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1 The PROBLEM with Plan-Do-Study-ActcyclesJulie E Reed,1 Alan J Card2,31 NIHR CLAHRC NWL, ImperialCollege London, London, UK2 Department of Management,University of Notre Dame, NotreDame, Indiana, USA3 Evidence-Based HealthSolutions, LLC, Notre Dame,Indiana, USAC orrespondence toDr Julie E Reed, NIHR CLAHRCNWL, Imperial College London,Chelsea and WestminsterHospital, 369 Fulham Road,London SW10 9NH, 23 November 2015 Published Online First23 December 2015 cite:Reed JE, Card Qual Saf2016;25:147 improvement (QI) methods havebeen introduced to healthcare to supportthe delivery of care that is safe, timely,effective, efficient, equitable and costeffective.

2 Of the many QI tools andmethods, the Plan-Do-Study-Act (PDSA)cycle is one of the few that focuses onthe crux of change, the translation ofideas and intentions into action. As such,the PDSA cycle and the concept of itera-tive tests of change are central to manyQI approaches, including the model forimprovement,1lean,2six sigma3and totalquality provides a structured experimen-tal learning approach to testing , concerns have been raisedregarding the fidelity of application ofPDSA method, which may underminelearning efforts,5the complexity of itsuse in practice56and as to the appropri-ateness of the PDSA method to addressthe significant challenges of article presents our reflections onthe full potential of using PDSA inhealthcare, but in doing so we explorethe inherent complexity and multiplechallenges of executing PDSA.

3 We argue that the problemwith PDSA is the oversimplification ofthe method as it has been translated intohealthcare and the failure to invest in arigorous and tailored application of VALUE OF PDSA IN HEALTHCAREIMPROVEMENTThe purpose of the PDSA method lies inlearning as quickly as possible whether anintervention works in a particular settingand to making adjustments accordingly toincrease the chances of delivering andsustaining the desired improvement. Incontrast to controlled trials, PDSA sallow new learning to be built in to thisexperimental process.

4 If problems areidentified with the original plan, then thetheory can be revised to build on thislearning and a subsequent experimentconducted to see if it has resolved theproblem, and to identify if any furtherproblems also need to be addressed. Inthe complex social systems of healthcare,this flexibility and adaptability of PDSAare important features that support theadaption of interventions to work inlocal successful PDSA process does notequal a successful QI project or pro-gramme. The intended output of PDSA islearning and informed action. Successfulapplication of the PDSA methodologymay enable users to achieve their QIgoals more efficiently or to reach QIgoals they would otherwise not haveachieved.

5 But it isalsosuccessful if itsaves wasted effort by revealing QI goalsthatcannotbe achieved under realisticconstraints or if it identifies new pro-blems to tackle instead of the originallyidentified issue. A well-conducted PDSA promises learning . But it does not, andcannot, promise that users will achievetheir desired PDSA has been translated intohealthcare from industrial settings, anemphasis has been placed on rapidsmall-scale tests of change, often on one,three and then five patients in ramps ofincreasing scale, and responsibility dele-gated to frontline staff and improvementor Quality managers.

6 This pragmaticapproach has been embraced and hasbeen seen as providing a new freedomfor healthcare staff to lead change andimprovement in local care , the process of change rarelyprogresses in simple linear of PDSAs can reveal otherrelated issues that need to be addressed inorder to achieve the improvement issues may relate to minor changesto current practices or processes of care,but can often reveal larger cultural ororganisational issues that need to beaddressed and PROBLEM JE, Card Qual Saf2016;25:147 152. on July 7, 2022 by guest.

7 Protected by Qual Saf: first published as on 23 December 2015. Downloaded from on July 7, 2022 by guest. Protected by Qual Saf: first published as on 23 December 2015. Downloaded from on July 7, 2022 by guest. Protected by Qual Saf: first published as on 23 December 2015. Downloaded from Recent evaluations have reported on the failure ofthe PDSA method to help frontline staff address themultiple improvement challenges they faced as thescale of investigation and range of issues they neededto address report evaluating the SaferClinical Systems programme in the UK identified theneed for clarity about when improvement approachesbased on PDSA cycles are appropriate and when theyare not.

8 Viewing some challenges as too big andhairy for the PDSA method and beyond the scope ofsmall-scale tests of change run by local clinical argue that any improvement situation, no matterhow big and hairy, is conducive to application of thePDSA method. The four stages of PDSA mirror thescientific experimental method of formulating ahypothesis, collecting data to test this hypothesis, ana-lysing and interpreting the results and making infer-ences to iterate the improvement initiatives have been plannedat national level to support standardisation of care orplanned over a cup of coffee to solve a minor localproblem, we believe there will always be a role forPDSA.

9 In moving from planning to implementing achange in practice, PDSA provides a structure forexperimental learning to know whether a change hasworked or not, and to learn and act upon any newinformation as a it is not a magic bullet. Increasingly complexproblems require increasingly sophisticated applicationof the PDSA method, and this is where we believe theproblem with the PDSA method SIMPLICITY BELIES ITS SOPHISTICATIONOne of the main narratives surrounding the use ofPDSA in healthcare is that it is easy, and can beapplied in practice by anyone. At one level this is true,and the simplicity of the PDSA method and its applic-ability to many different situations can be viewed asone of its main strengths.

10 However, this simplicityalso creates some of the greatest challenges to usingPDSA successfully. Users need to understand how toadapt the use of PDSA to address different problemsand different stages in the lifecycle of each improve-ment project. This requires an extensive repertoire ofskills and knowledge to be used in conjunction withthe basic PDSA of the main problems encountered in usingPDSA is the misperception that it can be used as astandalone method. PDSA needs to be used as part ofa suite of QI methods, the exact nature of which maybe influenced by the broader methodologicalapproach that is being followed (eg, model forimprovement, lean).