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Test and Refine Actions on a Small Scale

Once you have selected interventions, the next stage of the cycle is to develop and test specific changes. It helps to think of this stage as a number of “mini-cycles” within the larger improvement cycle, in the sense that the microsystem or team is likely to go through multiple iterations of testing and refining before the specific changes add up to a real intervention.

Small-scale tests of the interventions you wish to implement help refine improvements by incorporating small modifications over time. Conducting these small tests of change within a microsystem can be very powerful:

  • They allow for incremental modifications of interventions to fix problems, which helps the larger implementation run smoothly.
  • Failures are low-risk because you have not tried to change the entire culture.
  • You create enthusiasm and positive “word-of-mouth” for early successes.
  • It is easier to accumulate evidence for implementation when people are engaged in making something work rather than focused on the “failure analysis.”

Most improvement strategies require some adaptation to the culture of the organization. Patient-centered improvement strategies have to consider the needs of patients and their families as well as the staff. Moreover, front-line staff will frequently resist new ideas if they are not allowed to modify them and test their own ideas.

4.B.4. Act: Expand Implementation to Reach Sustainable Improvement

Building off of the development and testing of specific changes, the final stage of the PDSA cycle involve adopting the intervention and evaluating it against the goals of the improvement project and the measures established for tracking improvement progress. For example:

  • Did the intervention succeed in reducing the time required to see a specialist?
  • Are members and patients reporting better experiences with regards to getting care quickly?

This part of the improvement cycle is really the ongoing work of health care and where your teams will spend most of their time. There are no set rules about how long this part of the cycle takes. It depends in part on how frequently you monitor your CAHPS scores and other quality measures.

It is important not to let the work go on too long without ongoing measurement in order to make sure you are making progress toward achieving your aims. Most monitoring takes place on a monthly or quarterly basis. The team can use data on the impact of the intervention to see if it is making progress towards the goals and to determine whether to conduct a new set of analyses of its CAHPS performance. The purpose of this effort is to get some sense of what worked, what did not work, and what further or new interventions may be needed. To the extent that the improvement initiative was successful, the team must also think about ways to sustain and spread the improvements over time.