Implementing site changes with Plan-Do-Check-Act

Many healthcare organizations are contemplating making dramatic changes in the way they do business and treat patients.  Some of these are driven by the recently passed Accountable Care Act and the Tarp Bill.  They are planning on adopting electronic medical records, becoming Accountable Care Organizations or becoming Patient-Centered Medical homes.

Unfortunately, like many businesses, they will undergo a lot of stress and loss of resources in time and money in making these changes.  They will end up like Napoleon when he invaded Russia in the summer of 1812.  By the winter he and his army had suffered tremendous losses.  I believe that much of these losses will be due to the silo mentality found at many healthcare sites.  The article “How Teams Work—Or Don’t—In Primary Care:  A Field Study of Internal Medicine Practices” in the May 2010 issue of Health Affairs documented this.

One approach to successfully implementing desired changes at a site has as its basis an approach that is understood and used by most in clinical medicine—the scientific method.  In problem solving and implementation theory, it is often called Plan-Do-Check-Act.  Most good hospitals use this approach but few primary care sites do.

Let me briefly illustrate how to use this approach.  Suppose an ambulatory site has decided to adopt the patient-centered medical home model (PCMH) with the goals set out by NCQA.  The PDCA cycle at the site could look something like this:

Plan. A team of physicians and administrative staff is formed to assess which of the goals the NCQA has set for PCMH’s it has achieved.  The assessment should include diagrams or narratives of how the site is currently meeting the goals.  After paying particular attention to the ten “must pass elements” it decides to focus further on tracking tests and identifying abnormal results.

The team decides that it should designate one individual at the site to keep track of the tests that have been ordered and follow up in collecting the results; this could be a non-physician care coordinator, someone who focuses on the care of the patients with chronic conditions.

Do. The non-physician care coordinator becomes familiar with the methods the physicians use to order tests.  This coordinator may keep track of the ordered tests on a paper log or through a registry.  The coordinator daily checks with the providers of the tests to see if there are results available.  If there are, then the ordering physician or another designated clinician is notified of the result in order to notify the patient.

Check. An internal audit of the process is carried out.  Someone other than the care coordinator selects a random sample of relevant documents to see that test results were collected and patients notified in a timely manner.  The results of the audit are reported to the team originally formed to plan the sites approach to reaching the goals.  The results are scored and compared to the NCQA’s scoring rubric.

Act. The team verifies whether the site has successfully achieved the goal as set forth by the NCQA.  If it has, then it documents and standardizes the process.  If the team finds that the site did not meet the goals, then is should work together to redesign the process in order to meet the goal, going through the PDCA cycle once again.  Even if the goal is reached, the team should go through the PDCA cycle in the future with this goal in order to make further improvements.

With the PDCA approach health care sites can solve many of the problems it encounters and plan for future changes which will go much more smoothly.

Donald Tex Bryant is a consultant who helps healthcare providers meet their challenges. He can be reached at Bryant’s Healthcare Solutions.

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