This article, by Nami Nelson and Sophie Hill, was originally published on August 18, 2020 on the Shared Decision Making in Healthcare blog. The blog has now been archived and is no longer accessible.
Shared decision making (SDM) fits very well with quality improvement and systems thinking and is one way of helping a more systematic, sustainable implementation of SDM.
Safer Care Victoria has been using the US Institute for Healthcare Improvement’s (IHI) quality improvement methodology as a guiding framework. This has also been used by NHS England because it is a ‘structured improvement methodology…involving all stakeholders, and [that] rigorously evaluating progress can enable a quality system to develop and spread sustainably’.
You can find information about the NHS England’s SDM program here or watch the IHI Quality Improvement video for an overview of how the IHI understands quality improvement:
As Dr Don Berwick describes in the video, quality improvement is about systems thinking. At the core of what it means to be a systems thinker is ‘constant curiosity about a world that you may not understand never fully but might take the next step to understand a little better’.
This kind of curiosity sits at the core of SDM. A health professional who is facilitating an SDM process with a patient is demonstrating their curiosity about that patient’s unique needs and preferences in order to help them find the most appropriate care option for their health and well-being.
Many other concepts in IHI’s Quality Improvement methodology can also be useful when thinking about implementing SDM. Perhaps the most important lesson is to keep things simple and target small incremental changes that will help you move towards your vision or goal. If you are just getting started and have a identified a vision for SDM as standard practice – don’t be overwhelmed by the scale of tasks that might be needed to achieve this vision. As the IHI video explains, their quality improvement methodology doesn’t ask you to implement a perfect vision all at once. It suggests identifying smaller changes that are needed to achieve your vision and that you can observe, monitor and adapt in a continuous improvement cycle.
In 2020, our pilot implementing SDM project funded by Safer Care Victoria is exploring how different services can get their SDM journey started. One site is working with a multidisciplinary team including consumer representatives to unpick and identify what the current situation, systems and gaps are and then map out what a perfect future state would look like. This ‘future state’ becomes their change vision and will guide their gradual change process. For the pilot project, the incremental change being focused on is development and use of a decision aid. Many other systems and behavioural improvements or changes were identified during the mapping of the future state mapping and will no doubt become part of their longer term continuous improvement plan.
At a systems level, this continuous improvement process is where the IHI video’s rolling Plan/Do/Study/Act (PDSA) cycle comes in. It gives structure to what you do to develop, test, learn and adapt how SDM is implemented at a service. A simplified example could be:
- Plan: Map your current situation and context identifying the gaps, obstacles and issues. Also map what your vision for a future system will be and the steps or smaller changes that will need to occur in order to achieve the vision. Prioritise the steps/changes you will implement first – in this case, introduce use of a decision aid.
- Do: Develop a plan for the introduction of a decision aid including, if needed, the training of staff who use it and how you will measure its use. Then start testing it with patients.
- Study: Collate the data from how you measured the frequency or use, experience of use and effectiveness of the decision aid and summarise the findings and recommendations.
- Act: Review your plan and identify what needs to be adapted or changed and start the PDSA cycle again.
On an individual level we can also see how when using SDM with an individual patient you can use the PDSA cycle:
- Plan: Identify the options for a particular decision and identify the best available evidence for the various harms and benefits for each option. Know what activities or tools you will use to support the patient reflect on their preferences and what they mean for the different options and their health and well-being.
- Do: Facilitate SDM with the patient during a consultation(s).
- Study: Do the SURE test (O’Connor and Légaré, 2008) to understand how confident the patient is about the decision they are about to make or have made.
- Act: If the patient indicates that they are not yet ready to make the decision and more work is needed to support them to do this – identify the right actions and go through the PDSA cycle again.
In summary, if you are thinking about getting started with implementing SDM, we recommend these important factors:
- Know what your vision is for SDM at your service
- Keep it simple by mapping the incremental changes and steps you need to achieve your vision
- Remember that ‘curiosity’ to identify how we make things better is at the core of all levels (e.g. system or individual) of quality improvement and SDM.
Questions to consider:
- Have you established what the current situation is at your service and what your vision for quality care might be if SDM was used?
- Does your service follow the IHI methodology for quality improvement or another quality improvement framework? Talk to the person or team responsible for supporting continuous quality improvement at your service about how SDM can be integrated into existing change management or quality improvement systems/frameworks.
Institute for Healthcare Improvement (IHI). Science of Improvement: How to improve [website]. Accessed June 2022 http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx
IHI. Dr Mike Evans: An illustrated look at quality improvement. Accessed June 2022 https://www.youtube.com/embed/nPysNaF1oMw
O’Connor,T and Légaré, F. The SURE Test ©. 2008. Accessed June 2022: https://decisionaid.ohri.ca/docs/develop/Tools/DCS_SURE_English.pdf