PDSA Steps and Tools

This is a guide to the 11 steps through a Plan Do Study Act Cycle. Included for each step: the purpose, procedures, a list of possible tools an improvement team might use to accomplish their goals and the outcome.

People Matter, Words Matter

People matter and the words we use to describe them or the disorders they have matter. Words can transmit stigma. Studies have shown that people with psychiatric and/or substance use disorders often feel judged, outside and inside the health care system. This can lead them to avoid, delay or stop seeking treatment. The way we talk about people with a behavioral disorder can change lives – in either a positive or negative manner.

You will find downloadable posters that address:

  • Use of Supportive Language That Makes a Person Feel Safe
  • Destigmatizing Language About Suicide
  • Culturally/Racially Aware Language
  • Perceptions about Mental Health Conditions
  • Using People First Language
  • Use of Compassionate SUD Language

Performing Root Cause Analysis (RCA) with Performance Improvement Projects (PIPs)

Overview: A Root Cause Analysis (RCA) is a structured, facilitated team process to identify root causes of an event that resulted in an undesired outcome and develop corrective actions. The RCA process provides a way to identify breakdowns in processes and systems that contributed to the event and how to prevent future events.

Reason’s Model of Accident Causation: aka The Swiss Cheese Model

The purpose of a RCA is to find out what happened, why it happened, and determine what changes need to be made. It can be an early step in a PIP, helping to identify what needs to be changed to improve performance.
Once you have identified changes that need to be made, the steps you will follow are those you would use in any type of PIP.

Use this Step-by-Step Guide for Performing Root Cause Analysis with Performance Improvement Teams to investigate events in your facility (e.g., adverse event, incident, near miss, complaint).

Download this fillable RCA PIP Team Template to track progress toward process improvements.

“Every system is perfectly designed to get the results it gets.” – W Edwards Deming

NOTE: Facilities accredited by the Joint Commission or in states
with regulations governing completion of RCAs should refer to those requirements to ensure all necessary steps are followed.

Personal Protective Equipment (PPE) Use When Caring for Patients with Confirmed or Suspected COVID-19 Competency

This tool is designed to support nurses, social workers, case managers, and others conducting effective discharge planning and care coordination for adults with disabilities who received care or treatment for COVID-19 illness in an acute care setting, are no longer COVID-19 positive, and require continuation or reconnection to supports and services. While not exhaustive, the resources and considerations proposed in this tool comprise promising practices to be addressed when practicable.

Pharmacist’s Response to the Opioid Epidemic: Advanced, Opioid-Specific Counseling Webinar – 1.5 hours ACPE continuing education credit, free when using code.

An on-line instructional webinar created in collaboration with IPRO QIN-QIO and the University at Buffalo can be accessed at the link above.

Prescribers and pharmacists who work or live in DC, DE, CT, MA, MD, ME, NH, NJ, NY, OH, RI, VT can earn 1.5 hours of free ACPE continuing education for completing this program by using this code when prompted: qinub23.

It is available October 1, 2023, through September 30, 2025, and covers a review the opioid epidemic and regulatory responses, identifies legitimate medical use vs. illegitimate opioid use, reviews basic counseling items with relationship to opioids, identifies advanced counseling items related to opioids and identifies overdose risks indicating provision of naloxone.

Supporting documents for this program include:

Opioid Stewardship – Opioid Counseling Checklist

This tool is intended to help remind pharmacists about opioid-related counseling points as needed.

https://drive.google.com/file/d/1zYRl_w_59f-ydAu-JSfEcmugdELk1SXz/view?usp=drive_link

Conversation Starter – Opioid Dispensing, Education, and Management for Pharmacists

The Conversation Starter helps pharmacists guide the conversation they have with patients regarding opioid management and lifestyle management, opioid assessment and plan, recommendations, and follow-up steps. This guide is intended to ease what could potentially be a difficult conversation.

https://drive.google.com/file/d/1yA_xQ1iKvjXvdKA92_cVoWBzCBNDJOh-/view?usp=drive_link

Pain Management Zone Tool

A guide for patients and care partners to assess pain and seek medical care when appropriate using a stoplight concept of green (all clear), yellow (caution/warning), and red (emergency).

https://drive.google.com/file/d/1TPSuOIdbGzG8Ue6TnBBA3bLA0IzHd8aA/view?usp=drive_link

Pain, Enjoyment, and General Activity (PEG) Scale for Assessing Pain Intensity and Interference

The Pain, Enjoyment, General Activity (PEG) Scale assesses pain intensity and interference and is considered the gold standard for pain scales.

https://drive.google.com/open?id=1cLGRvi483BEt_FpZxNRuydyGdEpbq393

PRAPARE Tool

The Protocol for Responding to and Assessing Patients’ Assets, Risks, and Experiences (PRAPARE) is a national effort to help health centers and other providers collect the data needed to better understand and act on their patients’ social determinants of health. As providers are increasingly held accountable for reaching population health goals while reducing costs, it is important that they have tools and strategies to identify the upstream socioeconomic drivers of poor outcomes and higher costs.

The PRAPARE Screening Tool has been translated in over 30 languages. Use this link to locate a non English version.

Project RED

Hospital based care transition model that coordinates the patient’s discharge plan throughout the hospitalization and then provides a post-acute discharge guide and follow-up telephone calls.