3 COMFY Quality Improvement (QI) Strategies

from Jan


In this context, relationships can mean interaction between any two or more involved people. My examples are from my family and about food, but they can be applied in other circumstances...use your imagination or leave a comment with your questions! 

PDSA Model for Performance Improvement 

This is the one that made me get interested in QI. Three questions. Four words. So simple. No intent to make it complicated.

Let's take a look: 

What are we trying to accomplish? To stop eating 22,000 pounds of snacks before bed (which for a 4 year-old adds about 2 hours to the bedtime "routine"). 

How will we know that a change is an improvement? Four-year-old will eat less snacks and more dinner each night. 

What changes will be made that will result in improvement? Less snacks late in the afternoon (I sense a snacking pattern here.) A later dinner time, to ensure that everyone is hungry. Pick out bedtime snack in afternoon. 

OK, so here we go with the fun part: Plan. Do. Study. Act. 

Plan-We will not have any snacks past 3pm to increase the chance that everyone is hungry at dinnertime. 

Do-At 2:45pm, 4-year-old was offered snack and declined.  Around 4:30pm, said individual was famished, but dinner was not for one more hour. I allowed a "small snack" which still interfered with dinner (although not as much) and also caused much debate on how exactly a "small snack" was measured. There was an improvement in the amount of dinner (more) and bedtime snacks (less) consumed; but, I had not anticipated that a snack would be declined and I did not think to explain to the young whippersnapper our new system.  

Study-After carefully considering the data collecting on this first cycle, I determine that more information about the new system needs to be given to all parties involved. I was correct that no late afternoon snacking would lead to greater dinnertime hunger, but I had misjudged my timing and had neglected to inform all participants of the new system. 

Act-In the next cycle, I will take time to explain the system to all members of the household.  Also, I will move "last snack time" to 3:30 to better fit our usual afternoon activities. All intermittent small snacks would be forbidden.  (Although, if I am getting help in making dinner and a tomato or slice of cheese gets eaten in the process, by him or me, I'm not one to be THAT picky.  Technically, dinner food is being consumed!) 

And, so the iterative cycle goes. The best part: as you do it over and over again you may count even tiny improvements as successes!  So, if on night 2 of your cycle, only 20,000 pounds of snacks are eaten...SUCCESS!  Doesn't that feel nice! 

Stages of Change Theory 

Some might not classify this as a QI strategy, but it does give a framework for change/improvement in behavior and that is what I need! 

Precontemplation-Joshua likes snack food more than dinner food. Joshua is more hungry at snack time than dinner time. He sees no need to change his behavior, it is currently working for him. 

Response-Mommy and daddy stop snacking late in the afternoon and go on (and on) about how much dinner they can eat since they are sooooo hungry. They talk about having more energy to play after dinner because they ate well. 

Contemplation-Joshua begins to realize that he has some control over what is served for dinner. Mommy mysteriously stops giving Joshua snacks late in the afternoon and he starts getting hungrier at dinner time. Oh, but those bedtime snacks are so yummy. 

Response-Mommy cuts off late afternoon snacking and adjusts dinnertime. 

Determination-Joshua is getting more hungry by dinner time, but is not sure what is for dinner. What if he does not like it? Then he'll be really, really hungry.  Ugh, what is a growing boy to do! 

Response-Mommy starts involving Joshua in meal planning and preparation. Small bites of ingredients are snuck in to increase buy-in for dinner. 

Action-Joshua begins to find dinner more interesting now that he has some say in the matter.  But, he is so used to a big bedtime snack, that he has trouble eating a lot of dinner because he is expecting a big snack. 

Response-Some parameters are set around dinner. Everyone needs to try their dinner and there is always one item on the table that each person is known to like. If the new food is disliked, a person is not forced to eat it. But they should eat the item they like to help fill them up.  Also, the person can suggest an easy alternative (yogurt cup, appropriate leftovers, etc.) to the item disliked. Until that is eaten, no additional snack food will be consumed. 

Maintenance-Joshua (and the whole family) is, most nights, enjoying a reasonably sized dinner with a reasonable bedtime snack. 

Response-Joshua continues to be involved in meal planning and preparation.  Also, mommy or daddy ask him what he would like to add to the grocery list to have on hand for snacks. Joshua has a snack shelf in the pantry and is free to look in the refrigerator at any time (although is expected to close the refrigerator door in a timely manner)! 

Recurrence-Dinner was ready very early. A new recipe took a much shorter time to prepare than mommy expected. Since dinner was eaten early, no one was that hungry at dinnertime.  But, at bedtime snack time, we fell back into our old pattern of a large snack. 

Response-Mommy and daddy realize that it was a weekend day when the schedule was not being followed very well throughout the whole day. Snacks were given at bedtime with an explanation of why it was larger than usual and how we would get back on track the next day. 

This theory never plays out in life as smoothly as it sounds on paper.  But, it provides a framework for action, response, and progression (and sometimes regression) which is exactly what a theory should do! Now I have a well-thought-out plan.  I've taken the most difficult step out of changing behavior by having this framework. Reality will intervene, but I have a foundation for my thoughts and actions. 

Involve Stakeholders 

I don't have a particular reference for this except for my social work training (I am sure there are a lot of scholarly articles talking about the benefits of stakeholder involvement).  Here is what I can tell you: 

A few weeks ago, I stored all of my cut-out-of-magazine recipes on an app on my phone. They are all listed nicely with a picture of the meal. One afternoon that Joshua was very tired, we started scrolling through the recipes/pictures. At that point, I probably had about 50 recipes saved. Joshua patiently scrolled through them all and told me which ones looked good to him. There were about 35! And they were of a good variety of meals...pasta and chicken of course, but even things that had vegetable in the pictures were chosen!  For the past 3 weeks I've picked 4 new main dish recipes each week from Joshua's list (the other 3 days I make things we've had before).  Out of those 12 recipes, Joshua has actually tried 10 of them and enjoyed eating 9 of them. He eats a proud portion of the dinner he selected and eats less snack at bedtime. Stakeholder involvement, I'm sold. 

All-in-all, I come back to one of the central lessons I learned while earning my Masters of Social Work: start where your client is.  Think about that person's experience and perspective. His or her needs and desires. Keeping site of your goal can be difficult when only tiny, incremental change is gained.  But, there is gain!  The focus here is on IMPROVEMENT, not perfection.