The director of a neonatal intensive care unit (NICU) notes an elevated failed extubation rate of 47% among preterm infants. She decides to implement a quality improvement (QI) plan with the goal of reducing the failed extubation rate by 30%. The director determines that the primary issue responsible for the elevated failed extubation rate is a lack of standardized extubation strategies. She leads a team to design a new extubation checklist and standardized protocol, which form the cornerstone of the QI plan. She provides 4 training sessions over 2 weeks to the NICU physicians and staff, all of whom pass a post-test administered after the training. Based on the Plan-Do-Check-Act paradigm, which of the following is the most appropriate subsequent action?
The Plan-Do-Study-Act (PDSA) and Plan-Do-Check-Act (PDCA) paradigms are quality improvement (QI) tools that involve cyclical processes with the goal of continual improvement. Once a QI issue is identified (eg, elevated rate of failed extubations among preterm infants), a 4-step process is put in place to address it, as follows:
Plan: Identify any factors contributing to the issue (eg, lack of standardized extubation strategies), set an objective (eg, reduce failed extubation rate by 30%), and put a plan in place to carry out a cycle (eg, new protocol and checklist development, training in preparation for implementation).
Do: Implement the plan (ie, new protocol) while making sure to collect data and document problems and unexpected observations.
Study (or Check): Using the data gathered, complete a data analysis that compares the results obtained to the objectives set (eg, evaluate variations in failed extubation rates). Although the terms PDSA and PDCA (which may have developed in different settings) are sometimes used interchangeably, the use of "S" ("Study") in PDSA is felt to better emphasize the need for a full analysis.
Act: Based on these data, identify changes that need to be made and lessons learned, and then begin work on the next cycle if needed to achieve the objective.
These 4 steps can be repeated as needed. Adjustments may be considered based on results. For example, another training session may be useful to provide additional instruction or to ensure retention; however, it is unlikely to be helpful at this time given the recent training and post-test administration (Choice D).
(Choices B and C) The approach described in this case represents a QI project that does not include an experimental intervention. It does not require approval by the institutional review board (ie, research ethics board), a randomized controlled trial, or additional informed consent.
(Choice E) A report could be provided to hospital leadership but is not a necessary element at this junction of the cycle when results have not yet been obtained. Reports to leadership are sometimes useful in the early stages of a QI project if the project requires significant additional resources, which does not seem to be the case in this scenario.
Educational objective:
The Plan-Do-Study-Act and Plan-Do-Check-Act paradigms are quality improvement tools. They are 4-step cyclical processes with the goal of continual improvement.