Science of Improvement: Testing Multiple Changes

Model for ImprovementTypically, teams test more than one change at a time. All of the changes are aimed at achieving the same ultimate goal. Using several linked Plan-Do-Study-Act (PDSA) cycles allows a team to test more than one change simultaneously.

See also: Testing Changes, Tips for Testing Changes, Linking Tests of ChangeImplementing Changes, Spreading Changes.


Example of Testing Multiple Changes

A team working on reducing the average extubation time for elective coronary artery bypass graft (CABG) patients worked on several changes at the same time. Each of the changes went through several linked Plan-Do-Study-Act (PDSA) cycles. 



Change 1: Standardize pain management.
In order to be extubated early, patients must not be too heavily sedated. The team began by revising the existing standards for postoperative pain management. Instead of using the traditional high dose of morphine, the team tested the use of smaller, more frequent doses. In this way, patients' pain was managed adequately, yet patients were awake enough to be extubated safely.

Change 2: Standardize anesthesia management.
Patients cannot be extubated if they are heavily sedated. The team tested having anesthesiologists use lower doses of sedatives to prevent patients from remaining heavily sedated long after the surgery was completed.

Change 3: Establish a rapid weaning and extubation protocol run by nurses and respiratory therapists.
The team also developed a set of criteria that patients need to meet in order to be extubated safely, given the changes in anesthesia and pain management.

Change 4: Reduce delays in obtaining arterial blood gas (ABG) results.
The team identified delays in obtaining ABG results and weaning parameters as barriers to early extubation. They assigned a dedicated respiratory therapist to obtain these results.

Change 5: Educate physicians, nurses, certified registered nurse assistants (CRNAs), and respiratory therapists on the new goals and procedures for early extubation.

Change 6: Extend the changes from elective CABG patients to all CABG patients.

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