Another Application of the Test-Implement Table

I've already discussed the wisdom of Table 7.1 of The Improvement Guide, 2nd edition written by my colleagues at API (see this post.)

Here is the the table again:

(Table 7.1 G. Langley et al. (2009), The Improvement Guide, 2nd edition, Jossey-Bass, San Francisco © Associates in Process Improvement)

Last week, my colleague Colleen Lampron told me about a dental clinic that was eager to start assessing the risk of caries (“cavities”) in its patients. 

The leader of the clinic understood the benefits of caries risk assessment (CRA) and assured Colleen that the other leaders and staff shared her high degree of belief in the importance of the change.

In terms of the table, it seems like a “Large-scale Test” or jumping all the way to implementation is in order, depending on an assessment of cost of failure.

I recommended that the clinic actually start very small, testing CRA with one provider.  Why?

What to Change and How to Change

At the end of the my first post about the Test-Implement table, I mentioned that I try to remember to evaluate the What and the How of a change when I apply the table's guidance.

In other words, apply the table to the What and How separately and then consider the where you fall on the test-implement scale.

In the dental clinic example, what to change is the assessment of caries risk, so that every patient will be assessed for their risk.

The clinic leader wants to move quickly so every provider assesses risk and tracks the assessments in the electronic record system.  

On the other hand, providers in the clinic have not been doing risk assessment regularly.  They don’t yet have a way to track CRA in their electronic record system.  They can’t predict the number of minutes it will take to assess risk and document patient status.

All of these points are related to this question:  How will the new work happen reliably?

I recommended that the clinic start with very small-scale tests to develop the “how.”  These tests will help staff who will do the assessments to create a method to assess caries efficiently and effectively.   

What’s very small scale?  Start with one provider to begin to develop the method.

Given leadership commitment and high degree of belief in the change itself, the health center should be able to rapidly test ideas related to the How.  Their tests will define electronic record code design and use, adjustments to the workflow, crafting the “why we are doing CRA” message for old and new staff and defining how everyone will know that CRA is in place and working for every patient, every time.