QI Focus PDSA - New Template

[Audio] Welcome to the Quality Improvement Introduction Session. Quality improvement is a key priority aligned with our commitment to patient safety, excellence in care, and JCI standards. It focuses on continuously identifying gaps, improving processes, and achieving better outcomes for our patients and families. In this session, we will introduce the basic principles of quality improvement and how you can contribute to meaningful, measurable change in your daily work. Let's begin.".

[Audio] Let's quickly look at what we'll cover today. We'll start with a simple question—what does Quality Improvement mean in your daily work? Then, we'll introduce key QI methodologies and how to choose the right tool for the right situation. Our main focus will be the FOCUS PDSA model—how to identify a problem, understand the process, analyze root causes, and select effective solutions. As we go through, I encourage you to think of a real example from your area where these tools could be applied. By the end, you should feel confident to start or contribute to a QI project.

[Audio] In every job, whatever you do, it is important to have a focus on quality and making small steps to improve processes, we have 2 roles , to do our job and improve our job. In the health and care sector, continuous improvement is a shared responsibility that extends across all roles and disciplines. Every interaction, process, and decision presents an opportunity to enhance the quality, safety, and experience of care we provide..

[Audio] Quality Improvement is everyone's responsibility, and it is most effective when driven collaboratively by both staff and the people who use our services. Patients and families bring valuable lived experiences, while staff contribute clinical expertise and system knowledge. Quality Improvement thrives on collaboration—bringing together different perspectives to generate meaningful and practical ideas. By listening to those impacted and working in partnership, we ensure improvements are relevant and effective. Focusing on what matters most to service users—patient safety, quality, experience, efficiency, and access—drives outcomes that truly make a difference..

[Audio] Quality Improvement focuses on small, everyday changes that, over time, lead to significant and lasting impact. It is not random—QI is a structured and planned approach that empowers us to make meaningful differences in care. Using proven methods to test and implement changes quickly and effectively, QI enables continuous learning and sustainable improvement..

[Audio] So, what do we mean by Quality Improvement? At its core, QI is a structured approach to identify and fix process issues—by reducing waste, minimizing variation, and involving everyone in the organization. At Sidra, this approach helps us achieve sustained improvement across cost, quality, and delivery—ensuring we provide safe, efficient, and timely care. Ultimately, our goal is simple: deliver the highest quality care, in the fastest and most efficient way, while making the best use of our resources..

[Audio] Small changes can drive big impact. Simple solutions—like reminder texts, better communication, streamlined processes, and clear signage—improve efficiency and patient experience. These focused improvements show how everyday changes can deliver meaningful results across care quality and operations. Even in busy environments, small changes can make a big impact. Quality Improvement is most effective when changes are thoughtful, practical, and embedded into everyday work. By integrating improvement into daily practice, we create sustainable changes that continuously enhance care and outcomes..

[Audio] QI started in manufacturing with Walter A. Shewhart, who introduced a scientific, data-driven way to understand and improve processes. In the 1920s. W. Edwards Deming expanded Shewhart's work by refining the cycle into PDSA (Plan–Do–Study–Act) and emphasized that quality improvement is continuous, system-wide process. Deming promoted the idea that most issues come from processes, not individuals, and that organizations must use data, learning, and long-term thinking to continuously improve. This concepts were later adopted in the Health and Care sector to improve patient outcomes, safety, and service quality—demonstrating their value across different fields..

[Audio] A range of Quality Improvement methodologies support different types of improvement work. FOCUS–PDSA and the IHI Model of Improvement enable rapid testing and continuous, small-scale changes at the frontline. VMI QI supports structured improvement within clinical settings, while Lean Six Sigma (DMAIC) is used for complex, data-driven projects requiring deeper analysis and sustainable results..

[Audio] Every organization strives to deliver high‑quality services at the lowest cost, in the shortest time. In healthcare, achieving all three at the same time can be challenging, as improving one area may affect the others. Quality Improvement, or QI, provides a structured approach to balance cost, quality, and delivery through data‑driven decisions and continuous testing of change. At Sidra Medicine, QI helps us achieve sustained improvements that enhance patient outcomes, improve safety, and reduce inefficiencies—while maintaining high standards of care..

[Audio] At Sidra Medicine, Quality Improvement is guided by structured methodologies. DMAIC is used for more complex, organization-wide projects. While FOCUS PDSA supports rapid, day-to-day improvements at the unit level. For the purpose of this LMS , we are going to dive-into FOCUS PDSA. It combines two powerful components: FOCUS helps teams clearly define the problem, organize a knowledgeable team, understand the current process, identify root causes of variation, and select targeted improvements. PDSA (Plan-Do-Study-Act) allows teams to test changes on a small scale, evaluate their effectiveness using data, and refine interventions before wider implementation..

[Audio] The FOCUS–PDSA method is a structured Quality Improvement approach used to solve business and healthcare problems. It begins by Finding a process or problem that needs improvement, then Organizing a multidisciplinary team to support the work. Next, teams Clarify the current process and collect data to establish a baseline. They then Understand the process by identifying root causes and opportunities for improvement. Finally, teams Select a specific improvement to test using PDSA cycles, supporting effective and sustainable change..

[Audio] The first step in the FOCUS–PDSA method is to find a process that needs improvement. This involves identifying high‑risk or high‑impact areas that align with organizational priorities. Improvement opportunities often arise from patient safety risks, patient experience feedback or complaints, and mandatory regulatory requirements such as JCI, MOPH, or Magnet standards. Performance data, including KPIs, KQIs, OPPE results, and clinical registries, also help highlight processes where improvement is needed. Selecting the right process ensures QI efforts focus on areas that add the greatest value to patients and the organization..

[Audio] An important aspect of Quality Improvement is ensuring organizational alignment. This means that all improvement efforts—whether at the unit, department, or organizational level—are connected to our overall strategic priorities. When teams are aligned, we are all working toward the same goals, using consistent methods, and measuring success in a meaningful way. In practice, this involves linking QI projects to key organizational objectives such as patient safety, quality outcomes, patient experience, and operational efficiency. It also ensures that leadership priorities are translated into actionable initiatives at the frontline. Organizational alignment helps us avoid duplication, focus our resources effectively, and achieve sustainable impact. It ensures that every improvement effort, no matter how small, contributes to the bigger picture of delivering high-quality care..

[Audio] At Sidra Medicine, Datix is the primary system used to report, monitor, and learn from patient safety events. Understanding common patient safety risks helps staff recognize hazards early and take action to prevent harm. Frequently reported risks include medication errors, patient identification errors, patient falls, and communication gaps among care teams. Medication errors may occur at any stage of the medication management process and can significantly impact patient safety if not identified and addressed promptly. Patient identification errors pose risks during clinical procedures, medication administration, and investigations, emphasizing the importance of consistently using approved patient identifiers. Falls remain a common risk, particularly among vulnerable patient populations, and require ongoing assessment and preventive strategies. Communication gaps between healthcare professionals can also contribute to delays in care, misunderstandings, and adverse events. Reporting these risks in Datix supports a culture of safety and transparency. It allows Sidra Medicine to analyze trends, identify system‑level issues, implement targeted improvement initiatives, and meet regulatory and accreditation requirements. Consistent reporting and learning from Datix help strengthen patient safety, improve care quality, and promote a proactive approach to risk management across the organization..

[Audio] Patient experience is a key pillar of quality, and feedback and complaints are valuable sources of insight for improvement. Every piece of feedback—whether positive or negative—helps us understand the patient's perspective and identify gaps in our processes. Complaints, in particular, highlight areas where expectations were not met and where improvement is needed. Our goal is not only to respond to feedback, but to learn from it. This means analyzing trends, identifying root causes, and implementing changes that prevent recurrence..

[Audio] By actively seeking better ways of working, we can ensure that our services remain responsive, effective, and patient-centered. This commitment involves listening to the voices of our patients and families, valuing the contributions of our colleagues, and fostering a culture of collaboration and learning. By actively listening and responding to our patients and families, we can enhance communication, improve service delivery, and build trust..

[Audio] Another key driver for Quality Improvement is compliance with accredited and regulatory bodies. Standards from organizations such as JCI, MOPH, and Magnet provide a framework to ensure we are delivering safe, high-quality, and patient-centered care. In addition, external audits and survey findings give us valuable insights into areas that require improvement. Alongside this, we monitor Key Quality Indicators to measure our performance. These indicators help us identify gaps when we fall below established benchmarks or expected standards. By reviewing these standards and analyzing our performance data, we can detect trends that may indicate non-compliance or variation in care. The goal is to use this information proactively—to prioritize improvement initiatives, ensure compliance, and continuously enhance the quality and safety of our service.

[Audio] Once you have identified a process to improve the next step is to define clearly the problem statement.

Problem statement. A Problem Statement should include: Who is the customer? What is the need or target? What is the Gap from the current situation to the desired target.

We need more doctors to reduce the wait time Our nurses need to start their shifts earlier The department is chaotic We need supplies cabinet in every room.

Our average reporting time of extravasation events is 3 days after the event has occurred and this should be reported within 15 minutes Our patients wait more than 60 min for medication administration and our organizational target is 30 min nurses take an average of 12 min to find consent forms that should available in every station Our supplies are out of stock 50% of the time and our goal is 5%.

[Audio] Oncfe we have clearly identified the problem , the second step in the FOCUS–PDSA method is to organize a team. This involves forming a multidisciplinary team that is directly involved in the process being improved. The team should include process owners, frontline staff, clinical and non‑clinical stakeholders, subject matter experts, and a quality or patient safety representative. Bringing together diverse perspectives ensures the problem is well understood, solutions are practical, and improvements can be implemented and sustained effectively. It is important to include people that are involved in the process as they are usually the once knowing the problem best and potential solution to solve it..

[Audio] Effective Quality Improvement relies on clear roles and shared accountability across the team. We recommend to identify a different roles within the project to ensure successful project outcome. The Project Sponsor provides strategic oversight, removes barriers, and ensures alignment with organizational goals. The Project Lead and Co-lead drive the project forward, ensuring timely execution and progress toward objectives. The Project Advisor offers expert guidance and evidence-based recommendations, while Taskforce Members support implementation as action owners, collaboration, data collection, and communication..

C – Clarify the problem. Understand the current process Map how things actually work , using process mapping and other tools. Identify gaps or variation by identifying waste in the process where delays, inconsistencies, inefficiencies or errors are happening Use data collection tools to validate the issue like time motion studies , surveys , Gemba walks, incident reports, KPIs, audits , check sheets. Align the team on the same understanding communicating and agreeing with the team on what the problem is before trying to fix it . Why it matters If the problem isn’t clearly defined and understood. You risk solving the wrong issue Interventions may be ineffective or misdirected Teams may work with different assumptions.

Helps you to “see the work” and understand the flow of material and information as a product or service Identifies processes that do not provide value so they can be improved. Discovers processes that could be streamlined, areas of improvement and waste that could be eliminated.

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[Audio] value stream map clearly identified process steps , identify accountability of each process step and document or system used to conduct each step of the process..

[Audio] if we need to clarify the process in a more detailed way a time-motion study could be conducted as It focuses on watching each step of the process in real time and measuring how long each step takes and how people move during the tasks, this exercise helps to find wastes and inefficiencies easily..

[Audio] In addition to the previous step, also helps to map the cycle time of each process and waiting time between each step.

[Audio] SIPOC analysis helps in understanding the overall workflow, clarifying the scope of the project ,where the processess starts and where the processess ends.,identifying the stakeholders and understanding the relationship between the suppliers ,inputs ,processes , output and customers ..

Initial Assessment. Lab Tests. Deliver Care. SIPOC Diagram Example.

[Audio] On of the most important exercise to be enable to clarify the problem is walk‑through observations at the point of care, also known as Gemba, which means observing the process where the work actually happens. It helps teams understand how processes truly operate—not just how they are expected to work. By seeing the reality firsthand and viewing it from both patient and staff perspectives, teams can identify gaps, inefficiencies , uncover challenges and spot where improvements are needed..

[Audio] During Gemba its easy to identify the waste in the process, one of the tools that can be used to identify waste is the 8 wastes , remembered as DOWNTIME. In healthcare, defects could be medication errors that require correction or re-administration. Overproduction might be ordering unnecessary tests or preparing reports that are never used. Waiting occurs when patients or staff experience delays, such as waiting for lab results or physician approvals. Non-utilized talent happens when skilled staff perform basic tasks that others could do, instead of using their full expertise. Transporting can be seen in moving patients, samples, or files unnecessarily between departments. Inventory refers to excess stock of medications or supplies that may expire or go unused. Motion includes unnecessary walking or searching for equipment due to poor layout or organization. Extra-processing is doing duplicate documentation or entering the same data into multiple systems without adding value..

[Audio] Teams can clarify the process using tools like process mapping. This process map outlines the patient journey from the Initial point of entry through to completion of care. Identify: Steps in patient journey Handovers between teams Decision points Identification of waste.

[Audio] At Sidra Medicine, understanding the problem is the foundation of effective Quality Improvement. This step focuses on clearly identifying why a problem exists by systematically analyzing available data and uncovering underlying root causes. Root cause analysis tools, such as the Fishbone diagram and the 5 Whys, are used to explore contributing factors..

[Audio] in order to identify why the problem exists, it is essential to conduct a root cause analysis. The root casue is : Core factor that ultimately leads to the problem. It is clearly a major cause of the symptoms. It can be resolved.

[Audio] Root Cause Analysis – Fishbone Diagram One of the most used tool to understand the root cause of a problem is cause and effect or most known fishbone diagram. Different factors—such as patients, providers, processes, policies, and the environment—are identified and broken down to understand how they contribute to the overall issue. By exploring these factors ,teams can move beyond symptoms and identify the true root cause of a problem . This enables more targeted and effective improvement interventions later on..

[Audio] As an example , you can see how the fishbone diagram was used to identity the root causes of a clinical problem: the increased number of extravasation events. It organized potential causes into key categories. teams uncovered gaps—such as knowledge limitations, workflow inefficiencies, or system issues..

[Audio] Out of all the potential root causes , the fishbone diagram can also help to identify the top contributing factors affecting the problem..

[Audio] 5 Whys is another tool to get to the root cause of the problem quickly. As an example in the extravasation case , the problem identified by the 5th WHY is very different from the original event and therefore required a different solution..

[Audio] Name after Italian economist Vilfredo Pareto, the pareto chart is another tool to understand the problem. Pareto showed that approximately 80% of the land in Italy was owned by 20% of the population. Pareto principle (also known as the 80/20 rule) roughly 80% of the effects come from 20% of the causes. By obtaining data and quantifying objectively the main contributing factors to the problem we can be more successful on solving the problem..

count No MD orders Transportation issues Waiting for Lab / DI test result Family not available Change in patient condition Medication not ready Miscommunication 72 60 23 12 11 6 5 % No MD orders Transportation issues Waiting for Lab / DI test result Family not available Change in patient condition Medication not ready Miscommunication 0.38095238095238093 0.69841269841269837 0.82010582010582 0.88359788359788349 0.94179894179894164 0.96825396825396814 0.99999999999999989.

[Audio] selecting the right intervention is a critical step in ensuring successful and sustainable quality improvement. This phase focuses on choosing the most effective, realistic, and high‑impact improvement opportunity based on the findings from the problem analysis..

[Audio] To find solutions to problems is important to brainstorm with the team potential ideas that could solve the root causes. We encourage to conduct a brainstorming exercise with project MDT to obtain as many different perspectives and ideas as possible. There are seven rules to conduct a successful brainstorming sessions. Select a main contributing factor to the problem that you want to find solution. Encourage wild ideas, (3) no idea is a bad idea. 4) Build on ideas of others Stay focus on topics, remind them of the objective and keep moving. One conversation at a time 7) Go for quantity: set a goal for number of ideas and surpass it. the more ideas the better..

[Audio] As an outcome of brainstorming exercise, we will have different potential solution to each of the main contributing factors. As an example, we illustrated the outcome of the brainstorming exercise to the extravasation project. To aid in decision making process and focus your efforts we use a pick chart to evaluate the improvement ideas. Once you have listed all of the possible solutions for each of the causing factors. You'll need to prioritize them using a pick chart.

[Audio] You can prioritize potential solutions using a pick chart taking into consideration their impact vs the ease of implementation. The chart is divided in to four quadrants. For solutions of high impact and easy implementation it is suggested that these get prioritized and be implemented first (Just do it) For solutions of low impact and easy implementation you can consider them to be implemented as they are your low hanging fruits (Quick wins) For solutions of high impact and difficult implementation these are challenging, but important you can work on resolving them with longer term plan while you work on the others (Long term) For solutions of low impact and difficult implementation , they will not make an impact full change so you can reject them, abandon them (Kill the idea).

[Audio] As an example of our clinical project case of extravasation the fishbone exercise identified the five main root causes contributing to increase extravasation events Patients: Fragile veins Providers: Knowledge gaps, delayed escalation System: No system alerts, no IV tracking And then the PICK chart helped prioritize improvement strategies: - High-impact, easy-to-implement actions -standardized IV site assessment - Roll out Staff education on extravasation Vs infiltration - Referral and escalation pathway for SME extravasation evaluation - High Impact , difficult to implement actions: Standard extravasation documentation in the EMR Automated referrals to VMT based on extravasation score real-time IV monitoring dashboards, Based on this result a brainstorming exercise took place to identify the potential solutions to this problem and the PICK Chart tool helped to identifies solutions based on impact and ease of implementation..

[Audio] Once we identify the solutions to solve the problem , the Plan-Do-Study-Act methodology will help us to implement the potential improvement in a systematic way..

[Audio] State the objective of the improvement. 2. Set SMART goals: Specific Measurable Achievable Relevant Time-bound goals to guide your efforts. 3. Develop an action plan: Outline clear steps, activities, and timelines for implementing your chosen approach. Who? What? When? Where? What data is to be collected?.