Improvement Cycles

Improvement cycles based on plan, do, study, act, cycle (PDSAC) methods are essential to using and scaling innovations with fidelity and good outcomes. To use innovations and implementation drivers with fidelity in practice is to invite problems and the need to quickly resolve problems. Changes in contextual factors and the need for continual improvement to produce and scale socially significant outcomes mean the work is never done.

Improvement cycles are critical to continued use of effective innovations and are an essential part of using effective Active Implementation methods.  To use innovations and implementation drivers in practice is to invite problems.  There are big problems such as changes in the economy or social expectations and there are local problems like working conditions, salary expectations, staff turnover, leadership changes, and so on.  These environmental factors are coupled with the need to continually improve the usability and effectiveness of an innovation and of the competency, organization, and leadership drivers to produce and scale socially significant outcomes.

Implementation and improvement are Siamese twins joined at the heart.  To “choose one” is folly.  Improvement science needs implementation science.  Improvement methods themselves must be used as intended (with fidelity) if they are to be effective in practice.  Taylor et al. (2014) conducted a review of 73 published studies that reported application of plan, do, study, act, cycle (PDSAC) methods.  They found that only 2 (3%) of the 73 studies included all five components of PDSAC.  While all 73 had a plan there was virtually no indication of how well the plan was done, only 7 studied results in a systematic way, 2 indicated how they acted on the information/data, and 14 reported conducting an ensuing cycle.  Thus, if improvement methods are to be used fully and effectively in practice, then implementation methods must be used to assure their use as intended (with fidelity).  This point has been made by others who have studied the use of improvement methods in practice (Khodyakov et al., 2014; Leis & Shojania, 2017; Marshall et al., 2017; Øvretveit et al., 2017; Oyeledun et al., 2017; Reger, Gustafson, DeMarie, & Mullane, 1994; Shojania & Grimshaw, 2005; Westphal, Gulati, & Shortell, 1997).

Implementation science needs improvement science.  No matter how successful attempts are to achieve socially significant outcomes, there always is room for improvement.  There are no perfect innovations, totally effective implementation methods, or completely enabling policies.  Implementation is a world of imperfection that is constantly striving for noticeable improvement.  Improvement cycles are based on trial and learning approaches to problem solving in all aspects of implementation.

For Active Implementation the Improvement Cycles are PDSAC and usability testing.  Each is based on the PDSAC logic; only the time frames, participants, and goals vary.  The PDSA Cycle involves a “trial-and-learning” approach in which the PDSA steps are conducted over iterative cycles designed to discover and solve problems, and eventually leads to achieving high standards while eliminating error.

Plan:     Specify what is intended; develop a plan to produce the intended change (the beginnings of a Usable Innovation and Implementation Drivers)

Do:       Try to use what is intended; carry out the test by following the plan (the beginnings of a fidelity assessment and Implementation Driver supports)

Study:  Assess what was done and what the outcomes were; observe and learn from the test (the beginnings of relating fidelity of use and proximal outcomes of an innovation)

Act:      Use the information to establish a new plan; determine what modifications should be made to the plan that is being tested (the beginnings of using a Decision Support Data System to support action planning and effective decision making)

Cycle:   Repeat PDSA until the problem is solved or the goal in accomplished (the beginnings of establishing a no-shame no-blame learning organization)

PDSA Cycles can be done rapidly one person or method at a time.  Rapid cycles are helpful for situations that are repeated frequently, such as engagement strategies with recipients, the use of medication protocols, methods for conducting coaching, and so on.  This provides many opportunities each day or each week to plan, do, study, act, and try again to solve a problem or reach a goal.

The key to using PDSAC effectively is to use PDSAC as intended, that is, with fidelity to the PDSAC process.

Fit, adapt, adjust, tailor

Innovations are new ways of work in any organization or system.  Problems are expected as innovations are considered and their first uses are attempted in practice.  Anticipating problems is built into the Active Implementation frameworks.  For example, attempting to skip Exploration and Installation and moving right into Initial Implementation is not a good idea.  The problems associated with “lack of buy in,” “poor fit,” and “resistance to change” are the anticipated results of “lack of planning and preparation” during Exploration and staff Selection.  Even so, there will be unanticipated problems when attempting to introduce or sustain an effective innovation in the unique environment of any organization or system.  Unexpected problems are an expected part of the Active Implementation process.  Solving problems is the work of using the Improvement Cycles and Systemic Change methods.

For Active Implementation: Plan to use an innovation as intended; Do the innovation with Implementation Driver supports for high fidelity use of the innovation; Study the fit with existing practitioner behavior, organization operating procedures, and system influences; Act on the information to tailor practitioner behavior, adapt organization routines, and adjust system practices to improve fit with a Usable Innovation; and develop a plan to assess the impact of those changes in the next Cycle.  If there is something about the innovation that attracts attention in this process, then the innovation becomes the focus of PDSAC to arrive at an adapted-but-still-effective version of the innovation.  However, the initial focus is on adapting the context to fit the use of the innovation with fidelity so that desired results can be obtained.