Using the plan–do–study–act (PDSA) cycle to make change in general practice

Abstract

As new members of the team, GP trainees can provide a fresh perspective on practice systems. They are, therefore, ideally placed to enact change within practices. However, GP trainees may feel ill-equipped to suggest and deliver change to their practices. This article will explore the concept of change management using the plan–do–study–act cycle and consider how to initiate change by providing a structure to guide the process.

The GP curriculum and change management

Contextual statement 2.02: Patient safety and quality of care states that as a GP you should:

Understand principles of improvement methodology to facilitate change

Show that, as a specialty trainee (GP) within the team environment of general practice, your experiences gained in previous settings can be shared with colleagues. Recognise that the formal Patient Safety Agenda is relatively recent and may be unfamiliar to well-established colleagues

Illustrate how changes in behaviour and/or systems can influence patient safety

Contextual statement 2.03: The GP in the wider professional environment states that GPs should be able to:

Take into account the needs, feelings, values and expertise of others

Understand the process of change and factors that influence it, and use resources for obtaining support in developing and leading change

Apply quality improvement methodologies

Demonstrate the ability to improve the quality of healthcare delivered to your patients by the practice

Engage positively with change

Successfully manage a simple quality improvement project

The change process

The use of a structured approach to make a change can not only ensure better delivery of healthcare, but also help develop team work and leadership skills (RCGP, 2016a). Use of this structured approach can address specific quality problems and positively influence organisational culture (Reed & Card, 2016). Quality improvement activities form a mandatory component of the curriculum for GP trainees. GPs are also then expected to continue undertaking quality improvement activities as part of appraisal and revalidation (RCGP, 2016b).

Failure to manage change effectively can leave members of the practice feeling excluded, confused and powerless (Strebel, 2009). As illustrated in Box 1, barriers to change can be divided into individual, organisational and external factors (National Institute for Health and Clinical Excellence (NICE), 2007).

Box 1.

Barriers to change.

• Individual factors: There may be a knowledge-deficit on how to enact change or a lack of motivation or time to engage with change (NICE, 2007). Individuals may carry out change without reference to a structured process, thus, threatening successful implementation of change (Reed & Card, 2016). Individuals may fail to consider the requirements for sustainable improvement (Auerbach, Landefeld, & Shojania, 2007).

• Organisational factors: Lack of resources or personnel to deliver change (NICE, 2007). Practice culture resistant to change or engaging with the process of change (Reed & Card, 2016). Perceived cost implications of engaging with change such as loss of time for clinical commitments (Auerbach et al., 2007).

• External factors: Conflicting priorities set by commissioning bodies and financial disincentives for the desired change at practice level (De Silva, 2015).

The plan–do–study–act cycle

Although there are multiple models offering frameworks for change, this article focuses on the plan– do–study –act (PDSA) cycle. The PDSA cycle, also known as the Deming cycle, was adapted from the works of Shewart in the 1920s. The four-stage cycle focuses on the continual improvement of a product or process. In the ‘plan’ stage, a change aimed at improvement is identified. The ‘do’ stage sees this change tested and the ‘study’ stage examines the success of the change. The ‘act’ stage identifies adaptations and next steps to inform a new cycle (Taylor et al., 2013). The PDSA cycle is widely used within the healthcare setting (Taylor et al., 2013) and is recommended by the RCGP’s Quality improvement for general practice guide (RCGP, 2015). Figure 1 illustrates each stage of a PDSA cycle.

Figure 1.

PDSA cycle.

The PDSA cycle can be considered an efficient way to collect data, as it advocates collection of just enough data to inform future PDSA cycles. The iterative nature of the PDSA cycle helps to minimise resistance when change is implemented. This is achieved by small intervention cycles that help increase confidence in the change by incremental modifications and refinements (Leis & Shojania, 2016). Although the PDSA cycle is simple in concept, it can be challenging to authentically execute (Reed & Card, 2016).

In the next section, the PDSA cycle will be explained with an example. The example illustrates how a GP trainee may initiate change within a GP surgery by designing an anticoagulation template for the GP computer clinical system. The aims of the change allow for a standardised approach to anticoagulation initiation and drug-monitoring standards.

Plan stage

The first step before making a change is to stop and describe what is currently going on (RCGP, 2015). This helps justify the reasons for making a change. There are a variety of tools that can help identify potential areas of change. A strengths, weaknesses, opportunities and threats (SWOT) analysis is a strategic planning tool that can be used to consider internal and external factors that currently affect the organisation (Iles & Sutherland, 2001). GP trainees may, therefore, find this a useful way of identifying an area within the GP surgery that may benefit from a quality improvement activity. Haberburg (2000) identifies that there is uncertainty over the origins of the SWOT analysis, although it was thought to have been used by academics at the Harvard Business School during the 1960s. Box 2 details each domain of a SWOT analysis. A sample SWOT analysis, seen in Table 1, can be completed individually or shared among the practice team to gather an overview of the current position of the practice.

Table 1.

SWOT analysis.

Strengths (What works well at the practice?)	Weaknesses (What does not work well at the practice?)	Opportunities (Are there any upcoming opportunities for the practice?)	Threats (Are there any upcoming threats for the practice?)
• Onsite dispensary affording patients an easy way of redeeming prescriptions • Excellent team morale fostered by a daily coffee break • GP with experience designing templates for the computer clinical system	• High number of inappropriate home visit requests • Frequent interruptions when signing repeat prescriptions • No standardised approach to anticoagulation initiation or monitoring	• New premises • New funding for a service needed by the community • New teledermatology equipment	• Withdrawal of funding for a community service • Suspected closure of a nearby practice • Pending retirement of the practice’s asthma nurse

Box 2.

SWOT analysis domains.

• Strengths: Advantages, positive factors, successful activities, attributes and areas where the practice team excels

• Weaknesses: Disadvantages, negative factors, failures and areas where improvement is needed and preferably possible

• Opportunities: Areas that present the prospect of improvement and potential benefit to the practice team by the implementation of change

• Threats: potential problems, areas that may have negative consequences in the future, activities or areas that may need to be appropriately managed/ require change

Results from the SWOT analysis can uncover an area to develop for a PDSA cycle. In this example, the practice does not have a standardised template for commencing patients on a direct oral anticoagulant (DOAC). There may be inadequate record-keeping on patients being adequately counselled when initiated on a DOAC. Without adequate record-keeping, there will be no evidence that adequate information has been given to patients (for example, on carrying an anticoagulation alert card or advice on drug monitoring).

Other examples include: restructuring the repeat prescription signing process at the practice (to provide protected time for script-signing), creating a doctor-led triage system for home visit requests (to assess suitability and reduce unnecessary home visits), and designing an intervention to recall asthma patients requesting frequent reliever therapy (to optimise asthma management).

Once the area requiring change has been identified, it is important to define what changes are proposed. The pro forma in Table 2 can be a used as a means of structuring a PDSA cycle. The pro forma has been completed using the example of implementation of an anticoagulation template.

Table 2.

Example pro forma to assist with change management.

Title: Developing an anticoagulation template for the GP medical record
Name:	Date:
Stakeholders: GPs, practice nurses, administration, pharmacist, clinical commissioning group (CCG), anticoagulation clinic, patient participation group (PPG).
Area of change: Implement an anticoagulation template accessible from the GP medical record to help ensure all patients with a CHA₂DS₂VASc score of one or greater have been adequately informed about anticoagulation. This will help ensure that the correct monitoring is being performed and that appropriate safety nets have been put in place for those on anticoagulation, such as an anticoagulation alert card.
Why needed: No current standardised approach to practice-initiated anticoagulation and varying levels of baseline tests for DOACs.
Proposed method of achieving change: • Liaise with CCG/ anticoagulation clinic to ascertain if a template is currently available • Meeting with PPG to assess suitability • Meeting with community pharmacist to identify anticoagulation medication interactions that should be flagged on template • Meeting with clinical system administrator on designing computer system templates • Training event to inform GP/practice nurses of the template
Proposed timeline: • Complete stakeholder meetings: First 2 months of placement • Template design and implementation: Months 3 and 4 of placement
Action plan: Meet with clinical supervisor to discuss suitability of above changes.

Note: Example pro forma adapted from page 58 of ‘Quality improvement for General Practice’ London: RCGP.

It is important to define the intended outcomes of the PSDA cycle, and this can be done by making the outcomes SMART: Specific, Measurable, Achievable, Realistic and Time-based (Doran, 1981). Leis and Shojania (2016) advocate small goals that can be tested, and then modified as needed. Therefore, for the initial PDSA cycle, the focus is on one DOAC with plans to include other anticoagulants on the template in future cycles.

It is important that anyone involved or affected by the change has an opportunity to input into the change process. Organisations or people that are affected by the changes in PDSA cycles are known as stakeholders (Iles & Sutherland, 2001). Presenting a completed pro forma at a practice meeting or in a tutorial with a clinical supervisor can help identify stakeholders.

A stakeholder analysis is a tool to assess the influence and resources that the stakeholders bring, and it has the value of increasing the chance of successful change by influencing both planning and delivery (Varvasovszky & Brugha, 2000). It is important to identify the stakeholders in the change process, so that barriers and challenges can be overcome at an early stage. Possible stakeholders may include GPs, practice nurses, GP trainees, medical students, allied healthcare professionals, administration, the patients and the practice manager. As part of the analysis it may be necessary to organise meetings or telephone calls with the stakeholders to understand their perceptions and perspective. For example, meeting the community pharmacist may lead to learning on drug interactions with the DOAC, which will help inform the anticoagulation template. Early involvement of stakeholders is encouraged, to help ensure successful change (RCGP, 2015). This can provide clarity on the changes intended from an early stage and encourage stakeholder ‘buy in’. Proposed changes may be at risk of not being implemented if there is a lack of consensus on the necessity for change among the stakeholders (Dixon-Woods, McNicol, & Martin, 2012).

In the example in Table 2, it may be identified from discussions with the practice team that another GP surgery within the Clinical Commissioning Group has already implemented the use of an anticoagulation template. It may, therefore, be possible to share ideas with the respective practice team to see if a similar template can be adopted. Further to the stakeholder analysis, the pro forma should be updated to reflect any modifications made.

Do stage

In the ‘do’ stage, the changes identified are implemented (Gillam & Siriwardena, 2013). Changes from quality initiatives can have wide ranging consequences and include unintended or unplanned consequences. These should be considered when measuring the effectiveness of the change (Illes & Sutherland, 2001). In the example, a template could be designed with the support of a GP from the team who has experience of creating computer templates for the clinical system. The initial template might provide a stepwise approach to standardise how GPs initiate a specific DOAC and set-up a recall for drug monitoring. The GPs could then be informed about the new template, and its use monitored over 3 months. A planned effect might be greater compliance with drug-monitoring, and an unplanned effect might be improved time-efficiency within the consultation when using the template to assist record-keeping.

It is rare that efforts to drive improvement go smoothly (Leis & Shojania, 2016). For example, the template might be difficult to locate, leading to poor uptake by GPs at the practice. Reed and Card (2016) identify that key learning can occur when changes do not go as planned. In this example, difficulty locating the template might encourage a redesign of access to the template, so that it appears automatically when typing a designated read code.

Study stage

The ‘study’ stage identifies if the change implemented has made an improvement and whether further change is required. A suitable means of assessing whether there has been an improvement in quality of care should be utilised. For example, an audit could be performed to identify whether adherence to anticoagulation blood test monitoring guidelines has improved with the introduction of the anticoagulation template. This might have patient safety implications, for example, by ensuring that patients are on the dose of DOAC appropriate to their renal function.

The Institute for Healthcare Improvement (IHI) states that ‘While all changes do not lead to improvement, all improvement requires change’ (IHI, 2017). A reflection can be useful to consider whether the changes introduced amount to an improvement (Gillam & Siriwardena, 2013). A reflective log entry in the Trainee ePortfolio may assist with development of critical-thinking, analysis of learning and the identification of areas for further development (RCGP, 2017).

The RCGP’s Quality improvement for general practice guide (RGCP, 2015) encourages the results of the change to be communicated with the stakeholders regardless of whether an improvement has been achieved. This ongoing communication will keep the stakeholders up-to-date throughout the PDSA cycle and aligned with any plans for future cycles. For example, the anticoagulation template could be cascaded to other practices at a local learning group to demonstrate the learning from the process and any improvements achieved. However, it is important to note that change initiatives may not translate across organisations, for example, due to different organisational cultures and engagement with the iterative process of PDSA cycles (Walshe & Freeman, 2002).

Act stage

Leis and Shojania (2016) identify that improvements may not occur with the first PDSA cycle. Therefore, the ‘act’ stage focuses on what should be planned for the next PDSA cycle. This should incorporate any modifications that are deemed necessary from the ‘study’ stage that may lead to an improvement (Gillam & Siriwardena, 2013).

The PDSA cycle demonstrated in Fig. 1, should not be thought of as a process involving just a single rotation of the cycle. Further rotations are required for continuous improvement (Taylor et al., 2013). Dixon-Woods and Martin (2016) identify that organisations often fail to stick to changes from quality improvement projects after initial implementation, and that replication can help ensure success. In the example, the anticoagulation template might need improvement with the incorporation of other anticoagulants. Further engagement by the practice team with the PDSA cycle could ensure ongoing improvements to the template and shared ownership of successful change by the practice team.

Conclusions

Engaging with a structured approach to change, such as the PDSA cycle, can assist GP trainees with delivering change. Although not every change is an improvement, significant learning can occur through engaging with a quality improvement activity. An important aspect of delivering change is to ensure involvement of stakeholders throughout the change process. This increases their confidence in the process and will increase the likelihood of success. The PDSA cycle should not be considered as singular event, but rather as a continuous process that aims to achieve incremental improvement. Undertaking quality improvement activities using a PDSA cycle will benefit GP trainees in their future careers and develop skills and experience in team-working, leadership and change management.

Key points

Practice teams can benefit from the insight that GP trainees bring from experience in other general practice and secondary care placements

The analysis of strengths, weaknesses, opportunities and threats can provide a useful tool to identify possible areas for change

Use of a pro forma may help GP trainees to structure a change management proposal

Resistance to change from members of the primary care team can be reduced by involving them in the change process

Skills in change management can be developed by GP trainees, and will be valuable throughout their careers

Footnotes

Acknowledgement

Dr Daniel Crowfoot would like to thank the Health Education East Midlands GP Fellowship Scheme for funding his time at the University of Nottingham.

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