Green Book

Appendix C

Implementation frameworks

C.1 The ‘plan, do, study, act’ cycle

The ‘plan, do, study, act’ (PDSA; Figure C1) cycle uses simple measurements to monitor the effects of change over time. It is widely used in healthcare improvement, either as a standalone method or as part of wider QI approaches, such as the Model for Improvement, Total Quality Management, Continuous Quality Improvement, Lean, Six Sigma or Quality Improvement Collaboratives.1

The PDSA encourages starting with small changes, which can be built into larger improvements quickly, through successive cycles of change. It emphasises starting unambitiously, reflecting and building on learning. It can be used to test suggestions for improvement quickly and easily based on existing ideas and research, or through practical ideas that have been proven to work elsewhere.

Plan the change (P)

  • What do you want to achieve, what actions need to happen and in what order?
  • Who will be responsible for each step and when will it be completed?
  • What resources are required?
  • Who else needs to be kept informed or consulted?
  • How will you measure changes to practice?
  • What would we expect to see as a result of this change?
  • What data do we need to collect to check the outcome of the change?
  • How will we know whether the change has worked or not?

Do the change (D)

Put the plan into practice and test the change by collecting the data. It is important that the ‘do’ stage is kept as short as possible, although there may be some changes that can only be measured over longer periods. Record any unexpected events, problems and other observations.

Study (S)

  • Has there been an improvement?
  • Did your expectations match what really happened?
  • What could be done differently?

Act on the results (A)

Make any necessary adaptations or improvements, acknowledge and celebrate successes. Collect data again after considering what worked and what did not. Carry out an amended version of what happened during the ‘do’ stage and measure any differences.

Cycles of improvement may occur at different levels, and new actions may be planned as a result of previous cycles. Few organisations or individuals achieve all of any desired change in one step. Improvement is most often an iterative process of a number of small changes, with reflection on the impact of each and revision of behaviour. The process is iterative or occurs over a number of cycles.

As progress occurs, new skills may be learned, barriers to change overcome and new areas targeted for improvement. Testing small changes sequentially means design problems may be detected and amended earlier rather than later. Similarly, performance tends to fall away with time. Repeated measurement of both process and outcomes helps to identify current performance and any areas of concern. Self-assessment of performance, while necessary, often overestimates performance and might not be accurate or sufficient. When reviewing your progress:

  • check that your goals have been achieved
  • decide if the goals have been realistic
  • see if the energy invested has led to the desired degree of change. Is the return worth the effort?
  • document which factors have helped or hindered the change
  • consider if there any further strategies or measures needed to bring about the desired changes and/or improve cost effectiveness

C.2 Knowledge-to-action framework

The knowledge-to-action (KTA) framework2 includes seven essential components for the knowledge translation necessary for successful implementation guidelines:3

  1. Identify the problem – identify, review, select knowledge tools/resources
  2. Adapt knowledge tools/resources to local context
  3. Assess barriers and facilitators to knowledge use
  4. Select, tailor and implement interventions
  5. Monitor knowledge use
  6. Evaluate outcomes
  7. Sustain knowledge use4

While each phase reflects on the previous and prepares for the next,4 two key processes comprise the KTA framework. The first is the knowledge creation process, which focuses on the identification of critical evidence and results in knowledge products. The second is the action cycle.4 These components reflect a dynamic and iterative process.

Figure C2 offers an example of how the KTA framework can be implemented.

Adapted with permission from Straus S, Tetroe J, Graham I, editors. Knowledge translation in health care: Moving from evidence to practice. Chichester, West Sussex, UK: Wiley-Blackwell BMJ Books, 2009.

C.3 The DMAIC model

The DMAIC (define, measure, analyse, improve, control) model is a data-driven quality improvement (QI) tool. It is an integral part of a Six Sigma initiative, but can be used as a standalone procedure or as part of other process improvement initiatives.5–7

DMAIC is an acronym for the five phases that make up the process:

  • Define the problem, improvement activity, opportunity for improvement, the project goals, and customer (internal and external) requirements.
  • Measure process performance.
  • Analyse the process to determine root causes of variation, poor performance (defects).
  • Improve process performance by addressing and eliminating the root causes.
  • Control the improved process and future process performance.

Adapted with permission from Holtz T. New CIO priority list – Why care and what to do. Houston, TX: TBO International, 2014.  [Accessed 21 March 2018].