---
title: "Designing and Testing Changes"
---

::: {.callout-note appearance="minimal"}
"What changes will we make to lead to improvement?"
:::

## Connecting Aims with Interventions

Once you've decided what you want to improve (the *aim*), you can figure out the changes you could make (the *interventions*) that would lead to the improvement you're looking for. A driver diagram can help you identify the processes involved and modifications you could make to them.

```{mermaid}
flowchart RL
  B(Primary Driver) --> A(Aim)
  C(Primary Driver) --> A(Aim)
  E(Secondary Driver) --> B
  F(Secondary Driver) --> B
  G(Secondary Driver) --> C
  H(Secondary Driver) --> C
  L(Change Idea) --> E
  M(Change Idea) --> E
  N(Change Idea) --> F
  O(Change Idea) --> F
  P(Change Idea) --> F
  Q(Change Idea) --> G
  R(Change Idea) --> H
  S(Change Idea) --> H

```

1.  Write down the **Aim** that you developed in [Choosing What to Improve](choosing-what-to-improve.qmd).

2.  Identify the **Primary Drivers**: What are the key factors that are most likely to influence the achievement of the aim?

3.  Identify **Secondary Drivers:** For each primary driver, what are the specific factors or interventions that are necessary to achieve it?

4.  Generate **Change Ideas:** For each secondary driver, what specific interventions or actions could be tested and implemented?

::: callout-note
## Worksheet {.unnumbered .unlisted}

[Driver Diagram Worksheet](worksheets/driver-diagram.qmd)
:::

::: {.callout-caution appearance="simple"}
As you think about potential changes, consider not only how they will affect the improvement you're trying to make, but also how they will affect the system as a whole, for better or worse.
:::

## Categories of Changes

Here are some types of changes you might think about:

1.  Agency policies and procedures
2.  Medical protocols
3.  Data system, including changes to workflow, form layouts, validation rules, or prompts
4.  Education/training

::: {.callout-caution appearance="simple"}
Education/training is not your only tool. Many people make the mistake of doing more training, when a different kind of change would be more effective. For example, training your personnel to remember to do a stroke scale on suspected strokes is not as effective as implementing a validation rule in your data system that prompts them to do a stroke scale. Remember, performance improvement is about improving *systems* and *processes*.
:::

::: {.callout-tip collapse="true"}
## Example: Improving Pediatric Care

:::: {.clearfix}
![Example: Driver Diagram](images/example-driver-diagram.jpg){.example}Mackenzie's agency has decided to improve pediatric patient care. To help her think up ideas of changes she can make to improve pediatric care, she fills out the [Driver Diagram Worksheet](worksheets/driver-diagram.qmd):
::::

```{=html}
<table id="driverdiagram">
  <thead>
    <tr>
      <th>Aim</th>
      <th>Primary Drivers</th>
      <th>Secondary Drivers</th>
      <th>Change Ideas</th>
    </tr>
  </thead>
  <tbody>
    <tr>
      <td rowspan="3">
        <span contenteditable="false">Improve Pediatric Care</span>
      </td>
      <td>
        ←<span contenteditable="false">Accurate Medication Dosing</span>
      </td>
      <td>
        ←<span contenteditable="false">Documenting Weight</span><br/>
        ←<span contenteditable="false">Calculating Dosage</span><br/>
      </td>
      <td>
        ←<span contenteditable="false">Move Weight to more prominent location in ePCR</span><br/>
        ←<span contenteditable="false">Add validation rule for weight in ePCR</span><br/>
        ←<span contenteditable="false">Stock length-based tape in ambulances</span><br/>
        ←<span contenteditable="false">Implement auto-calculation of dosage in ePCR</span><br/>
      </td>
    </tr>
    <tr>
      <td>
        ←<span contenteditable="false">Pain Management</span>
      </td>
      <td>
        ←<span contenteditable="false">Documenting Pain Scale</span><br/>
        ←<span contenteditable="false">Giving Pain Medication</span><br/>
      </td>
      <td>
        ←<span contenteditable="false">Add validation rule for pain scale in ePCR</span><br/>
        ←<span contenteditable="false">Add pediatric instructions to pain management protocol</span><br/>
        ←<span contenteditable="false">Stock intranasal fentanyl in ambulances</span><br/>
      </td>
    </tr>
    <tr>
      <td>
        ←<span contenteditable="false">Minimizing Hypoxia</span>
      </td>
      <td>
        ←<span contenteditable="false">Recognizing Hypoxia</span><br/>
        ←<span contenteditable="false">Giving Oxygen</span><br/>
      </td>
      <td>
        ←<span contenteditable="false">Practice taking vital signs on pediatric patients in training</span><br/>
        ←<span contenteditable="false">Practice applying oxygen on pediatric patients in training</span><br/>
      </td>
    </tr>
  </tbody>
</table>
```
:::

## SMARTIE Changes

Now that you have some ideas of changes to try, you can develop them along the lines of "SMARTIE goals." Make each change:

<ul>

<li class="icon specific">

**Specific:** What exactly are you going to change, and how?

</li>

<li class="icon measurable">

**Measurable:** How will you know change has happened? How much, or how many?

</li>

<li class="icon action-oriented">

**Action-oriented:** Are there intermediate actions or milestones?

</li>

<li class="icon relevant">

**Relevant:** Can you realistically achieve it with the resources you have?

</li>

<li class="icon time-bound">

**Time-bound:** What's the deadline? How will you tack progress over time?

</li>

<li class="icon inclusive">

**Inclusive:** How will you include those affected by the change in your decision making?

</li>

<li class="icon equitable">

**Equitable:** How will the change reduce inequities?

</li>

</ul>

::: {.callout-note appearance="simple"}
For more information, see ["SMARTIE Goals"](https://www.oregon.gov/oha/HPA/dsi-tc/Documents/SMARTIE-goals-handout.pdf) by the Oregon Health Authority.
:::

## Testing Changes

You've decided on a change to make. Next, test it in a small way before you implement it agency-wide. This is where *Plan-Do-Study-Act (PDSA)* comes in.

```{mermaid}
flowchart LR
  A(<img src="site_libs/bootstrap/images/i-act.svg"/> Act) --- B(<img src="site_libs/bootstrap/images/i-plan.svg"/> Plan)
  A --- D
  B --- C
  D(<img src="site_libs/bootstrap/images/i-study.svg"/> Study) --- C(<img src="site_libs/bootstrap/images/i-do.svg"/> Do)
```

<ul>

<li class="icon plan">

**Plan:** Figure out what change you'll make.

</li>

<li class="icon do">

**Do:** Make the change.

</li>

<li class="icon study">

**Study:** Check the data to see how the change worked.

</li>

<li class="icon act">

**Act:** Decide what to do next:

-   **Adopt** the change agency-wide if it worked well.

-   **Adapt** the change if it partially worked but could be better. Send it back through PDSA.

-   **Abandon** the change if it didn't work.

</li>

</ul>

::: {.callout-tip appearance="simple"}
*Testing a change in a small way* might mean that you try it on:

-   One unit
-   One crew or shift
-   One day of the week

You don't know if a change will work until you test it, so test it in a small way before you roll it out to your entire agency.
:::

::: {.callout-tip collapse="true"}
## Example: Testing a Change to Improve Hospital Relationships

:::: {.clearfix}
![Example: Plan-Do-Study-Act](images/example-plan-do-study-act.jpg){.example}Karson has an aim to improve his agency's hospital relationships. Using the Driver Diagram, he has identified getting patient outcome information from the hospital as a primary driver. He wants to test a change that he hopes will help his agency get outcome data more often. He tests the change idea using the PDSA cycle:
:::

<ul>

<li class="icon plan">

**Plan:** Karson's plan is to add barcode scanning of hospital medical record numbers (MRNs) into his agency's ePCRs. He works with one of the hospitals served by his agency, and they agree to add a barcode to their face sheet. He picks the "B Shift" crew in his agency to try out the change. He identifies where to add the barcode reader in the ePCR form.

</li>

<li class="icon do">

**Do:** The hospital adds the barcode to its face sheet, and Karson adds the barcode reader to the ePCR. He shows the B Shift crew how to use it.

</li>

<li class="icon study">

**Study:** Karson looks at the percentage of PCRs that have a hospital MRN, by crew. He sees that the B Shift crew has a higher percentage of PCRs with an MRN. He also looks at a report of average time from hospital arrival to unit back in service and sees that the B Shift crew is spending about the same amount of time at the hospital as the other crews. He talks with the B Shift crew, and they recommend moving the barcode reader to a different spot in the ePCR form.

</li>

<li class="icon act">

**Act:** Karson **adapts** the change idea. He moves the barcode reader in the ePCR form and tests out that change. It goes well, so he starts planning the full roll-out of the change for all crews and all hospitals his agency serves.

</li>

</ul>
:::
