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Leading Change Module 0.5 Credit CME

Quality improvement using Plan-Do-Study-ActStrategies for local quality improvement.

Team-Based Learning
Learning Objectives:
At the end of this activity, you will be able to:
1. Identify how to plan a quality improvement initiative
2. Describe how to implement a quality improvement initiative
3. Explain how to evaluate the performance of a quality improvement initiative
4. Recognize how to adjust a quality improvement initiative based on the results

STEPS Forward™ is a practice improvement initiative from the AMA designed to empower teams like yours to identify and attain appropriate goals and tactics well matched to your practice’s specific needs and environment. Wherever you find your team on the practice improvement continuum, the American Medical Association can help you take the next steps – the right steps – to improve your practice. Learn more

How will this module help me successfully make changes in my practice?

  1. Four STEPS to quality improvement using the (PDSA) method

  2. Answers to common questions about the PDSA method

  3. Downloadable toolkit with samples and templates

Quality improvement using Plan-Do-Study-Act

PDSA provides a straightforward, iterative approach to quality improvement in your practice. The framework is easy to adopt regardless of practice size or resources. As ongoing quality improvement becomes part of your practice’s culture, your team will continue to find opportunities to make existing and “improved” processes better.

Institute for Healthcare Improvement. Science of Improvement: How to Improve. 2016.

Four STEPS to use PDSA:

  1. Plan: develop the initiative

  2. Do: implement your plan

  3. Study: check the results

  4. Act: make further improvements

Step 1 Plan: develop the initiative
Select your improvement initiative

Involve your team in selecting the quality improvement initiative. Most good ideas for improvement come from the people doing the work, so consider the perspectives of the clinical team members as well as the clerical staff. Patient surveys can also be used to identify areas for improvement.

To identify areas for improvement, consider asking these questions:

  • Where does your practice need to improve patient care?

  • Where is your practice less efficient than it should be?

    • Staff may be able to identify bottlenecks in the workflow. Prioritize those areas that you have some control over and that the team thinks will be most impactful. Use a “go and see” approach of respectfully observing the work and then asking “why?” A team member can help identify key areas for workflow improvement within the bottleneck.

  • What about the day is most frustrating for your team and/or patients?

    • Ask patients and staff. This will generate a list from which you can prioritize areas for improvement.

Reference the module on selecting sustainable change initiatives for more guidance on choosing areas for improvement in your practice.

Box Section Ref ID


Identify your PDSA team

Quiz Ref IDThe people doing the work should be the ones planning and guiding the process improvement initiative. Your PDSA team should thus include representatives from all areas of your practice that will be affected by the improvement. Set expectations for the time commitment to the PDSA team early in the cycle and plan to continue working together through implementation. You may also choose to have a core quality improvement team that rotates in specialized representatives based on the initiative. Most teams work best with a maximum of 10 people. Practice members who are not on your PDSA team should receive regular updates about the initiative’s progress.

Box Section Ref ID


  • What is an example of a PDSA team?

    Your team could include physicians, practice leadership, nurses, medical assistants, receptionists, potentially patients, IT and coding and/or compliance staff. For example, if your practice’s first PDSA project is to increase rates of adult pneumococcal vaccinations, your team may consist of the following representatives:

    • A physician champion or leader can provide clinical expertise and secure support from providers as well as practice and/or system leadership.

    • The front desk lead can distribute information about vaccines to appropriate patients upon check-in or before their appointments through email or a patient portal.

    • A practice manager or supervisor can work directly with the electronic health record (EHR) or IT representative to develop a daily report of patients over the age of 65 who do not have a documented pneumococcal vaccination. The practice manager could also serve as the project manager and administrative lead for the initiative.

    • A nurse or medical assistant can offer insight about current workflows and the most effective way to reshape the practice’s current workflow to reflect the new process. He or she will likely be the one administering the vaccine, so his or her input is particularly important.

    • An IT representative can program a clinical decision support reminder to administer and record vaccinations.

  • Why is leadership support important?

    Keeping your leaders informed will help you gain their support and could help your team obtain the resources needed to make the desired change. For larger-scale initiatives, senior-level support is essential. Communicate with leaders about the potential for improved performance measures, workflow efficiencies and/or cost savings. See the Starting Lean module for more information about identifying a champion for your quality improvement work.

  • How can I include patients in my practice’s PDSA effort?

    It is important to design care with patients, instead of designing care for patients. Towards this end, your practice could include one or two trusted patients on the quality improvement team. If your practice does not use patient advisors regularly, start with a simple survey to find out what patients value in the process that you are focused on improving.

Develop your plan

Your quality improvement team should work together to develop a plan. Using the framework of Lean – the plan is an experiment that will help you identify what you do not yet know about the work. A Lean A3 worksheet is a useful tool to help guide this plan. In addition, the following questions can help you formulate your plan:

  • What does my practice want to accomplish?

  • Why is this a priority? (Of all the possible areas for improvement, why is my practice focused on this one in particular?)

  • What current process is my practice changing?

  • What does the new process look like?

  • How will the new process become hardwired into the practice?

  • Who will enact the changes?

  • When will the changes be made?

  • Where will the changes take place?

  • What team training and preparation are required?

  • Will patients be affected? How? Which patients will be affected?

  • What results do you expect?

  • How will you measure the impact of the changes? What process and outcome measures will you use?

  • How and when will you inform the team about progress?

ACP Quality Connect: PDSA planning worksheet
Process map toolkit
Box Section Ref ID


Step 2 Do: implement your plan

With a committed team and a specific plan, you are ready to implement your quality improvement initiative. Communicate with the team about the new process to keep your practice on track, and share any inspiring stories to keep the team excited about the change. Conduct regular audits to ensure the new process is hardwired into the practice by the team. Discuss adoption of the new process regularly at huddles and meetings.

“My practice benefited from making changes, especially in team-based care. I have felt empowered through education and have been able to provide better care through better staff engagement that involves everyone in practice improvement.”

Brenda Vozza-Zeid, MD, FACP; Henderson, TX
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  • What is the best approach to rolling out the change in my practice?

    Start small by piloting the improvement with one physician or in one pod. This can help the initiative gain traction, and it can help the PDSA team and pilot team work together to successfully implement the new process. Team leaders can communicate with the rest of the practice and practice leadership about the initiative’s progress and promote its importance.

  • Are there any support networks that can help my practice improve?

    Organizations that provide support to practices implementing quality improvement initiatives include:

    • Area Health Education Centers (AHECs)

    • Health Information Technology Regional extension centers (RECs)

    • Quality Improvement Organizations (QIOs)

    • Quality Innovation Network QIOs (QIN-QIOs)

    • Practice-based Research Networks (PBRNs)

    • Local or regional Practice Transformation Networks (PTNs)

Step 3 Study: check the results

This step may also be referred to as “Check.” Use the process or outcome measures the PDSA team chose during the planning phase to evaluate the success of the process change. A classic technique to visualize changes over time is a run chart, which can be displayed in a team area or shared regularly at meetings.

Run chart

Quiz Ref IDAt this stage of the PDSA cycle, your team can review the results of the process change implementation. Compare your actual results to your expected results (as well as to previous outcomes or process measures, if available), and consider the factors that might have contributed to the findings. You may discover that your team has been very successful or that you are not seeing the improvement you anticipated. You can work together with your team to identify why the observed results were achieved.

Simplified practice assessment
ACP quality connect: setting your QI goals worksheet

“I thought I had a good handle on managing my diabetic patients but I learned about facilitating good decision-making by my patients, coaching behavioral changes and gaining insight into patient compliance. I also learned about how to engage my office staff into optimizing OUR care of OUR diabetic patients.”

Robert Dobbin Chow MD, MBA, MACP; Baltimore, MD

Robert Dobbin Chow MD, MBA, MACP; Baltimore, MD

Box Section Ref ID


  • What are some examples of process and outcome measures that we can monitor?

    Process measures assess the actions undertaken by the clinical team. Examples include:

    • Percentage of patients with diabetes who have a current A1c documented

    • Percentage of patients who have their blood pressure checked at their visit

    • Percentage of patients who have pre-visit labs obtained

    Outcome measures assess results. Examples include:

    • Percentage of patients who have an A1c less than 7.0

    • Percentage of patients with blood pressure at goal

    • Patient, physician and team satisfaction ratings

Step 4 Act: make further improvements

This phase may also be referred to as “Adjust.” During this final stage of the PDSA cycle, your team can take the following courses of action: Quiz Ref ID

Restart the cycle at the planning phaseThe plan is not achieving the desired results. Based on your analysis, define failures in the plan or execution and correct them.
The plan is meeting or surpassing the desired results, and the team sees opportunity for even better outcomes. Based on your analysis, refine the current process in the next planning phase. Look for other areas in your practice to expand your successful improvement.
Discontinue the planThe plan did not work or is better suited for another time or environment. Go back to the planning phase to overhaul the existing plan or develop a new one.

The PDSA cycle is meant to be continuous; even your best processes can be improved and become more consistent. You can further refine your processes by repeating the cycle.

Box Section Ref ID


  • What are some real-world examples of PDSA analyses and follow-up actions?

    The table below provides some examples of analyses and follow-up actions from real practices.

    Table 1.

    PDSA examples

    AMA. Practice transformation series: Plan-Do-Study-Act. 2016.

  • What methods should I use to communicate the results of the PDSA cycle?

    Your team, stakeholders and patients will be eager to learn more about your successes. Write up a brief summary of the quality improvement initiative and its results. Present a summary of the report during a lunch time meeting and celebrate your successes. Post a summary of the effort, with photos, on a bulletin board in a common area. Consider making a data wall or dashboard that tracks every initiative and displays practice goals. Continue to prominently display regular updates of run charts. This kind of positive reinforcement through communication and recognition can drive greater teamwork and continued quality improvement in your practice.

  • How should I communicate the results to patients?

    Patients and their caregivers can be an integral part of your quality improvement efforts. Surveys that gather outcomes data can help you monitor the patient experience in your practice. Summarize your results and report them to patient advisory groups, through your patient portal or by email.

AMA Pearls
Start small

Try using the PDSA framework on a simple initiative first so you can gain familiarity and comfort with the methodology. For example, if you want to increase rates of flu vaccinations in your practice, use PDSA to develop and implement a communications strategy during the upcoming flu season. Take what you learn to make improvements to your approach during next year’s flu season.

Use other analysis tools to approach improvement

This module provides the framework for making local changes in your practice. If you are taking on a larger quality improvement effort, try these tools:

Set SMART goals for your PDSA quality improvement initiative

Help your team stay focused and efficient through impactful goal setting. For example, one practice goal may be to increase depression screening among patients with a diagnosed substance use disorder. Using the SMART approach, your goal would look like this:

  • Specific: Your practice will increase depression screening from 20 to 50 percent of patients with diagnosed substance use disorders.

  • Measurable: You will use manual or electronic chart audits to document depression screenings.

  • Achievable: You’ve set a reasonable goal of 50 percent rather than 100 percent. You want to set an attainable goal; the bar can always be raised if your change is successful.

  • Relevant: There is a clear gap in care because only 20 percent of your target population is being screened for depression.

  • Time-bound: The goal will be achieved over the next three months. A reassessment (the “study” step of PDSA) will occur three months from now.


Any practice team can accomplish quality improvement if they use straightforward, small steps. Foster your internal capabilities and expertise to develop more reliable systems to improve care. With careful thought given to each aspect of the PDSA cycle, ongoing communication between team members, practice staff and patients, and careful attention to metrics, your practice can successfully reach its goals.

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Where CME credit is designated, the activity is part of the American Medical Association's accredited CME program. The AMA is accredited by the Accreditation Council for Continuing Medical Education to provide continuing medical education for physicians.
Article Information

Target Audience: This activity is designed to meet the educational needs of practicing physicians.

Statement of Competency: This activity is designed to address the following ABMS/ACGME competencies: practice-based learning and improvement, interpersonal and communications skills, professionalism, systems-based practice and also address interdisciplinary teamwork and quality improvement.

Planning Committee:

  • Alejandro Aparicio, MD, Director, Medical Education Programs, AMA

  • Rita LePard, CME Program Committee, AMA

  • Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA

  • Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

  • Sam Reynolds, MBA, Director, Professional Satisfaction and Practice Sustainability, AMA

  • Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA

Author Affiliations:

  • Laura Lee Hall, PhD, Director, Center for Quality and Office of Grants, American College of Physicians


  • Marie Brown, MD, FACP, Associate Professor, Rush University Medical Center; Bernard M. Rosof, MD, MACP, Chief Executive Officer, Quality in Healthcare Advisory Group; Doron Schneider, MD, FACP, Chief Patient Safety and Quality Officer, Abington Health; Christine Sinsky, MD, Vice President, Professional Satisfaction, American Medical Association and Internist, Medical Associates Clinic and Health Plans, Dubuque, IA; Becca Moran, MPH, Program Administrator, Professional Satisfaction and Practice Sustainability, AMA; Ellie Rajcevich, MPA, Practice Development Advisor, Professional Satisfaction and Practice Sustainability, AMA

About the Professional Satisfaction, Practice Sustainability Group: The AMA Professional Satisfaction and Practice Sustainability group has been tasked with developing and promoting innovative strategies that create sustainable practices. Leveraging findings from the 2013 AMA/RAND Health study, “Factors affecting physician professional satisfaction and their implications for patient care, health systems and health policy,” and other research sources, the group developed a series of practice transformation strategies. Each has the potential to reduce or eliminate inefficiency in broader office-based physician practices and improve health outcomes, increase operational productivity and reduce health care costs.

Disclosure Statement: The content of this activity does not relate to any product of a commercial interest as defined by the ACCME; therefore, neither the planners nor the faculty have relevant financial relationships to disclose.

The W. Edwards Deming Institute.  The Plan-Do-Study-Act (PDSA) Cycle. https://www.deming.org/theman/theories/pdsacycle. Accessed November 30, 2015.
American Medical Association.  Small changes, big impact: creating thriving physician practices [video]. https://www.youtube.com/watch?v=XDNDq76sMfw. Updated December 11, 2015. Accessed January 4, 2016.
Institute for Healthcare Improvement.  Science of improvement: how to improve. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementHowtoImprove.aspx. Accessed November 30, 2015.
Institute for Healthcare Improvement.  Science of improvement: forming the team. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementFormingtheTeam.aspx. Accessed November 30, 2015.
Institute for Healthcare Improvement.  Science of improvement: testing changes. http://www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx. Accessed November 30, 2015.
Institute for Healthcare Improvement.  Run chart tool. http://www.ihi.org/resources/Pages/Tools/RunChart.aspx. Accessed November 30, 2015.
Agency for Healthcare Research and Quality.  Workflow assessment for health IT toolkit. https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit. Accessed November 30, 2015.
American College of Physicians Immunization Portal.  Practice improvement tool. http://static.acponline.org.s3.amazonaws.com/media/immunization/acp_adult_immunization_section1.pdf. Updated August 2011. Accessed November 30, 2015.
National Diabetes Education Program.  Improve practice quality. http://ndep.nih.gov/hcp-businesses-and-schools/practice-transformation/improve-practice-quality/index.aspx. Accessed November 30, 2015.
Centers for Medicare & Medicaid Services.  The Merit-Based Incentive Payment System (MIPS) & Alternative Payment Models (APMs): delivery system reform, Medicare payment reform, & the MACRA. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Value-Based-Programs/MACRA-MIPS-and-APMs/MACRA-MIPS-and-APMs.html. Accessed November 30, 2015.
American College of Cardiology.  Quality programs. http://www.acc.org/tools-and-practice-support/quality-programs?w_nav=FN. Accessed November 30, 2015.
American Society of Clinical Oncology (ASCO) Institute for Quality (iQ). http://www.instituteforquality.org. Accessed November 30, 2015.
Agency for Healthcare Research and Quality.  Quality improvement in primary care. http://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html. Updated June 2014. Accessed November 30, 2015.
Agency for Healthcare Research and Quality.  Building quality improvement capacity in primary care. http://www.ahrq.gov/professionals/prevention-chronic-care/improve/capacity-building/pcmhqi2.html. Updated April 2013. Accessed November 30, 2015.
DuBosar  R. Chronic pain program provides model for small practices. ACP Internist. http://www.acpinternist.org/archives/2015/11/success.htm. November/December 2015 issue. Accessed November 30, 2015.
American College of Physicians.  ACP Practice Advisor: Improving clinical care. https://www.practiceadvisor.org/Modules/improving-clinical-care. Accessed November 30, 2015.
National Committee for Quality Assurance.  Patient-centered medical home recognition. http://www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx. Accessed November 30, 2015.
National Diabetes Education Program.  Examples of PDSA cycles for quality improvement activities to address elements of the chronic care model. http://ndep.nih.gov/media/Table_1-Examples_of_PDSA_Cycles_for_Quality_Improvment_Activities.pdf. Accessed November 30, 2015.
Stratis Health.  Goal setting. https://www.stratishealth.org/expertise/index.html. Accessed February 1, 2016.
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