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Testing for Improvement

The goal of this module is to provide an overview of proven methods used for testing changes to a health care system for the purpose of improving that system. The module further describes the importance of testing changes prior to their implementation. A hypothetical case study is presented throughout the module to exemplify the benefits of using best practices for testing changes made to a health care system. The following is an overview of each section's content:

Part 1: Introduction

Part 2: Methods for Testing Changes

Part 3: Successful Tests of Change

Part 4: Test for Improvement

Part 5: Implementation

Part 6: Supporting Information

Part 1: Introduction 

Improving care and outcomes for patients are often the goals when changing a health care process. An organization needs to change its current system to improve performance and quality. However, not all changes result in improvement. This module focuses on the importance of testing a change before its implementation and describes proven approaches and methods for testing that are used by experienced QI teams. It also illustrates the importance of using reliable data and provides several field examples to illustrate the improvement team's role during the testing process.

Why Testing Before Implementing Change Is Important

Improving the daily practice of health care requires making changes in the processes of care. Thinking about making improvements is a natural first step and comes easily to most; however, most experts in the quality improvement field agree that making changes that lead to improvements are more difficult. The challenge may be deciding on which approach is best for making a change, and each organization may choose a different change strategy. Discussed below are a few of the methods many organizations may be using now once they recognize the need for a change. While these are legitimate tactics for change, their effectiveness for successful quality improvement is undetermined, and they do not have the same benefits as the Model for Improvement, discussed later in this module.

Approaches Being Used

Top-Down Approach

Implementing a change often creates apprehension and resistance within the organization. In order to successfully carry out the change, the process requires considerable leadership. Leaders are chosen because of their ability to influence and guide individuals and groups in a positive and productive way. Overcoming the resistance and fear that change instills in staff may be accomplished through the support and influence of top-level leaders. The top-down approach to organizational change asserts that one or more members of top-level management should envision strategies and tactics first. The leadership then communicates these plans to the staff, highlights their benefits, and then oversees their successful implementation.

Committee Approach

Developing or using a committee to make changes can play an important role in an organization. It allows more people to be involved and builds commitment of its members to the organization. A committee can discuss and review changes in detail and bring recommendations to the organization's leadership. The work of the organization becomes more efficient, and the specialized skills and interests of the committee's members are used to their full advantage. More members get involved in the detailed work of the organization and responsibilities are often shared according to the skills and interests of the committee's members.

Trial-and-Error Approach

Many organizations have used the trial-and-error approach in making improvements. This approach often involves making a change within the organization and then observing if it has an adverse effect. It is built on the concept that an organization learns more from analyzing its failures and trying again, than from improvement that results from changes made early in the process. The latter has been criticized as moving to solutions without adequately understanding or studying the change and its overall impact on the organization.

A Preferred Approach: The Model for Improvement

In quality improvement work in health care settings, the stakes are high, because changes have an impact on patients and health care delivery. Also, the systems impacted are complex and a change in one part can have unanticipated consequences elsewhere. Fortunately, a great deal of work has been done to evaluate the effectiveness of change methodologies in health care over the last two decades. One of the most effective is the Model for Improvement, which has been used successfully around the world in multiple industries, including health care. The model was crafted to provide a pragmatic and practical framework for the work of improvement. The rationale for this approach includes two key concepts--small incremental tests of change and benefits of testing changes before implementing. Additional information on the Model for Improvement is specifically described in Part 2 of this module.

Small Incremental Tests of Change

Testing a change provides an organization with a preview of the result before implementing it throughout the organization. It is comparable to test driving an automobile before purchasing it. It is ill-advised for an individual to make a financial commitment without ensuring the automobile meets the buyer's needs. If the buyer later discovers the new vehicle does not meet his or her needs, then resources have been wasted, or in this case, money spent on the new vehicle. This is the same philosophy that should be applied when making changes in an organization. Moving directly to a new change without appropriately testing it can have a negative impact on the organization. Although the change may not have a direct fiscal impact, it can have a negative effect on patient or staff satisfaction. Testing allows an organization to try a change in a controlled situation, which minimizes risk and the potential for a system-wide adverse event.

Reasons to Test Changes

An organization may experience one or more benefits when it tests a change before implementing it. The following list provides some examples of why organizations test changes before moving to implementation:

  • To increase buy-in and confidence that the change will result in improvement
  • To decide which proposed changes will lead to the desired improvement
  • To evaluate how much improvement can be expected from the change
  • To decide whether the proposed change will work in the actual environment of interest
  • To decide which combinations of changes will have the desired effects on the important measures of quality
  • To evaluate costs, social impact, and side effects from a proposed change
  • To minimize staff resistance during the implementation of a change

Below is a case study that is followed throughout the module, which depicts a fictional QI team and its efforts to improve the rate of adult patients receiving influenza vaccinations in its organization. The case study may be read in its entirety by clicking here.

Case Study: The Problem.

The amount of testing an organization should perform before moving to implementation varies; however, high- risk and impact changes should receive more comprehensive testing. Part 2 describes methods that many organizations use for testing changes for improvement.

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