Mildred's Case Study: FOCUS-PDSA and SPO Model for Patient Safety

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.

Several structural deficiencies were identified in Mildred's case:

Process failures included:

The following adverse outcomes resulted:

FOCUS-PDSA Quality Improvement Cycle

FOCUS-PDSA is a straightforward, logical, and systematic method for achieving incremental improvement of an existing procedure, reshaping a current process, designing an entirely new procedure, or solving a specific problem. The following steps were applied to Mildred's case.

There was a clear lack of communication among the care team and hospital staff. When Mildred arrived, no one was working from the same information, which made diagnosing her condition extremely difficult.

A great deal of incorrect information was provided in the effort to help Mildred. The team was disorganized — members talked over one another and, in some cases, did not collaborate effectively while Mildred lay in her bed confused. An organized team needs to be formed that works together harmoniously and operates from a shared understanding of the patient's status (JC, 2006). This team must have access to accurate chart information and must demonstrate the ability to function cohesively.

Despite knowing that the general goal was to reduce falls, team members felt they did not have adequate data to identify what specifically needed to improve. As a result, the team needed to gather information on how the fall assessment process was currently being carried out (Bozorg, 2012). As part of this effort, the team conducted an analysis of falls over the previous quarter. They tracked the number of falls and categorized them by ward location, type of fall (from a chair or bed), time of occurrence, recurrence rates, and exact location within the facility (bedroom or kitchen). Through this process, the team recognized that a significant proportion of the total falls were repeat falls.

Using a root cause analysis (RCA), the team repeatedly asked "Why" events occurred until they reached the fundamental reason for the falls. They first identified that there was insufficient data for meaningful follow-up after a fall occurred. The team concluded this was because key data needed to modify the cause of the fall was regularly missing. They then determined that the missing information resulted from the lack of a systematic, complete procedure to identify root causes in Mildred's situation. This gap in procedure negatively affected the facility's ability to gather accurate background information on Mildred — including something as basic as her age and dietary requirements. The team was unable to come together in time to uncover the underlying cause of Mildred's falls, a situation that nearly proved fatal.

The team needed to engage the relevant Patient Safety Commission and, with the commission's guidance, apply a root cause analysis quality improvement procedure — this time utilizing it to evaluate every type of fall reported.

The team needed to plan and test the application of an RCA process specifically for Mildred's fall history. This included designing a pilot test to evaluate whether the new process would reduce the number of repeat falls.

Team members and other staff applied the program as discussed, adhering to established deadlines. Each member completed assigned tasks according to the plan. The team collected and graphed data on the total number of falls, the number of repeat falls, and the number of patients experiencing circumstances similar to Mildred's.

After a two-month pilot, the team reviewed fall and restraint data and discussed results with staff. Progress was made toward the goal of reducing repeat falls. However, overall fall rates in certain areas of the facility remained above the target. A review of physical restraint data showed that the number of patients in restraints had not increased and had, in fact, declined during the pilot period.

The new process was implemented across the full capacity of the facility. The team continued to gather data on Mildred's condition, with the overarching goal of achieving at least a 50% reduction in her likelihood of falling again. The team continued to evaluate and refine the procedure using a Rapid Cycle PDSA approach. The facility proceeded to test small changes to their fall care system through frequent monitoring and assessment until their overall objective was met. Follow-up monitoring allowed the facility to confirm that changes made for Mildred and other patients in similar situations were sustained over time, moving them toward a significantly higher level of performance.

Conclusion

Mildred's case highlights how systematic quality improvement frameworks can address persistent patient safety problems such as falls. By applying the SPO model alongside the FOCUS-PDSA cycle, care teams can identify root causes, organize effective responses, and implement sustained improvements. The combination of structural analysis, process clarification, root cause investigation, and iterative testing provides a comprehensive path toward safer, more communicative, and more patient-centered care.