Q As the nurse manager of a primary care clinic that sees a high volume of patients diagnosed with hypertension, I've noticed the percentage of adult patients with hypertension has increased and follow-up care has decreased this past quarter. How can I use the Plan-Do-Study-Act (PDSA) process to intervene?
The PDSA model is a valuable tool to use when implementing a process improvement. Consider the following steps as an example of how it could be applied in this type of scenario.
Plan: Defining the problem and developing a plan are critical first steps for any improvement process. Decide what measures to track and set a goal for improvement. Measures generally fall into one of three categories: structure, process, and outcome. Structures are stable features of a system, such as staffing, policies, and physical workspace.
For this situation, who screens and creates follow-up care plans? Process measures reflect the activities that clinic staff members use to provide patient care; for example, the screening and follow-up care processes. Outcomes are measured effects on the patients' health; for example, the percentage of hypertensive patients with controlled BP.
Assemble your clinic team to discuss factors contributing to your problem. A fishbone diagram will help identify multiple contributing factors. A common reaction is to identify "the one" factor that drives the problem. Healthcare organizations are complex and often the problem is caused by a combination of multiple factors. The use of a fishbone diagram helps identify the policies, procedures, patient, equipment, and human factors involved.
Suppose that your team identifies an increase in the number of new patients who haven't had regular primary care in the past, and they determine that the new policy to reduce visit encounter times limits the time a provider can spend educating these newly diagnosed patients. They also note a decrease in the number of follow-up care plans in patient records. In addition, the senior nurse who was the primary care coordinator for these patients recently left the clinic. A full-time replacement hasn't been secured yet, and contingent workers are providing support to the clinic.
Do: The team plan is for the clinic nurse manager to oversee the process and assign the clinic LPN to contact all newly diagnosed hypertension patients to ensure they got their medication and understand how to take it.
Study: The small test reveals that the LPN misses contacting some patients because of interruptions in workflow. The strategy doesn't accomplish the goal.
Act: The team reconvenes and develops a long-term solution. Information technology will create automatic emails to be sent through the electronic health record to all patients with hypertension. The first email will provide an overview of their prescribed medications. A second email be sent a week later with diet instructions. Each email will provide a phone number to contact the clinic with questions. The final step is to monitor the clinical indicators for progress. The new RN will manage the new electronic process once onboarded.
A framework to follow
Of course, the precise steps will vary depending on your specific situation, but this example provides a framework to follow as you proceed toward an optimal outcome.
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