): 290-298. DOI: 10.1136/bmjqs-2013-001862