How to Get a Project Started

The SVS Quality Improvement Committee has assembled the resources linked below to help any vascular team successfully start a new project for improving patient outcomes. If you have questions, please email svsquality@vascularsociety.org. PDSA (Plan-Do-Study-Act) Framework for QI projects:

  • What is the PDSA cycle? While there are many different frameworks for organizing a project, the PDSA cycle is one of the most commonly utilized and referenced. PDSA stands for Plan-Do-Study-Act and this method originates from industry but is easily applied to the healthcare setting.
  • What are the steps of the PDSA cycle?
PDSA Quality
  • PLAN: 
    • Start by asking: what are we trying to improve? For example, perhaps your group notices that your surgical site infection rate after lower extremity arterial bypass has been above the regional and national mean for the past three quarters. Once you have identified an opportunity for improvement (see tips and tools), you then execute the following steps:
      1. Recruit a team: a diverse team of members who have varying areas of expertise (ex. subject matter, quality or process improvement) is helpful. Once assembled, clarify roles and responsibilities, set timelines and a meeting schedule
      2. Identify opportunities for improvement in the current process (ex. surgical site infection prevention)
        • Search the literature and interview experts to identify relevant best-evidence practices. Example: antibiotics within 30 minutes of incision time, normothermia, sterile surgical site preparation with alcohol-based preparation and appropriate hand washing are associated with decreased SSI after lower extremity arterial bypass.
        • Map out your existing process and compare the existing state to the desired state.
          • Identify major steps in the process, who is involved and whether the steps are performed consistently. The goal is to compare what we think is happening with what is actually happening. This may include direct observation or audits in addition to interviews with process owners.
          • Identify if there are missing steps or areas where there is an opportunity to improve the steps. Also, take note of any wasted or areas of inefficiency if relevant.
          • You may use a process map or swim lane map to organize the information and review with stakeholders. 
          • You can utilize a pareto chart or fishbone diagrams in this step to brainstorm any specific causes of error or problems. 
      3. Identify specific interventions that you feel will result in improvement in the process and outcome. 
        • Interventions should address the key drivers of error or problems identified in step two. A driver diagram can be used to organize this information. 
        • Tip: Focus on the low-hanging fruit. Considerations for interventions should prioritize simplicity rather than complexity such as improvements in existing processes instead of new processes. In addition, interventions that do not rely on memory are much more effective (ex. integration into an existing orderset rather than providing education and reliance on memory
        • When there are multiple possible interventions available, use your team to help prioritize a few changes as an initial start.
      4. Draft a problem statement and a SMART goal: The problem statement helps clarify the specific problem. SMART stands for specific, measurable, achievable, relevant and time-bound and a SMART goal helps clarify what level of improvement you are hoping to achieve and in what time frame. 
        • For example, the steps above reveal many patients are prepped with Betadine and antibiotics prophylaxis is frequently administered after incision. Plan - switch all skin preparation from Betadine to Chlorhexidine and add commonly used antibiotics to the PICS in the preoperative area to avoid delays in delivery to the OR.
        • Resultant example problem statement and SMART goal:  Postoperative surgical site infection is associated with increased morbidity and cost of care. Surgical site infection rates following lower extremity arterial bypass at our institution are significantly higher than the national benchmark (ex. 8% vs. 3%). We will decrease surgical site infection rates following lower extremity arterial bypass by half within 8 months by switching the type of skin preparation and ensuring antibiotic prophylaxis is administered within 30 minutes of incision.
      5. Develop a project charter that includes the problem statement, SMART goal and also the process and outcome measure you will track and use to define success. The charter will also include the roles and responsibilities you outlined for your team earlier in the planning phase. See the template project charter here. 
  • DO:
    1. Implement the proposed changes. 
      • It is vital to review the process changes with the process owners to anticipate any barriers, particularly if there are process owners who are not a part of your team.
      • Have a plan for how to determine if the process changes are actually happening (ex. regular audit of skin preparation type and time of antibiotic prophylaxis prior to incision).
      • It is helpful to have a specific kick-off date and a plan to celebrate early wins (ex. public shout-out to the team members who have the best adherence to set goals or provide weekly compliance rates for team members to review).
      • Make sure stakeholders have a clear way to report any unanticipated challenges or barriers.
      • Have a plan for when and how to review the results with both your team and various stakeholders
  • STUDY:
    1. Gather data that is relevant to your SMART goal and review it regularly. The timeframe will vary depending on the process and how frequently it is utilized (ex. if you only do one lower extremity bypass a week, then you may want to review monthly).
    2. Are there any unanticipated outcomes that have occurred as a result of your changes? These are often called balancing measures. For example, if your goal is to reduce the length of stay, it’s possible you may achieve this goal but at the expense of increased readmissions.
  • ACT:
    1. If your interventions have resulted in the desired outcome, then this step consists of making these changes permanent and identifying a plan for monitoring over time to address any new problems
    2. In many cases, there is some improvement but not at goal or perhaps no discernable change. If you can confirm that the proposed changes in the process are happening (ex. >80% compliance), then you should return to the PLAN phase and reevaluate. Multiple PDSA cycles may be utilized for a project.

 

Supplemental Tips and Tools for Success

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Quality Improvement