Plan, Do, Study, Act (PDSA) cycles and the model for improvement
The Plan, Do, Study, Act (PDSA) cycle started out as the Plan, Do, Check, Act cycle and was introduced by Walter Shewhart in the 1920s. It formed the basis of Dr. WE Deming’s approach to organizational development and leadership.
What is it?
The model for improvement provides a framework for developing, testing and implementing changes leading to improvement. It is based on the scientific method and moderates the impulse to take immediate action with the wisdom of careful study.
Using PDSA cycles enables you to test out changes on a small scale, building on the learning from these test cycles in a structured way before wholesale implementation. This gives stakeholders the opportunity to see if the proposed change will succeed and is a powerful tool for learning from ideas that do and don’t work.
This way, the process of change is safer and less disruptive for patients and staff.
When to use it
When planning any improvement or change to work processes, it is essential to know what you want to achieve, how you will measure improvement, and be explicit about the idea to be tested.
You may not get the results you expect so it is safer and more effective to test out improvements on a small scale before implementing them across the board.
How to use it
The framework includes three key questions to answer before testing an improvement concept and a process for testing change ideas:
- What are we trying to accomplish? (The aims statement)
- How will we know if the change is an improvement? What measures of success will we use?
- What changes can we make that will result in improvement? (The change concepts to be tested).
The model for improvement
This approach has been unusual in a healthcare setting because traditionally, new ideas are often introduced without sufficient testing.
Using Plan Do Study Act (PDSA) Cycles
Here we will explore what it is and how you should use it in your project.
Let us start with a great quote from The Institute for Health Improvement (IHI), adapted from William Edwards Deming. “Every system is perfectly designed to get the results it gets!”
Every system that we work in, so including health service systems or service settings, produces output or performance exactly as it is designed.
This is an important concept in improvement work because if you want a different output or result, you have to change the system in some way. This is where the PDSA cycle comes into play, to test changes to our system in a methodical and mindful way.
The Do Stage
Literally you ‘do the test’, so your assigned person uses the form and makes those observations about ease of use and time taken.
Study Stage
Here, compare what actually happened in the do stage with what you predicted would happen in the plan stage. In our example, ask yourself if the time to fill in the form decreased as you wanted it to and also was the form still easy to use?
In effect you are analysing what happened in your PDSA cycle. You can then ask yourself if you wish to Adopt (keep the change because it worked), Adapt (try something similar in your next PDSA, but ‘tweaking’ it because it did not fully meet your predictions) or Abandon (because it did not work as well as you hoped that it would).
Act Stage
In this stage you use your thoughts from the Study stage to inform what you might do in the next PDSA cycle.
You may choose to test the form again at a larger scale or in a different way (such as another member of staff testing it) or you may change it and re-test or decide that the test is not going to work and stop doing any further testing.
So, knowing what a PDSA cycle is, how do we apply it? To do this we need to think about the list of change ideas that we have developed on our Driver Diagram, deciding which of the change ideas might have greatest impact on our aim and starting to test that aim first is a good way to start.
Once that decision is made, we use the PDSA cycle in an iterative and repeated process that we refer to as a PDSA ramp, which is quite simply a set of consecutive PDSA cycles; each cycle providing you with more knowledge about what works and what does not, leading to an overall improvement in your system.
As you progress through the cycles, it is recommended that you increase the scale of your testing; from ‘small to all’ as we say. By the time that you have done enough cycles, you can be confident that your change is making a consistent improvement.
You may need to gather data specifically to do this. In our example you may wish to plot a chart of data points of how long each form takes to fill in.
PDSA cycles are used in ramps to test out our change ideas and in so doing, learn about what works to help achieve our project aim and just as importantly, what does not work or help. It is easy to feel down-hearted when a PDSA does not work or fails to make an improvement, but it is better to think of such an outcome as good learning; we have ‘failed forward’ by learning what does not work. And that is something that is very positive!
A PDSA cycle is systematic approach to ‘trying out’ or testing a change in your system, consisting of four stages:
The four stages of the PDSA cycle are:
Plan – the change to be tested or implemented
Do – carry out the test or change
Study – based on the measurable outcomes agreed upon before starting out, collect data before and after the change and reflect on the impact of the change and what was learned
Act – plan the next change cycle or full implementation
As with any change, ownership is key to implementing the improvement successfully. If you involve a range of colleagues in trying something out on a small scale before it is fully operational, you will reduce the barriers to change.
The Plan Stage
The Plan Stage
Think about what part of your system you want to test and what it is that you are going to do differently.
You can at this stage, develop a hypothesis about what you think will happen when you make the change.
An example of this might be a change to an assessment form; ‘if we fill out the form with different information or in a different way, we think that the assessment process will take less time to complete’.
You also need to plan who is going to test your change, when the change is going to happen and how you are going to collect information (data) about whether the change makes an improvement.
So, in the assessment form example, you would assign someone to try the form out and ask them to note whether the form was easier to fill in and to record how much time it took them.
Start by answering the three essential questions.
- What are we trying to accomplish?
Teams need to set clear and focused goals with measurable targets. These goals require clinical leadership and should focus on problems that cause concern, as well as on patients and staff. They should be relevant to the length of the project and be bold in aspiration.
An example of an aims statement from cancer services:
To improve access, speed of diagnosis, speed of starting treatment and patient care for people who are suspected of having bowel cancer. This will be achieved by:
• Introducing booked admissions and appointments. Target: more than 95% of patients
• Reducing the time from GP referral to first definitive treatment to less than 15 weeks
• Ensuring that over 80% of patients are discussed by the multidisciplinary team. - How do we know if the change is an improvement?
In order to answer this question, you will need to measure outcomes such as a reduction in waiting time. If we make a change, this should affect the measures and demonstrate over time whether the change has led to sustainable improvement.
The measures in this model are tools for learning and demonstrating improvement, not for judgment.
Each project team should collect data to demonstrate whether changes result in improvement, reporting progress monthly on time series graphs known as run charts or statistical process control (SPC) charts.
You may also want to undertake a qualitative analysis through patient questionnaires.
(See gaining insights from/working in partnership with health service users)
- What changes can we make that will result in improvement?
There are many potential changes your team could make. However, evidence from scientific literature and previous improvement programs suggests that a small number of changes are most likely to result in improvement.
The Cancer Service Collaborative identified twenty-eight change principles grouped into four areas.
- Connect up the patient journey.
- Develop the team around the patient journey.
- Make the patient and care experience central to every stage of the journey.
- Make sure there is the capacity to meet patients’ needs at every stage of the journey.
Step 2
You should now start the PDSA cycle. There may be several PDSA cycles running sequentially, or even simultaneously. Sequential cycles are common when the study reveals results that suggest a different approach is needed.
Simultaneous cycles may occur when the changes are more complex, possibly involving several departments. It is important that you identify any interactions between simultaneous cycles, as a change in method in one cycle, may alter the impact of another somewhere else.
Step 3
Record your PDSA’s over time, to capture the learning and to demonstrate the improvement journey, which is often lost or not recorded. You could use the template below.
PDSA Tips
• Plan multiple cycles to test ideas.
• Test on a really small scale. For example, start with one patient or one clinician at one-afternoon clinic and increase the numbers as you refine the ideas.
• Test the proposed change with people who believe in the improvement. Don’t try to convert people into accepting the change at this stage.
• Only implement the idea when you’re confident you have considered and tested all the possible ways of achieving the change.
What next?
Continue with new PDSA cycles and continuous service improvement.
Having identified the changes with the greatest benefits, the next stage is to fully implement the change. This will require a stakeholder analysis. You will possibly need to use aspects of project management and benefits realization.
This course is DEPRECATED
The old PRINCE2 6th Edition Foundation and Practitioner syllabus was upgraded in 2024. Check out the brand NEW PRINCE2 7th Edition Masterclass, covering all the current syllabus, training material and online exam benefits HERE
Your Route To PRINCE2 6th Edition Practitioner
Study PRINCE2 6 Foundation and Practitioner Exams with our famous on-line course with streaming HD Video Lessons, study guides and mock exams. In the last fifteen years we have had 6,000+ Academy students successfully transform their careers as PRINCE2 Practitioners.
Do you want NHS-relevant PRINCE2 Practitioner personal Coaching?
PRINCE2® 7 Foundation and Practitioner
Learn PRINCE2® 7 Foundation and Practitioner Online
** Enhance your PRINCE2 career now **
PRINCE2® Masterclass gives you the skills necessary to manage projects effectively and achieve your objectives.
Get 7 days a week 12 months one to one coaching with ex PRINCE2 examiner Dave Litten.
PRINCE2® is a globally recognized project management framework. By completing both the Foundation and Practitioner courses through our self-paced e-learning, you will develop an understanding of the methodology and learn how to effectively adapt it to any project.
The PRINCE2® 7 Foundation and Practitioner Masterclass is PeopleCert Accredited and guarantees to take you from PRINCE2 Novice to PRINCE2 Practitioner with our famous video learning, study guides and practice exams.
What Does the Masterclass Cover?
The PRINCE2 Foundation examination assesses your knowledge and comprehension of the PRINCE2 project management methodology as detailed in the syllabus. The PRINCE2 Practitioner examination, on the other hand, gauges your ability to apply and tailor the PRINCE2 method. Candidates who pass the Practitioner exam should be able to start implementing the method on an actual project with some guidance. However, their effectiveness may differ based on their experience in project management, the complexity of the project, and the level of support they receive in their work environment.
