Institute for Healthcare Improvement (IHI) Model for Improvement
The Institute for Healthcare Improvement’s (IHI) Model for Improvement is a conceptually simple model that health care practices can apply as they begin their journey toward improvement. For many, the IHI Model for Improvement is a default model for change that works in concert with even more robust tools, such as Lean and Six Sigma.
An important component in the improvement journey is to establish a team. Ideally, the team should have a leader who is respected and can influence change (no matter how small). The leader will benefit from having other team members who represent other stakeholders in the health care practice or organization.
The IHI Model Involves the Following Steps
- Setting the Aim—The first step on the journey of change is setting a high-level aim. An example of an aim statement is “to increase the number of patients with diabetes who have a documented foot exam in the medical record every year.”
- Setting a Goal—A goal statement allows the team and staff to be very clear about exactly what outcome of interest needs to be improved, how much of an improvement is being sought, and during what time frame. An example of a goal statement is “to improve the percentage of patients with a diabetes foot exam in the medical record from 50% to 80% in the next 6 months.”
- Brainstorming—Health care practices should think about reasons why the current outcomes exist. They should consider all elements of the chronic care model during the brainstorming phase. The team should generate a list and consider which item(s) are most tightly linked to the outcome in question, and the first to try to change. For instance, if the team identifies in the brainstorm that patients are not being asked to take their shoes and socks off during a visit, then they can test this idea and proceed to the next phase in the model: testing using PDSA.
- PDSA Cycles—The PDSA cycle model stands for Plan, Do, Study, Act. PDSA cycles are very small cycles of change that allow for care to continue to be delivered while clinicians attempt small changes to processes. By design, these cycles should be small (even just one clinician testing the change), so that they are successful at first and allow the team to see that change is possible. Each success allows positive motivation to grow, which will lead to a greater appetite for even larger changes. Each step of the PDSA cycle model is described below:
- Plan—The team plans for a change in the process. In the above example, the plan may be to ask the medical assistant to ask patients with diabetes to take off their shoes and socks when entering the exam room during each visit.
- Do—The change in the process is performed for a short interval, usually one or two weeks.
- Study—A designated team member randomly selects five to 10 charts from patients who were seen during the change cycle. The team member performs an audit and sees how many out of the five to 10 patients had a documented foot exam. This data is then plotted on a chart and displayed for all of the health care team to see.
- Act—Based on the results of the study, the team will decide on next steps, including:
- Adapt—Change the process slightly, given that the outcomes are not where expected.
- Adopt—If success has been achieved, the health care team will adopt the new process as its standard.
- Again—If is not clear that the change will be adopted and more data are necessary, the change cycle is extended so that more data can be gathered.
- Abandon—If the change is determined to be unlikely to lead to improvement, the health care team will redo the PDSA cycle with a new tactic.
It is not uncommon for health care practices to run multiple cycles and chains of PDSAs at the same time. As an example, a practice may try to optimize the process for the medical assistant to room the patient while concurrently working on a patient engagement change that empowers the patient to know the goals of care and requisite process measures every year. A practice may be doing this while also trying to optimize its information systems to gather quality data. The key is to feel comfortable with small cycles of change; experience a few wins; and then proceed to more complex, larger change efforts.
After a change is deemed successful, the process change should be spread to other members of the practice and potentially to other practices.