Institute for Healthcare Improvement: Testing Changes

Example: Use a sliding scale for insulin to decrease hypoglycemic events.

Plan
The team predicted that both the physician and nurse would find the scale easy to use and that using the scale would not lead to any adverse drug events involving insulin. The plan was to have one physician and one nurse test the scale with one patient for one day.

Do
The day before the test, the team showed the sliding scale to the physician, who agreed to the small test. The day of the test, a patient was selected and it was agreed that all insulin doses for the day would be determined using the scale.

Study

Both the nurse and the physician liked the sliding scale.
The physician reported that the scale was easy to use and would likely save him a lot of time.
The nurse liked the scale but had some problems. She had to do some of the calculations manually and found the scale difficult to follow, as the dosages were in columns and it was hard to keep them straight.
The patient did not experience any hypoglycemic events.

Act

The team decided that the nurse could highlight the column with the correct dose range to make it easier to find.
The nurse suggested that weight calculations for common weights could be placed on the back of the sliding scale, for easy reference.
The team agreed to test the sliding scale for one more day with three patients, using the suggestion to highlight the column with the correct dose range for each patient.

Example: Use a sliding scale for insulin to decrease hypoglycemic events.

Cycle 1:	Tested a sliding scale for insulin with one physician and one nurse, for one patient receiving insulin one day.
Cycle 2:	Scale tested on three patients with the same physician and nurse for one day, with the correct dose column highlighted.
Cycle 3:	The physician agrees to have all of his patients receiving insulin on the medical unit have their doses determined by the sliding scale for one week.
Cycle 4:	The physician presents the results to other physicians who frequently admit to the medical unit, and they all agree to use it for one week.
Cycle 5:	The medical unit adopts use of the sliding scale for all patients receiving insulin.
Cycle 6:	Two more units begin use of the sliding scale.
Cycle 7:	The medical staff approves use of the sliding scale across the hospital.

High-Hazard Medications
Change 1: Use a sliding scale for insulin to decrease hypoglycemic events.

Culture
Change 2: Include pharmacists in daily rounds to decrease adverse medication events.

Cycle 1:	One pharmacist participates in rounds on one nursing unit for one day.
Cycle 2:	Test expanded to include a pharmacist in rounds on nursing unit every day.
Cycle 3:	Pharmacist participation in rounds spreads to a second nursing unit.

Core Medication Processes
Change 3: Improve the medication dispensing process.

Cycle 1:	Pharmacy technician checks for discontinued medications on nursing unit.
Cycle 2:	Rounds tested for one day of pharmacy technician removing discontinued medications twice per day.
Cycle 3:	Rounds tested for one week.
Cycle 4:	Rounds for removal of discontinued medications implemented house-wide.
Cycle 5:	Rounds expanded to three times per day.

Reconciliation
Change 4: Reconcile medications at admission.

Cycle 1:	Nurse in intensive care unit reconciles admission medication orders for the next three admissions.
Cycle 2:	Nurse and physician test an order form for admission orders that incorporates reconciliation on one patient.
Cycle 3:	Order form is tested with same physician for one week on all admissions
Cycle 4:	Two more physicians test the order form for one week.
Cycle 5:	Order form is adopted by intensive care unit, for all admissions.
Cycle 6:	Order form is tested on two additional patient care units for one month.
Cycle 7:	Order form is approved for use throughout the organization.

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