The Plan-Do-Check-Act Cyle

BY: FRANCINE TALAMERA MARY LUBELLE TALIDONG

OBJECTIVES
To explain how quality improvement processes can

be use to identify and address areas of opportunity to improve self-management support To identify areas of weakness in self-management support To define the different steps in the PDCA (continuous improvement) cycle. To enumerate and discuss the stages of the PDCA cycle. To be able to use this model to implement initiatives to improve self-management support

INTRODUCTION
Shewharts PDCA cycle, developed in the 1920s as a model to explain the necessity for ongoing organizational improvement and a process through which such continuous improvement was to occur. The theory of PDCA was first used in business management. This theory, the work cycle of quality management was come up by an American expert of quality management, Dr. W. Edwards Deming in the early 1950s.The work cycle of quality management which was also named as "Deming cycle" was generally acknowledged as one of the most effective methods of management.

Quality improvement in self-management support

One of the six key areas of a health care system that encourages high-quality chronic disease care is selfmanagement support. For the purpose of this, self-management support will be considered an isolated program or project. It should be remembered that self-management support is one of a number of components of the multidisciplinary Chronic Care Model. For a complete overhaul of chronic care provision, all elements of the Chronic Care Model should be considered.

Large scale improvements are dependent on external factors; the community, the health systems and the institution itself. It is suggested that a visionary clinical leader and solid financial backing are required to successfully integrate all components of the model. However, improvements can be achieved through taking small steps. An assessment of current practice will highlight strengths and weaknesses in the delivery of self-management support. Interventions can then be implemented to reduce the gaps between current practice and ideal practice. Not all initiatives require large expenditure and major changes.

Taking the first steps is the key to improving self-management support. A good starting challenge is to provide a case to finance and administrative staff of the benefits and needs for a qualitative improvement initiative. The benefits include: improving patients health enhancing patient satisfaction and loyalty improving staff satisfaction and retention

Assessment tools
There are a number of user-friendly assessment tests in the public domain that help to define the elements of self-management support and to set targets and benchmarks for quality improvement. The recommended assessment tools for this project are the: Assessment of Clinical Care Resources and Supports for Chronic Disease Self Management (CCRS). (This is an adaptation of the Assessment of Primary Care Resources and Supports for Chronic Disease Self Management (PCRS)). Patient Assessment of Chronic Illness Care (PACIC).

Results from using these assessment tools can help individual clinicians or teams identify areas where current practice does not reflect good self-management support, and use basic quality improvement processes to plan and implement changes to improve practice in this regard. It is proposed that combining information from the CCRS, which is based on clinicians reflecting on their practice, with information from the PACIC, which assesses the patient experience of care, will provide teams with a balance of feedback regarding current self-management support practices. The Assessment of Chronic Illness Care (ACIC) has a growing reputation as a reliable and valid instrument to assess the quality of chronic care provision. It is closely linked with the key elements of the Chronic Care Model and may be a more appropriate assessment tool for health practices wishing to improve on chronic care provision in its entirety (self-management support, delivery system design, decision support and clinical information systems).

Organize a Self-management Support Improvement Team

Deciding on a team

"A care team is the right mix of people coming together with the right tools to deliver the right care for a defined population of patients."
If the focus of implementing self-management is across a whole team or service, assembling a team to lead and drive this process will the key. However, ideally such initiatives are most successful if built into business as usual, in terms of an already existing forum or meeting, such as a management team meeting, multidisciplinary review meeting etc. On the other hand, putting together the right leaders is a key ingredient to a successful quality improvement plan. The team should bring together individual leaders who offer a range of abilities such as appropriate skills, knowledge, expertise, peer respect and leadership. It is essential to select those who have the enthusiasm, commitment and time to make valuable contributions. Team size will vary based on the setting, from a large multidisciplinary team to a small team possibly consisting of just two people. A small team is absolutely fine but will rely on each person taking on a range of responsibilities.

Examples of possible team and leadership composition may be:

For a private practice psychiatrist: Psychiatrist Clinic administrator For a multidisciplinary team within a private or public mental health service, leaders may be: Team leader/manager Psychiatrist Senior nurse/nurse specialist Admin support For a whole service, the focus of planning and implementing may be the service management team, and leaders will therefore include: Service manager (or delegate) Clinical director Quality facilitator Professional group clinical leaders (nursing, psychology, OT etc.) In this instance, it is likely to be important to also have a second tier of leadership within individual multidisciplinary teams, to lead the team in its own local process of PDCA cycles.

The benefits of a self-management care team

Team care is central to improvement in health care practice and, if undertaken effectively, should achieve the following key targets:
Ensures all of the needs are met in caring for the

chronically ill Uses the least expensive and best trained staff to perform each task Maximizes patient and staff satisfaction and retention Standardizes care, improving both quality and efficiency

In addition, the following benefits would also occur:

Clear expectations and available tools Easy to understand and discuss processes of care

Information is available when needed

Everyone on the staff is valued and respected Feedback of performance and opportunities to grow

Positive attitudes of co-workers.

Resources and Supports for Selfmanagement Assessment Tool

Assessment of Clinical Care Resources and Supports for self-management (CCRS) The CCRS has been adapted from the Assessment of Primary Care Resources and Supports for Chronic Disease Self-management (PCRS) to meet the needs of psychiatrists. It was developed by the Advancing Diabetes Self-management Program of the Robert Wood Johnson Foundation to assess the quality of selfmanagement support. The research supports the use of this tool and associated processes with other chronic conditions.

It can be used to:

provide self-assessment and feedback and serve as a

quality improvement tool to help build consensus for change well as gaps in resources, services and supports

identify optimal performance of providers and systems as

integrate changes into support team systems by

identifying areas where self-management support is needed

Best results are achieved by working in multidisciplinary teams. Expected outcomes include enhanced patient and staff abilities in self-management processes, as well as improved clinical and behavioral outcomes for patients. The recommendation is that the tool be used on a regular basis, for example quarterly, to monitor improvement and to guide self-management support into the health care systems.

It is consistent with current best practices in quality improvement and chronic illness care and can be applied across a range of work settings and chronic conditions.

The components of the CCRS

The key components of the CCRS are patient support and organizationalsupport.
Patient support: an assessment of the patient, provider and care team

individualized assessment of patients self-management educational needs patient self-management education goal setting and action planning problem-solving skills emotional health patient involvement patient social support linking to community resources

Organizational support: an examination of the characteristics of organizational support for self-management

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continuity of care coordination of referrals ongoing quality improvement documentation of self-management support services patient input integration of self-management support into clinical care patient care team staff training and education

The improvement process using the CCRS

The Patient Assessment of Chronic Illness Care Assessment Tool

Patient Assessment of Chronic Illness Care (PACIC) The PACIC has been developed as a tool to gather data on the receipt of quality chronic condition care from the patients perspective. It collates patient data on the extent to which specific actions and care have been received in the previous six months. The scale has been created to assess the level of patient-centered care provided, the key elements of which are central to selfmanagement support (collaborative goal setting, problem solving and follow-up). Studies support the PACIC as a practical instrument that is reliable and has face, construct and concurrent validity.

The PACIC is a 20 item survey which is divided into five sub-scales:

Patient Activation (items 13) Delivery System Design/Decision Support (items 4

6) Goal Setting (items 711) Problem-solving/Contextual Counseling (items 12 15) Follow-up/Coordination (items 1620)

Each of the five sub-scales is scored by averaging the items completed within that scale. The overall PACIC score is determined by averaging scores across all 20 items. Research results highlight that goal setting and follow-up support activities were conducted significantly less often than other actions. The MacColl Institute for Healthcare Innovation requests that users share results and provide feedback about the instrument to facilitate continual update of its work and improvements to the instrument.

The PACIC and the 5 As model (optional)

The 5 As model of behavior change has been recommended throughout this resource as a method to enhance self-management support. There are limited assessment tools to determine the quality of its delivery.

Glasgow et al have included additional items to the PACIC to measure the delivery of each of the 5 As as well as an overall 5 As score. Conclusions for this study support the PACIC and the new 5 As scoring method as useful for diabetic patients and encourages further research.

PlanDoCheckAct (PDCA)
Solving problems Plandocheckact (PDCA) is a four-step problemsolving process that can be used to coordinate quality improvement efforts. The concept of the PDCA cycle was originally developed by Walter Shewhart during the 1930s and was advanced by W Edwards Deming, an expert on Quality Management, from the 1950s. The PDCA cycle is also known as the Deming cycle, Shewhart cycle, Deming wheel, or plandostudyact (PDSA). It is an applicable tool to aid improvement in selfmanagement support.

The steps in each successive PDCA cycle are:

PLAN
Establish the objectives and processes necessary to deliver results in accordance with the expected output (the target or goals). By establishing output expectations, the completeness and accuracy of the specification is also a part of the targeted improvement. When possible start on a small scale to test possible effects.

DO
Implement the plan, execute the process, and make the product. Collect data for charting and analysis in the following "CHECK" and "ACT" steps.

CHECK
Study the actual results (measured and collected in "DO" above) and compare against the expected results (targets or goals from the "PLAN") to ascertain any differences. Look for deviation in implementation from the plan and also look for the appropriateness/completeness of the plan to enable the execution, Do". Charting data can make this much easier to see trends over several PDCA cycles and in order to convert the collected data into information. Information is what you need for the next step "ACT".

ACT
Request corrective actions on significant differences between actual and planned results. Analyze the differences to determine their root causes. Determine where to apply changes that will include improvement of the process or product. When a pass through these four steps does not result in the need to improve, the scope to which PDCA is applied may be refined to plan and improve with more detail in the next iteration of the cycle, or attention needs to be placed in a different stage of the process.

Stages of the PDCA cycle

The four steps in the PDCA cycle direct progression from identifying a problem (highlighted from the CCRS or PACIC survey) to solving the problem and consequently achieving improvement in selfmanagement support. It both emphasizes and demonstrates that improvement in self-management support must begin with thorough planning, must result in effective action, and must return to thorough planning in a continuous cycle.

Figure PDCA STAGES. The figure provides an explanation of the PDCA cycle. Information for this flow chart has been adapted from a number of sources.

A Case Study
Implementing CCSM for mental health patients within a general practice in a rural area: a case study

INTRODUCTION
This case study demonstrates an action research-based series of PDCA cycles which have been instituted within a busy country general practice (GP) in South Australia. It has been developed in a sustainable way for patients with mental health problems. It provides evidencebased, coordinated and planned care that is monitored according to a care plan. The study shows that it is possible to provide this care by means of the use of systematic care planning, consultant psychiatrist assessment and review, general practice responsibility and close collaboration with mental health nurses employed by the practice under the Mental Health Nurse Incentive Program (MHNIP). It has been associated with substantial changes in the ways that patients have been managed within the practice. The implementation of these positive changes has been externally evaluated on two occasions and is ongoing and a further PDCA cycle is currently under consideration.

BACKGROUND
The delivery of evidence-based psychiatric care in general practice is difficult for many contributory reasons which include the high prevalence of these disorders, skill levels of and the competing demands on GPs, the historically separate state-based mental health care focused on psychosis and hospitalization, stigma and resource deficits of manpower and support services in the community.

There are many barriers to effective care, created by the structure of general practice. The barriers include the patient-demand driven structure of the appointment system, time allocation for appointments which is less than adequate for patients with emotional distress and carries with it perverse financial incentives, the waiting time for expert psychiatric assessments and the problems in communication between the many agencies often involved in the care of these patients.

The behavioral disturbances of the patients may also create problems for the orderly conduct of general practice as a business at times. Failure to keep appointments, needing urgent appointments or longer sessions than booked times, can disrupt orderly schedules, and reception staff can feel less than competent to deal with disturbed behavior of these patients and others who have been kept waiting. In rural general practice these problems are further magnified.

PDCA cycle 1
Plan The psychiatrist was invited to visit the GP on a consultation basis and a referral model of care on a private practice basis, as a part of his limited rights to this as a senior staff Specialist Liaison Psychiatrist at a major teaching hospital. An application was made by the practice to enable sponsorship for ten sessions per annum with the support of the Medical Specialist Outreach Assistance Program (MSOAP) which defrays the costs incurred by the specialist for travel, service and accommodation. In this case study the selected psychiatrist was actively involved in teaching and researching chronic condition self-management (CCSM).

Part of the agreement with the GPs was that the psychiatrist would work as much as was possible as a support to the GPs. The aim was to avoid referral to tertiary care by using a care-planning approach, with case conferencing, comprehensive assessment and reporting being the main instruments. Secondly, an action research approach using plan-do-check (study)act cycles (PDCA) within the normal practice development paradigm, methodology and business model of the practice was confirmed.

The visiting psychiatrist commenced in February 2005 with the initial agreement from the GPs to try to develop a coordinated care-planning approach for all referred practice patients.

Do The psychiatrist made eighteen visits during that year. A total of eighty-one new patients were referred from the practice and fifteen from other regional GPs. For all eighty-one practice patients, the psychiatrist had recommended the development of a mental health, complex condition or shared care arrangements care plan which could be claimed from Medicare in addition to the usual billing item numbers.

Check The review showed that in only twenty cases had follow-through been possible. The psychiatrist wrote to the Practice Manager indicating that from a financial point of view much of the work of comprehensive and integrated mental health or complex care had been carried out but the practice had not received an appropriate financial reward for this.

Act
The issue was discussed and the PDCA cycle was repeated to formulate a new plan of action

The issue was discussed and the PDCA cycle was repeated to formulate a new plan of action.
Plan A decision was made to apply for a practice development grant. The application was successful and allowed the employment of an experienced registered nurse without mental health expertise, to see what could be done to follow through recommendations by the psychiatrist to develop a care plan.

Do The new initiative was for the nurse to work more closely with the psychiatrist at the time of the visit (lunch time and at the end of the day to discuss patients) in order to follow through, and to complete tasks to fulfill the criteria required for the care plan to be effected and the remuneration to be claimed. This was done by the psychiatrist sending a copy of the assessment letter to the practice nurse as well as the GP. The nurse then followed through by creating a draft care plan and drawing this to the attention of the GP. The nurse made an appointment for the patient to meet with the doctor to sign off on, and institute the care plan. One element previously missing was that a quantitative screening instrument had not been routinely used by the GP in order to claim the item number and this was remedied by the nurse administering the DASS 21.

Check At the same time that the revised plan was put into practice, the Division of General Practice conducted a qualitative evaluation of the project. After three months of using the new system, all patients were being followed through by the practice for the development of a care plan. A number of events occurred that changed patient flow including the coordination of care and referral out to a community psychologist and mental health services. The opportunity of the MHNIP occurred at this time and was followed through by the practice, resulting in the accreditation of the practice and the nurse as part of the program, with the nurse working closely with the psychiatrist and the GPs.

Act The new system was successfully implemented. It was agreed by the partners at three months that this arrangement was in fact financially viable and practicable in terms of space and demands on clerical staff. In addition GPs did not feel that their role with the patients was being usurped and the psychiatrist also found the role of the MHN to be supportive. Doctors were still clearly responsible for each of the patients and their management plan. It was agreed to trial this arrangement over a further twelve-month period.

DISCUSSION
A new PDCA cycle was put into place to explore and develop the role, function and effects of introducing a full-time mental health nurse to the psychiatric services delivered by the medical center. A triage function also developed for the mental health nurse, as did back-up educational and support services for the nursing staff at the Community Hospital when patients needed to be hospitalized. It also led to the MHN being over-booked, with a blowout of waiting times for her and the psychiatrist leading to the common problem of clogged up clinical demand. This persisted even after a second MHN was employed

The major issue confronting the clogged-up clinical demand within this medical center was the limited availability of the psychiatrist but also the failure for the medical center to seriously address the issue of patient self-management skill development. The psychiatrist had suggested the implementation of the Flinders Program of Chronic Condition Self-management but the implementation has been considered an option rather than a necessity due to training cost and the implications for organizational change. However, it has now come to a time where each of the mental health nurses has reached the limits of efficient operation because of the low capacity for self-management by the more chronic and frequently relapsing patients. They place demand on the system and receive care that fails to address their selfmanagement needs. The next PDCA cycle will focus on this issue. The MHNIP can be implemented by GPs or a psychiatrist in private practice employing MHNs and recharging the Commonwealth Department of Health and Ageing at $250 per three-hour session for their work.

One of the major problems in the provision of evidencebased care is the implementation of new knowledge within the real world of general practice as a business. This case study shows that it is feasible to establish and progressively implement an evidence-based, integrated and coordinated model of care within a country general practice. While it has been externally reviewed, formal evaluation and comparison to current best standard care for patients with mental illness could be conducted. This project is self-sustaining on a routine basis and is not simply a demonstration project which depends upon idealism and altruism, which although admirable, are not self-sustaining in the long term.

LESSON LEARNED
As a Nursing student, we often have the difficulty to manage every bunch of workloads, but by using PDCA cycle we could structure things to be organized without failing any works. The day starts with an initial to-do list (Plan); working through the list (Do), I complete tasks; I observe that the list grows and shrinks as new tasks come in, and existing ones are finished (Check). I alter priorities in the list (Act) to accommodate the day's unfolding requirements. Each day, therefore, consists of one or more iterations of the PDCA cycle.

Another thing, as a nursing student we often have the difficulty to generate or to absorb every lessons that was being discussed due to overwhelming number of lessons which was being discussed by every nursing subjects, we often have thoughts like "are we able to finish all things in a given time frame?" but through applying the four steps in PDCA model, we learn to control our thoughts regarding the overwhelming workloads which often affects our thoughts while learning. Through PDCA cycle it gives us the systematic approach that ensures our learning that will not jump into random doing things you deemed proper but which may not be the case.

BIBLIOGRAPHY
BOOKS
Bonomi AE, Wagner EH, Glasgow RE, VonKorff M. (2002) Assessment of Chronic Illness Care. A practical tool to measure quality

improvement. Chicago, IL. p791820.

Mclean, Gary N, (2006) Organization Development Principles Processes Performance. PDCA cycle San Francisco p. 19 Wagner EH, Austin BT, Von Korff M., (1996) Improving outcomes in chronic illness. Managed Care Quarterly. New York, NY United Statesp103

Pols RG, Battersby M, Haydon D.,(2010) Implementing Self-Management Support. A case study in a rural general practice. RANZCP Congress, Auckland.

 PERIODICALS Bodenheimer T, Wagner EH, Grumbach K. (2002) Improving Primary Care for Patients with Chronic

Illness. Journal of the American Medical Association

Bodenheimer T, Wagner EH, Grumbach K. (2002)

Improving Primary Care for Patients with Chronic Illness The Chronic Care Model, Part 2. Journal of the American Medical Association

ELECTRONICS
http://en.wikipedia.org/wiki/PDCA_cycle http://www.hci.com.au/hcisite2/toolkit/pdcacycl.htm Improving Chronic Illness Care website

http://www.improvingchroniccare.org http://www.improvingchroniccare.org/downloads/ICIC_Tool kit_Full_FINAL.pdf https://www.cahps.ahrq.gov/default.asp. http://www.diabetesinitiative.org http://www.diabetesinitiative.org/support/documents/PCRS overviewpresentation_000.pdf http://www.hci.com.au/hcisite2/toolkit/pdcacycl.html