Mildred's Case Study: FOCUS-PDSA and SPO Model for Patient Safety
This case study examines Mildred's healthcare experience as a framework for improving patient safety, specifically addressing the problem of patient falls. Using Donabedian's Structure-Process-Outcome (SPO) model, the paper identifies structural gaps, process failures, and adverse outcomes contributing to Mildred's fall risk and misdiagnosis. The study then applies the FOCUS-PDSA quality improvement cycle — Find, Organize, Clarify, Understand, Select, Plan, Do, Check, and Act — to systematically diagnose root causes and implement corrective measures. The paper also briefly evaluates Total Quality Management (TQM) versus Continuous Quality Improvement (CQI) as organizational approaches, concluding that CQI better suits Mildred's long-term care needs.
- Introduction: Overview of Mildred's case and chosen frameworks
- SPO Model Applied to Mildred's Case: Structure, process, and outcome gaps identified
- FOCUS-PDSA Quality Improvement Cycle: Nine-step cycle applied to fall prevention
- TQM vs. CQI for Mildred: CQI preferred over TQM for long-term care
- Conclusion: Summary of frameworks and improvement goals
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What makes this paper effective
- Systematically maps a real patient scenario onto two established quality improvement frameworks (SPO and FOCUS-PDSA), grounding abstract models in concrete clinical detail.
- Organizes the FOCUS-PDSA cycle step-by-step, giving readers a clear procedural walkthrough of how each phase applies to Mildred's situation.
- Uses the SPO table to efficiently compare structural deficiencies, process failures, and outcomes side-by-side, making root causes visually apparent.
Key academic technique demonstrated
The paper demonstrates applied framework analysis — taking a theoretical model (Donabedian's SPO and the FOCUS-PDSA cycle) and systematically applying each component to a specific patient case. Rather than describing frameworks abstractly, the author anchors every step to Mildred's clinical circumstances, showing how quality improvement methodology translates into actionable care decisions.
Structure breakdown
The paper opens with a brief contextual introduction, then presents the SPO model in tabular form to identify gaps across structure, process, and outcome dimensions. The bulk of the paper walks through all nine stages of the FOCUS-PDSA cycle in sequence, each as a labeled subsection. It closes with a short comparative note on TQM versus CQI. Citations follow APA style throughout, and a reference list is appended.
Introduction
Mildred's story was developed as part of a healthcare training course. The case takes a novel approach to educating healthcare professionals about the significance of non-clinical services, behavior, and attitudes in ensuring patient safety. It draws upon the experiences of patients within healthcare settings and information gathered from other high-risk industries to develop a strategy that allows healthcare workers to critically appraise and intervene in the development of patient danger.
There are numerous opportunities for improvement in Mildred's case. This paper focuses on effective communication and patient assessment as the primary areas to address the problem of patient falls. To do so, the SPO (Structure-Process-Outcome) model is applied alongside the FOCUS-PDSA improvement framework, using supporting tools such as the Fishbone diagram, the 6 Huts model, a flow chart, and the 5 Whys technique.
SPO Model Applied to Mildred's Case
Donabedian's Structure-Process-Outcome model is a useful framework for quality assessment and illustrates the connection between process and outcome. Facilities use this data to benchmark themselves against internal and external standards in order to focus their quality improvement efforts (Bader, 2003). In Mildred's case, process measures consist of the set of activities that occur between Mildred and her care providers. Outcome measures capture the change in her current and future health status as a result of the care she received. Each of these measures is discussed in more detail below.
Structure
Several structural deficiencies were identified in Mildred's case:
- Absence of skilled staff, such as nurses, to assist Mildred at home.
- No bracelet or identification aid was in place.
- Incorrect ambulatory supports were provided.
- Absence of adequate consultation.
- No leadership accountability or obligation.
- Mildred had suffered a stroke, which impaired her mobility.
- Staff spoke about her rather than to her.
Process
Process failures included:
- No conservational or environmental assessment was conducted.
- Complete care assistance was not provided.
- No falls valuation or formal fall assessment was performed.
- No fall restraint service was applied.
- No leadership obligation was demonstrated during care delivery.
Outcome
The following adverse outcomes resulted:
- No safe measures were in place to prevent Mildred from falling.
- No monitoring techniques for patient falls were implemented.
- No refinement of her care plan occurred.
- Cost of poor quality: extended hospital stay, unnecessary examinations, and ineffective surgical actions.
- Mildred was misdiagnosed with CVA instead of having her stroke correctly identified and treated.
References
Alireza, N. (2014). Evidence of using FOCUS PDCA. Retrieved December 10, 2015, from
Bader, M. K. (2003). Using a FOCUS-PDCA quality improvement model for applying the severe traumatic brain injury guidelines to practice: Process and outcomes. Evidence-Based Nursing, 23(9), 6–8.
Bozorg, A. A. (2012). Effects of implementation of FOCUS-PDCA model on registration of medical services. Indian Journal of Fundamental and Applied Life Sciences, 23(12), 212.
Farah Bakhsh, M. T., J. S., N. N., & A. R. (2011). The use of FOCUS-PDCA. Hakim Research Journal, 8(4), 212.
Heydaranlu, E., K. M., E. A., S. M., & A. N. (2013). Effect of FOCUS-PDCA performance in the activity of the emergency department of Shahid Maha. Military Medicine, 10(4), 440–453.
JC, G. (2006). Performance improvement with a hybrid FOCUS-PDCA methodology. Joint Commission Journal on Quality Improvement, 89(9), 660–672.
J, W. (2003). Application of the FOCUS-PDCA model to home care equipment management. American Journal of Medical Quality, 8(2), 94–96.
Moore, L. (2009). Donabedian's structure-process-outcome quality of care model: Validation in an integrated trauma system. Journal of Trauma and Acute Care Surgery, 78(6), 1168–1175.
P, S. (2010). Total quality management (TQM) and continuous quality improvement (CQI). Journal of Nursing Care Quality, 21(23), 32–45.
RS, H. (2007). Using CQI to reduce patient falls: A fresh perspective on a chronic problem. Public Medicine, 21(9), 21–24.
Shelton, P. J. (2012). Measuring and improving patient satisfaction. Aspen Publisher.
Sullivan, A. M. (2009). Quality improvement. Retrieved December 10, 2015, from
Wagner, K. C. (2009). FOCUS PDCA quality improvement tool used for creating family and patient library. Medical and Health Libraries.
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