When Befikadu Bitewulign, Senior Project Officer at IHI, wanted to work with hospital health care providers to increase use of a preventive antibiotic for newborns, he knew he would need to test changes over time. To develop ideas for change, test these changes, and implement successful changes more widely, he used Plan, Do, Study, Act (PDSA) cycles. The four steps in the cycle include:

An overview of the Model for Improvement and PDSA cycles | Source: Langley GL, Moen R, Nolan KM, Nolan TW, Norman CL, Provost LP. The Improvement Guide: A Practical Approach to Enhancing Organizational Performance (2nd edition). San Francisco: Jossey-Bass Publishers; 2009.

As is often the case, multiple PDSA cycles were needed to make successful changes. Each cycle should build on the current knowledge about the changes being considered and answer questions required before putting the change into standard practice. Using multiple cycles allows knowledge to increase as we progress from testing to implementing changes, thus minimizing the risk of failures. Numerous small-scale cycles accumulate into large effects

Sequential PDSA cycles for learning and improvement | Source: The Improvement Guide

At the recently established Bokoji Primary Hospital in the Oromia region of Ethiopia, staff members were largely unaccustomed to administering the antibiotic. In order to improve use of this medication for newborns at the hospital, Mr. Befikadu first answered three questions from the Model for Improvement to determine the aims of the project:

What are we trying to accomplish? (AIM)

To introduce, improve, and sustain the rate of tetracycline (TTC) eye ointment administration in the labor ward at the hospital at 95 percent of live births by the end of September 2017.

How will we know that a change is an improvement? (MEASUREMENT)

• Percent of live births at which TTC eye ointment is administered
• Number of orientations given on TTC eye ointment administration
• Number of focused mentorships (continuing group trainings) provided on TTC eye ointment administration
• Number of focused mentorships provided on documentation of TTC administration using the standard health record system, the integrated antenatal, labor, delivery, newborn & postnatal (IALDNP) card
• Number of days TTC eye ointment is out of stock (improve management to decrease this number)

What change can we make that will result in improvement? (CHANGE IDEA)

• Hold an orientation on TTC eye ointment administration.
• Offer focused mentorship on TTC eye ointment administration and documentation.

Then, Mr. Befikadu carried out three PDSA cycles:

PDSA cycle 1

Plan:

This cycle would test if orientation on TTC eye ointment followed by mentorship on administration and documentation leads to improvement in administration of TTC eye ointment. Mr. Befikadu would lead this change and collect data on TTC eye ointment administration on a monthly basis from IALDNP cards and data on number of live births from the delivery register.

Do:

In September 2016, Mr. Befikadu held an orientation, followed by four mentorships during subsequent visits.

Study:

Orientation was offered once in September, followed by four focused mentorships. The rate of TTC eye ointment administration for live births increased from 10.7 percent in September to 54.2 percent in November. For the last 15 days of the test period, the hospital ran out of TTC eye ointment and bought it from a private pharmacy – an added expense to families. Thus, there is a higher rate of administration of TTC eye ointment which is consistent with the prediction, and even when the ointment is out of stock.

Act:

Test the effect of only providing mentorship on administration and documentation for TTC eye ointment.

PDSA cycle 2:

Plan:

This cycle’s objective was to test if mentorship alone would lead to improvement in administration of TTC eye ointment. Accordingly, Mr. Befikadu would conduct mentorship during a hospital visit and collect data.

Do:

In December 2016, Mr. Befikadu conducted mentorship on TTC administration & documentation. Again, the hospital had used up the stock of TTC eye ointment and families bought it from a private pharmacy.

Study:

Mentorship was offered once in December 2016. During that month, the rate of TTC eye ointment administration for live births reached 62.3 percent, another improvement consistent with the prediction.

Act:

Continue to test the effect of mentorship alone, this time for several months.

PDSA cycle 3:

Plan:

This cycle’s objective was to test if mentorship alone will lead to improvement and sustainability in administration of TTC eye ointment over several months. .

Do:

Mentorship on TTC eye ointment administration was completed once per month from January through March during Mr. Befikadu visit.

Study:

Mr. Befikadu held mentorship once per month from January to March 2017. The rate of TTC eye ointment administration for live births reached 94.6 percent in January, 83.1 percent in February, and 93.8 percent in March. The hospital did not run out of TTC eye ointment. There is improvement consistent with our prediction.

Act:

Implement regular mentorship on administration and documentation of TTC eye ointment and sustain improvements at the hospital. The sustained improvements in TTC eye ointment administration are evident in the following control chart:

Control chart depicting improvement in TTC eye ointment administration after changes were introduced beginning in September 2016 and sustainability after April 2017.

Mr. Befikadu continued to provide monthly mentorship after the third PDSA cycle, and the high rates of TTC eye ointment administration continued as well. By testing these changes and putting them into practice, the hospital achieved and sustained an improvement in care for newborns. Use the PDSA worksheet to conduct your own tests of change over time and make a difference.

Zewdie Mulissa is a Senior Monitoring and Evaluation Officer at the Institute for Healthcare Improvement.