The pedi essay, or how I learned to PDSA

The first time I heard the abbreviation PDSA I was befuddled. We were in a hospital operations meeting trying to design an admission process for geriatric patients. Why, for goodness sake, would we want to write an essay about pediatrics? The project manager obviously had no idea what she was talking about, and everyone in the meeting was going along. Then they started babbling about cycles. Was this supposed to relate to helmets and safety somehow? It was during the third meeting on the topic that I figured out this was a mondegreen: not a pedi essay on cycles, but a PDSA cycle.

Plan, Do, Study, Act. Kind of catchy. The PDSA cycle did not spring into administrative glory in one quantum leap but was in fact an evolution of ideas. In 1939, Dr. Walter Shewhart, a physicist and engineer known as the father of statistical quality control, took a linear concept and turned it into a cycle, eponymically known as the Shewhart Cycle. The cycle had three steps—Specification, Productivity, and Inspection—and was meant to be used in the design and manufacture of products. Eleven years later, another statistics-minded engineer named Dr. W. Edwards Deming refined the cycle and added a fourth step: Design, Produce, Sell, and Redesign.

Dr. Deming's modification was presented in Japan in 1950 and had a major impact on Japanese industrial design. Over the next year, the cycle was changed to Plan, Do, Check (as in customer satisfaction), Action. It continued to be modified and became a cornerstone of Japanese economic productivity of the period. In the mid-1980s, Dr. Deming began to promote a new iteration of the cycle. The first step was Plan: Develop a new approach or modify an existing process. Next was Do: Try out the new process, preferably on a small scale. The third step was Study: After implementing this change, determine the impact. Was it helpful or not? Finally, there was Act: Do you adopt the process of this rapid cycle of improvement, or try something else? Thus, the PDSA cycle was born.

But Dr. Deming had many more ideas than just the modification of this productivity cycle. He developed a management system with 14 key points, many of which apply to the hospital environment. Among these are the constant drive to break down barriers between departments. He also wanted staff to have pride in their work and be trained and educated. He wanted to eliminate fear, implementing what we would call a culture of safety. He pushed for active top-level management that would avoid making decisions based on costs or quotas alone and instead consider improving systems of production. He wanted those in leadership to appreciate and understand the processes of those they managed, to understand the natural variation of productivity, and to appreciate the value of education and knowledge and the psychology of the worker and the consumer.

When we at Mayo Clinic opened our Rochester Hospital Operation Command Center (see “Commandos,” June 2020 Newman's Notions), I turned to the PDSA acronym and tried to learn from both its original concept and Dr. Deming's other important ideas. To do so, I found a different meaning in the letters: People, Data, Synthesis, and Action.

Forming a command center required the right people. We needed a true multidisciplinary team. We sought out engineers, analysts, project managers, and operations managers, plus all the hospital staff, from environmental service, transport, and bed management to clinical representatives like nurses, physicians, and therapists. They were my people, and I am profoundly grateful for their hard work and their forbearance of my tangential mental processes, nonlinear thinking, and dumb jokes.

Next was data. Bad data lead to bad decisions. People tend to believe the numbers they see on a dashboard are correct. The same physician who would question the evidence in a medical journal might accept blindly the numbers on a dashboard. Nothing like seeing the number of daily admits listed as 12,330 to make you question that, though.

Next was synthesis. You can give people data, but they must understand them, interpret them, and massage them. Otherwise, they're just a fancy display on an expensive oversized screen in a windowless basement. The product of this synthesis is an understanding of the system, its deficiencies, and acute and chronic challenges and successes.

Finally, there's action. You have the people, the data, and the synthesis, and you happily sit down in the command center, knowing what's going wrong, where the danger lies, and what disaster may be on the horizon. You use what you have learned and communicate it to those who can take action. MIssing any of these steps, the effort will be a failure.

The PDSA cycle is still used in hospitals and health care systems across the country and is a basic part of any administrative education. The technique applies to many projects. Using this basic concept, I planned this column, I wrote it, I read it, and thought perhaps I should delete it and start again.

Nah.