Module 2
How the Model for Improvement Works
The Model for Improvement, developed by Associates in Process Improvement and widely adopted in healthcare through the Institute for Healthcare Improvement (IHI), provides a simple but powerful framework for change. It centers on three guiding questions:
- What are we trying to accomplish? (Your AIM Statement in Module 3)
- How will we know that a change is an improvement? (Your Measures in Module 4)
- What change can we make that will result in improvement? (Your Change Ideas in Modules 5 and 6)
These questions are paired with Plan-Do-Study-Act (PDSA) cycles, which allow teams to test changes on a small scale, learn from results, and adapt before spreading more widely. Module 6.3 walks through how to run a PDSA cycle step by step.
Example Resource: Model for Improvement Worksheet. Use this to work through the three guiding questions above for your own project.
This model is flexible, easy to understand, and well-suited for the fast-paced and complex environments that a PMHCA will likely encounter in the emergency care space. It encourages small, rapid tests of change, reducing the risk of investing heavily in a process before you know it works. Unlike approaches that require lengthy planning and committee approvals before any action is taken, the Model for Improvement gets teams learning from real-world testing within days or weeks.
Example: Pediatric ED Mental Health Consult Wait Time Reduction
A pediatric ED team sets an aim to reduce wait times for mental health consults. They answer each guiding question:
- Q1: “Reduce average wait time for behavioral health consults from 4.2 hours to under 2.5 hours within three months.”
- Q2: Measure average wait time (order-to-consult-completion) weekly, tracked on a run chart. Also, collect staff satisfaction data monthly.
- Q3: Test a PMHCA-facilitated teleconsult model during peak daytime hours (10 AM–3 PM), when ED behavioral health volume is highest and wait times are longest. The PMHCA coordinator — available Monday through Friday during standard program hours — arranges a live video consult with a psychiatrist, who advises on assessment and disposition. Final care decisions remain with the ED provider. Starting with one day per week on Wednesdays.
PDSA Cycle 1: PMHCA-facilitated teleconsult offered on Wednesday daytime hours. The PMHCA coordinator connected the ED team with a psychiatrist via video during standard program hours; the psychiatrist provided guidance on risk assessment and disposition, with the ED provider making final clinical decisions. Wait times during Wednesday daytime hours dropped from 4.2 to 2.8 hours. Staff reported the model was workable but noted documentation of the consult in the EMR was inconsistent.
PDSA Cycle 2: EMR documentation template created for teleconsult encounters, with a designated field to capture the consulting psychiatrist’s recommendations and the ED provider’s clinical decision. Expanded to Wednesday and Friday daytime hours — both within standard PMHCA program availability. Wait times during covered hours averaged 2.4 hours.
PDSA Cycle 3: Expanded to all five weekdays during PMHCA program hours (8 AM–5 PM). Average wait time during covered hours: 2.1 hours. The team notes that after-hours and weekend gaps remain, and flags this as a separate planning priority outside the PMHCA team’s direct capacity.
Result: After three PDSA cycles, daytime consult wait times dropped by 50% during PMHCA-covered hours. The PMHCA-facilitated teleconsult model —connecting ED providers with psychiatric expertise while keeping clinical authority with the treating team — proved both practical and effective within standard program hours. The team acknowledges that evening and weekend coverage remains a gap requiring a separate solution, and begins planning for a hospital-owned on-call pathway to address those hours.
Audience-Specific Example
PDSA Examples
| Audience | Scenario / Application | Key Takeaway |
|---|---|---|
Emergency Physician |
Tests a new standardized order set for pediatric behavioral health patients to streamline the consult request process. Cycle 1: One attending on night shift for one week, measuring time from order entry to consult arrival. Cycle 2: Adjusts the order set based on nursing feedback (added a required field for acuity level). Cycle 3: Two attendings, two shifts. Cycle 4: Full night shift team. |
Iterative learning refines the tool before department-wide rollout. Each cycle builds evidence and staff confidence. |
EMS Provider |
Tests a new transport decision checklist for youth in behavioral health crisis. Piloted by two paramedic units over two weeks. Cycle 1: Crews report the checklist is too long (takes 3 minutes). Cycle 2: Streamlined to a single-sided laminated card with color-coded decision points. Cycle 3: Four units for four weeks — appropriate destination rate improves from 45% to 72%. Cycle 4: Department-wide rollout with orientation. |
Field-based rapid learning. Crew feedback drives practical design changes that increase adoption. |
PECC |
Tests a brief daily huddle at shift change focused on pending behavioral health consults and patients awaiting disposition. Cycle 1: One unit, 5-minute huddle, 1 week. Cycle 2: Adds a written handoff sheet summarizing pending patients. Cycle 3: Expands to two units. Measures: number of patients who “fall through the cracks” between shifts decreases from 3/week to 0.5/week. |
Reduced patients falling through the cracks. The huddle becomes a sustainable daily practice. |
School Clinician |
Tests a referral tracking spreadsheet shared between the school nurse, counselor, and one community agency. Cycle 1: 4 weeks, 12 referrals tracked. Finds that 3 referrals were lost at the community agency handoff. Cycle 2: Adds a column for agency confirmation and a 2-week follow-up call. Referral completion improves from 27% to 58%. Cycle 3: Standardizes across two school buildings. |
Improved visibility of referral status. Simple tool generates big gains when combined with accountability. |
Primary Care Team |
Tests a warm handoff protocol where the PCP personally introduces the behavioral health care manager to the family at the visit, rather than giving a referral card. Cycle 1: 5 families. 4 of 5 attend first behavioral health appointment (vs. baseline of 2 of 5). Cycle 2: 10 families, with a brief script for the introduction. Cycle 3: All PCPs in the practice, with care manager scheduling the first appointment before the family leaves. |
Patient-centered testing with rapid feedback. The warm handoff fundamentally changes the family’s connection to behavioral health care. |
Behavioral Health Staff |
A behavioral health clinician suspects families frequently leave the ED without a clear understanding of their discharge plan. She tests a structured “discharge teach-back” conversation — asking families to describe in their own words what they will do if symptoms worsen and who they will call. Cycle 1: Three families, one clinician. Finds 2 of 3 families cannot accurately describe the follow-up plan. Cycle 2: Adds a printed one-page summary with the clinician’s direct phone number and the next appointment highlighted. Cycle 3: All behavioral health staff, two shifts. Family understanding rates improve from 40% to 82%. |
A small test reveals a real comprehension gap that documentation review alone could not capture. The teach-back addition is low-cost and high-impact. |
Hospital Leadership / CMO |
The CMO pilots a weekly “behavioral health boarding brief” — a 10-minute standing agenda item at the Monday operations meeting where ED, psychiatry, social work, and bed management review the prior week’s boarding data together. Cycle 1: Four weeks, attendance required for all departments. Finds that psychiatry and bed management were previously unaware of boarding time trends. Cycle 2: Adds a shared run chart displayed in the boardroom. Cycle 3: Weekly brief expands to include patient-level review of any boarding episode exceeding 12 hours. Average boarding time decreases from 14.2 to 10.8 hours over the pilot period. |
Leadership visibility drives cross-departmental accountability. When all stakeholders see the same data weekly, silos break down and coordination improves. |