Do-Check-Act: How to Enact Your Plan for Medical Practice Improvement

Previously, I discussed using quality tools to improve the outcomes at a healthcare site. I chose to focus on the Plan-Do-Check-Act (PDCA) cycle and laid out the details of the Plan stage. Today, I will complete the PDCA tool, focusing on Do-Check-Act.

If you have not completed the Plan stage, then your Do stage will either end in failure or be much more difficult to accomplish.

To start to “Do” without any planning would be like starting on a long auto trip without money to buy gas or without planning your route. You should have the following in place:

  • A team
  • A leader who will oversee the implementation of the plan
  • Base data on the current state of a process, on patient outcomes or on the bottom line
  • A detailed document that includes the previous items as well as the steps of implementation
  • An independent coach to help with PDCA (if you feel you need one)

Do Stage
In the Do part of PDCA you will be implementing the steps laid out in the Plan stage. The steps should be carried out in the order that were laid out by the team. The Plan document should be posted in a place where all who are affected can see it. One person should be responsible for the implementation of the steps and the documentation of completion of the steps.

One step that will probably be included in most Plans is training. This training should be broken into sections as necessary. Too much new information may impede the successful completion of a step in the Do cycle.

As an example, a team of two physicians, two nurses’ aides, a front office staff person who checks patients out and the office manager have decided to design a Plan to create a process for implementing and using ePrescribing in their new electronic health record.

The steps include the physician signing onto the ePrescribing system, determining the pharmacy the patient wants to use, checking that there are no conflicts with the patient’s other medications and submitting the prescription. The final step is for the front office person, who may oversee the project, to verify the information of the prescription with the patient at checkout.

After the team has been trained to use the ePrescribing system, that step is marked off on the implementation Plan document. The team leader then lets those involved know when ePrescribing use will begin. She also makes sure that she has time to check with the physicians involved throughout the day to see if there any glitches.

She asks them about how long it has taken for them to write a prescription and how many they have completed that day without any problems. She will keep a record of any callbacks from the pharmacies used for clarifications of the prescriptions, such as missing information on the number of refills. All of the data collected will be used in the Check stage.

The team decided to pilot the Plan with only half of the staff. This way, if there were problems in the initial implementation adjustments could be made to the Plan to eliminate the problems.

This would be a part of the Act stage utilized in the Do cycle. The team is learning from the errors and problems as they go along. Using this approach, the implementation of the Plan should go much more smoothly with the rest of the staff and there will be experienced team members available to help the rest of the office as they learn to use the ePrescribing system.

Check Stage
At the end of the pilot implementation, the team leader should evaluate the data collected and interview the team members for suggestions for improvement to the Plan.

The data should be evaluated to see if there were significant improvements in the amount of time spent on a process if there were fewer errors committed by the staff, and/or if patient outcomes were improved. Improvements can be gauged by comparing the data collected during the Do stage to the baseline data collected.

In the ePrescribing example, the leader would see how many hours were saved per day and how many fewer callbacks there were from pharmacies. In the Check stage, it may be found that there was no improvement over the previous process. That is, the Plan was a failure. This should not lead the team to abandon its efforts.

The team should learn from implementation and adjust the Plan, incorporating suggestions from the team members. Sometimes, though, it may not be possible to improve upon a given process; then, the original process should be maintained. I would not suggest this with ePrescribing as there will be significant penalties for not adopting the process.

Act Stage
In most PDCA projects the Act cycle is carried out during the Do pilot. It is the act of adjusting the Plan as the team learns from mistakes or sees ways of improving the Plan.

At the end of the PDCA project, the team can decide what project to attack next. It may be that a new team needs to be formed to do this. There will always be ways to improve the delivery of care to patients and to eliminate waste in processes at a healthcare facility.

After the completion of a successful PDCA project, the staff may undertake more than one new project. It may seem that this would take too many resources and negatively affect the bottom line. However, the experiences of quality improvement teams have shown that the rewards from such efforts have returns that exceed the time and effort spent most of the time; as you work with PDCA you should determine what is the optimal amount of time that can be spent on it without affecting your services negatively. Of course, take time to celebrate successes at the end of a PDCA cycle.

When used wisely, the Plan-Do-Check-Act cycle yields significant rewards to all—both staff and patients. Those with some experience in PDCA may want to include patients as part of a team. The outcomes will be improved health for most patients, a better bottom line and a feeling of satisfaction by staff in their work.

How will you use the Plan-Do-Check-Act process for improvement at your practice?

Read part one of the PDCA series, “How to Create a Plan for Medical Practice Improvement,” here.

Donald Bryant is a healthcare consultant who helps healthcare providers meet their challenges. Visit Bryant’s Healthcare Solutions website to get a free article: 7 Challenges in Healthcare and How to Solve Them. You may also contact Mr. Bryant directly at 616-826-1699.

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