The Model for Improvement (MFI) is a tool for accelerating meaningful change and encompasses 3 questions and implementing testing cycles.

1. The first question relates to what is to be changed, specifically “what are we trying to accomplish?” Once an area for improvement is identified, the purpose can be formulated into an Aim statement. The aim should be measurable, timed, and address an important issue in a specific population. A clear aim will keep a project on track, help identify the process, and aid in identifying proper measurements (3).
2. The second question in the MFI is, “what changes can be made that will result in improvement?” The following are great starting points: eliminating waste, improving work flow, optimizing inventory, changing the work environment, managing time and focusing on variation or error proofing. (4)
3. The third question in the MFI is, “how will we know a change is an improvement?” There are three measures that are commonly used to help determine this: outcome, process and balancing. Outcome measures represent the ultimate results of the quality improvement plan. Process measures help to determine if the correct steps are being performed when attempting to achieve the end result. Balancing measures help identify whether the changes that are being made to one part of the system are causing problems in another part of the system.

Once the answers to the MFI questions are determined and the aim developed, a testing cycle can be implemented and accomplished by completing a PDSA Cycle, which is an acronym for Plan, Do, Study and Act.

• The Plan portion develops an intervention/change to test and determines how to collect the needed data.
• The Do portion of the PDSA cycle is actually trying out the test intervention on a small scale.
• The Study portion involves analyzing the data and reviewing the results of the intervention.
• The Act part of the cycle is used to either refine the change, or to test another change, based on what was learned from the test intervention; and to implement successful changes into the larger health system. (4)

Example of a project:

One quality improvement area relevant to geriatric populations is the number of patients undergoing cancer-screening tests without clinical indications. For example, 46% of patients aged 75 or older at the time of their initial negative screening colonoscopy result, received a repeat screening colonoscopy within 7 years.  To determine why geriatric patients are undergoing colonoscopies we can use a flowchart. This chart would start with a geriatric patient undergoing a screening colonoscopy with negative results and ends with the patient undergoing another screening procedure within 7 years. With the use of a flow chart we can determine if hospitals did not have clear guidelines for when and how often to do repeat screening colonoscopies in geriatric patients. In our case example, what should have happened was a geriatric patient undergoing a primary colonoscopy and not undergoing another screening colonoscopy for 10 years.

The next step is to identify how we reduce the amount of early/extra colonoscopies.

• A clear aim statement would be: to reduce unnecessary colonoscopies in the geriatric population by 50% in 1 year.
• Next we would need to establish outcome, process and balancing measures.
• For process measures: The percent reduction in the number geriatric patients with negative initial colonoscopy who are referred for repeat colonoscopy before 10 years.
• For balancing measure: The proportion of geriatric patients who had negative initial colonoscopy who are diagnosed with late stage colon cancer before repeat colonoscopy at 10 years. On a small scale we would implement an intervention. One intervention might be creating a hospital protocol to reduce the rate of unnecessary colonoscopies in geriatric patients.

This would eliminate waste, change the work environment and make the system more error proof. After implementation for a given time period we will study our measures to confirm the efficacy of our intervention, fully completing a PDSA cycle.