From Davis Balestracci -- Getting REAL with Rapid Cycle PDSA

Published: Mon, 02/01/16

From Davis Balestracci -- Getting REAL with Rapid Cycle PDSA

[~ 1150 words:  Take 5 to 7 minutes to read over a break or lunch]

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Another Case of "Don't just do something, stand there!"

Hi, Folks,

Marketers continue to be relentless in their efforts to seduce you with offerings of the fancy tools, acronyms, Japanese terminology – and promises – of their version of formal improvement structures such as QI, Six Sigma, Lean, Lean Six Sigma, or Toyota Production System -- each with its own unique toolbox. 

My last newsletter discussed the need of becoming more effective by using far fewer tools in conjunction with critical thinking to understand variation. 

In the midst of all this, I've seen Deming and Shewhart's brilliant, fundamental PDSA [Plan - Do- Study - Act] morph to an oft-spouted platitude, and I laugh to myself when I hear people casually comment that PDSA and PDCA are the same thing (they're not). 

And now the tool of Rapid Cycle PDSA is increasingly popping up in some way, shape, or form. Healthcare has especially taken a  "Go on...just DO it!" attitude encouraging anyone to test ideas in their routine work as a way to work around sluggish management.  The rallying cry is: "What can we do now?  By next week?  By Tuesday?  By tomorrow?"

Rapid Cycle PDSA in a nutshell:

  • Test on a really small scale. For example, start with one patient or one clinician at one afternoon clinic and increase the numbers as you refine the ideas
  • Test the proposed change with people who believe in the improvement. Don't try to convert people into accepting the change at this stage
  • Only implement the idea when you're confident you have considered and tested all the possible ways of achieving the change.

What sounds so easy and commonsensical at a conference or in a paper:

[Click here for source  [free full text access], which will allow you to download this and the next figure (below) as PowerPoint slides]

hits your messy reality when you try apply it in an everyday environment:
[Original article includes deeper discussion of this figure]

The simplicity of smooth upward linear progress is a myth.  

As many of us have discovered, application involves a complex tangle of frequent false starts, misfirings, plateaus, backslidings, and overlapping scenarios within the process.  Not all cycles have equal impact on project development and therefore vary in size, and not all cycles are completed. Positive or negative residual effects from a cycle can linger.  Cycles at varying levels of success interact with other cycles in various stages of the PDSA cycle. Some cycles explore or define limitations or setbacks, and it is not until later cycles that the challenges are harnessed to make improvement possible.  And even that may not always happen.

But don’t worry:  there are guides to (allegedly) help you, e.g., example #1 and example #2 .  You’d better have an aspirin bottle handy – I never fail to get a headache when I look at "prescriptive straitjackets" such as these. 

You are on the road to becoming an advanced practitioner when you realize that you don't need to keep learning additional prescriptive advanced tools -- and only 1 to 2 percent of you need advanced statistics!  Revisiting John Heider's quote from The Tao of Leadership

            Advanced students forget their many options.
            They allow the theories and techniques that they have learned to recede into the background.

            Learn to unclutter your mind.
            Learn to simplify your work.

            As you rely less and less on knowing just what to do, your work will become more direct
            and more powerful.

[The hands down best reference on PDSA remains The Improvement Guide]

The implicit "plan" of Rapid Cycle PDSA seems to be:  (1) Come up with a reasonably good idea to test and then (2) plan the test

There is a naïve assumption that it takes good people with good ideas doing their best to improve quality.

As Deming growled many times:
  • "They already are...and that's the problem!"
  • "For every problem, there is a solution:  simple, obvious...and wrong!"

Paraphrasing my mentor Heero Hacquebord:  The most important problems are not the obvious ones.  They are the ones of which no one is aware.

Remember the quality circles disaster in the 1980s?  20th century quality giant Joseph Juran's view was that success of these efforts required the need to be grounded in an already strong viable improvement culture with executive support.  Actually, Lean's foundation of "standardized work" is probably one of the best ways to initially focus such a process.

There is a danger that many "good ideas" could be naively applied to the more obvious, superficial symptoms of deeper, hidden problems. In addition, one must inevitably deal with resistance and unintended human variation every step of the way during testing the idea and then trying to implement the idea.  And there is the most non-trivial issue of collecting data during the change -- usually an afterthought and planned ad hoc…if any is collected at all.

My respected colleague Mark Hamel has astutely observed:

  • Human systems don't naturally gravitate to discipline and rigor.
  • Most folks are deficient in critical thinking, at least initially. [my emphasis]

Today?  Tomorrow?  Next Tuesday?  Next week? -- in an environment where the leaders are not instilling discipline, prompting critical thinking, or facilitating daily kaizen?

Application of rapid cycle PDSA requires important nuances and the uneven, dynamic, and messy reality of implementation.   Any environment has its own unique challenges and opportunities -- the 20 percent of its process causing 80 percent of its problem.  Change creates an interplay that is rarely neat and linear, and it is very culture specific.  

If you are at a conference session or read a paper that makes the process sound as simple as smooth uphill linear progress, they could either be naively (and dangerously) unconscious of the reality or have sanitized their situation beyond recognition (especially acceptance of the change).  In any case, don't trust any touted results...and ask lots of questions! 

Also ask yourself, "What would Deming say?"  And I've heard him:  "What's your theory?  Examples without theory teach nothing!"

If you apply critical thinking to your current efforts, you are guaranteed to run rings around the results of any neatly packaged and sanitized example that at best presents the 20 percent of their process that solved 80 percent of their problem -- in their unique culture.

By all means, use rapid cycle PDSA
Remember:  there is no avoiding being in the midst of the presence of variation everywhere -- including the variation in variation experienced among similar facilities!   Effective application of rapid cycle PDSA requires being conscious of the need to complement its intuitive nature with the discipline necessary for good critical thinking and appropriate formality. 
This also includes improving the process of using it.  After each cycle, ask:

  • What unexpected "variation" was encountered?  What was learned about the improvement process itself? 
  • How will it be improved for future interventions?
  • What aspects of the specific environment were relevant to the effectiveness of the intervention?
  • What were the elements of the local care environment considered most likely to influence change/improvement?
  • Will a similar intervention work in a different setting?  

But remember the crucial importance of initially formulating strong theories to test.  Make this a vital part of the "P."  Dialogue based on the following two questions could  be a good place to start:

  • Why does routine care delivery [or product quality] fall short of standards we know we can achieve?
  • How can we close this gap between what we know can be achieved and what occurs in practice?

Until next time...

Kind regards,
P.S. Are you ready to stop being frustrated by a vague improvement process that rests
on hope for "improvement in general" on vague problems while being perfectly designed
for vague support, vague data and vague results?

Wouldn't you rather get better faster...and get the respect you deserve with results that get attention?

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