The Model for Improvement and Decreasing Variation

The Model for Improvement developed by Langley et al⁴ is based on 3 fun­damental questions. What are you trying to accomplish? How will you know that a change is actually improvement? What changes can be made that will result in improvement?

The question “What are you trying to accomplish?” is best answered in an “aim statement.” This is a concrete statement agreed on by all members of the QI team.

The question “What changes can be made to result in improvement?” requires an understanding of the factors influencing your measurement of interest. To facilitate this, many use what is referred to as a key driver dia­gram. The key drivers are the anticipated conditions necessary to achieve your aim. Understanding the key drivers requires a solid knowledge of system processes. This may require spending time on the “frontline” or interviewing frontline personnel—better yet, invite a couple to be part of the QI team. Often, as you get to know your project better, new key driv­ers are identified. Flowcharting a process in chronologic sequence may help identify key process drivers. The key drivers are important, because they inform target areas with which to test changes. The key drivers are the pis­tons of your process engine. All pistons must function well and efficiently for your process to be successful.

The PDSA Cycle

The PDSA cycle is one commonly used method for testing system changes as one works toward process improvement. Plan is when a problem is iden­tified and a testing strategy for an improvement change is developed. It is important to predict and record what you think the results of the test will be prior to making changes. Do is when the testing plan is implemented with clearly defined personnel roles and expectations. The process is monitored and performance carefully tracked. If there are a lot of test cases, the change may be monitored on a run chart; however, notes may be more useful if there will only be a few cases. Study is the phase when data are analyzed and results summarized and discussed amongst the QI team. How do the results compare with your team's initial prediction? Act is the phase in which next steps are determined based on what was learned during testing. Perhaps the test is a tremendous success, and plans should be made to expand imple­mentation. Perhaps a few more tweaks need to be tested and reexamined with another PDSA cycle prior to larger implementation. Maybe the test was a failure, and you go back to the brainstorming phase. No test, however, is truly a “complete failure,” because each test, whether the result is positive or negative, allows us to learn what works and does not work in this system­atic trial-and-error process.

Other QI Methodologies

There are many different approaches to quality improvement—reviewing all of them is clearly outside the scope of this chapter.

Lean manufacturing or, simply, “Lean” is a QI strategy that considers expenditure of resources for any goal other than the creation of value for the customer to be wasteful. The goal of Lean is to preserve value with less work and less waste. Lean manufacturing is a strategy originating from the Toyota Production System and focuses on 7 common areas of waste that hinder overall customer value: overproduction, waiting, transport, extra processing, inventory, motion, and defects.

Both Six Sigma and Lean methodologies can be applied to neonatal and pediatric critical care transport. Decreasing variation in practice by instituting evidence-based treatment protocols for the common diagnoses a team transports would be an appropriate application of Six Sigma prin­ciples. Centralizing a transport service's stock of supplies and equipment to decrease restocking delays between stacked runs would be an important application of Lean concepts.