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How Will This Toolkit Help Me?

This toolkit is a primer on Plan–Do–Study–Act, an iterative quality improvement method that can be applied to projects of varied scope and scale. It is relevant to practices, health systems, or individual teams looking to save time, improve culture, and deliver exceptional value-based care.


Quality improvement using the Plan-Do-Study-Act (PDSA) method provides a straightforward, iterative approach to enhancing clinical care and outcomes in your practice. Quality improvement (QI) can support your efforts to achieve the Quintuple Aim1:

  1. Enhancing patient experience

  2. Improving population health

  3. Reducing costs

  4. Improving the work-life of your team members

  5. Achieving health equity

The PDSA framework is easy to adopt regardless of practice size or resources. As QI becomes part of your practice's culture, your team will continue to find opportunities to improve existing processes. Your efforts also can help you meet your value-based payment and professional certification requirements.

PDSA provides a structured methodology to test small changes in a practice's workflow or clinical services. Common questions are used throughout the iterative cycle (Figure 1).

Figure 1. The Plan–Do–Study–Act (PDSA) Cycle2
Four STEPS to Improve Your Practice Using PDSA

  1. Plan: Develop the Initiative

  2. Do: Implement Your Plan

  3. Study: Analyze the Results

  4. Act: Adjust the Plan or Process

STEP 1 Plan—Develop the Initiative

Several actions are crucial during the planning phase of your PDSA endeavor (Figure 2).

Figure 2. Ten Crucial Planning Actions

Define your improvement project or goal

Clearly articulate the specific improvement you intend to achieve. This involves identifying the problem or opportunity for enhancement and establishing a measurable target or outcome.

If your clinic is new to quality improvement, a good place to start is to choose an easy, important project for you and your colleagues that will save time. One way to identify such a project is to employ Getting Rid of Stupid Stuff (GROSS). GROSS is an approach to finding “pebble in your shoe” problems that may seem trivial but can cause considerable frustration or inefficiency. For example, your team may be able to identify bottlenecks in your clinic's workflow that waste time or resources. The Lean “go and see” approach to observing the work respectfully and then asking, “Why?” is another way to find a suitable project. Go and see approaches are a way for a team to visually map a process from beginning to end, often with a process map. Checklists are another tool for pinpointing problems or issues to address with PDSA. You may find inspiration in the related STEPS Forward® Change Initiatives Toolkit.

Other exercises include:

  • The “5 Whys,” a straightforward line of questioning that can help you pinpoint the root cause of your problem or process breakdown

  • A spaghetti diagram to spotlight redundancies, congestion, and delays in a workflow, such as the movement of medical assistants during the rooming and discharge process

  • Patient flow time mapping or patient flow analysis, which is exactly what it sounds like—tracking the time patients spend in each area of the clinic to detect issues such as rooming inefficiencies, breakdowns in communication, duplicated tasks, or ambiguous clinical roles

Gather relevant data and information

Collect and analyze data to provide insight into the current state and help identify potential root causes or factors contributing to the workflow or inefficiency you are trying to improve. This information will inform your decision-making process and guide your efforts. Your practice may already have performance measure data from a payer (federal, state, and/or private) or a patient care registry that can reveal gaps in care processes or patient outcomes.

Keep in mind that most good ideas for improvement come from the people doing the work, so consider the perspectives of everyone on the team—both clinical and nonclinical. Be sure you can answer “What's in it for me?” for everyone you expect to participate and who will be impacted by the change. A Listening Campaign, composed of 1 or more Listening Sessions, is one technique for soliciting, processing, and acting on clinician input about the practice culture, workflows, and work-life balance. A similar approach is LISTEN-SORT-EMPOWER, a team exercise to identify local opportunities for improvement adapted from a technique used by Mayo Clinic for decades.3 This process will help you assess the difficulty level and time needed to complete any project.

Posing the following questions to the care team and nonclinical team members may reveal issues that are not captured by other data sources:

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

  • Where does our practice need to improve patient care?

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

Lastly, patient surveys or input from the patient and family advisory council can supplement what you learn from your team.

Set priorities and establish timelines

Determine the key priorities and milestones for your improvement project. Set realistic timelines and deadlines to ensure you make progress within a specific timeframe. Prioritization helps allocate resources effectively and keeps the project on track. Prioritize those areas you have some control over and that the team thinks will be most impactful.

Assemble your improvement team

The people doing the work should plan and guide the process improvement endeavor. Identify and gather a diverse group of individuals who will actively contribute to the improvement process. This team should consist of stakeholders with relevant expertise and perspectives, ensuring a comprehensive and well-rounded approach to problem-solving.4

Your PDSA team should include representatives from all areas of your practice that will be affected by the improvement. Most teams work best with a maximum of 10 people. 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 a core QI team that rotates as specialized representatives who participate in the PDSA team based on the QI undertaking.

Develop an action plan

Your PDSA team should work together to develop an action plan that will test improvements in your identified process and help you reach your goal. Outline the specific actions and strategies required to achieve your improvement goal. This includes defining the tasks, responsibilities, and resources needed to execute the plan successfully. The action plan should be comprehensive, practical, and adaptable to potential challenges or unexpected circumstances.

Brainstorming to answer the following questions can help you formulate your plan:

  • What does my practice want to accomplish?

  • What current process is my practice changing?

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

  • What does the new process look like?

  • Who will enact the changes?

  • Where will the changes take place?

  • When will the changes be made?

  • 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?

Align your plan to desired quality measures, accreditations, or certifications

Quality measures are central to health system accreditation, professional certification, and value-based payment and reporting. Increasingly these programs encompass health equity measures. Programs such as Medicare Advantage also include consumer experience surveys as indicators of quality care.5 Aligning your QI plans with these measures can streamline your PDSA effort with health system, practice, and professional imperatives.

Your plan may also cover elements that support professional credentialling (ie, American Board of Internal Medicine Maintenance of Certification [MOC]), such as training on a new process with continuing medical education (CME) or formal QI activities that could earn points or MOC credits.

Set SMART goals

Help your team stay focused and efficient with impactful goal setting. SMART stands for Specific, Measurable, Achievable, Relevant, and Time-bound; goals established by this method are designed to be realistic.6

For example, a practice goal may be to increase depression screening in patients with a diagnosed substance use disorder. With the SMART approach, your goal could look like this:

  • Specific: Your practice will increase depression screening from 20% to 50% of patients diagnosed with substance use disorder or prescribed opioids for noncancer pain.

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

  • Achievable: You've set a reasonable goal of 50% rather than 100%. You want your goal attainable; the bar can always be raised if your change succeeds.

  • Relevant: There is a clear gap in care to correct—only 20% of your target population is being screened for depression.

  • Time-bound: The goal will be achieved over the next 3 months. A reassessment (the “study” step of PDSA) will occur 3 months from now.

Regularly communicate about the plan and seek feedback

Establish clear and effective communication paths to ensure all team members are informed and engaged throughout the planning phase. Regular communication channels should be established to provide updates, share progress, and address any concerns or questions that may arise. Practice members not on your PDSA team should receive updates about the project and your goals at team meetings, through newsletters or staff emails, and/or with bulletin board postings in staff rooms.

Communications can also engage key stakeholders, including team members, organizational leaders, or individuals affected by the QI plan to gather their insights and feedback on what you intend to do. Consider including stakeholders, such as senior leadership or management, to prepare them to approve the project, allocate resources, and protect care team member time to participate in the QI effort as you advance to the “Do” phase of the PDSA cycle.

Anticipate and mitigate challenges to refine your plan

Identify potential risks or obstacles that may hinder the successful implementation of your plan. Develop contingency measures or alternative approaches to address these risks proactively. This helps minimize disruptions and enhances the chances of achieving your desired outcomes.

Continuously review and refine your plan based on feedback, new information, or changing circumstances. This iterative process ensures that your plan remains relevant, responsive, and aligned with your organization's evolving needs, dynamics, and outside influences like changing quality measures or payment targets.

Obtain needed approvals and resources

Once your plan is finalized, seek the appropriate approvals from relevant stakeholders or decision-makers within your organization. Buy-in from senior leadership is essential for success. Resources may be funding, equipment, protected time, additional staff, or something else specific to your QI project or goals. Together, approvals and resources ensure that your improvement project has the necessary support to move forward effectively.

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STEP 2 Do: Implement Your Plan

With a committed team and detailed plan, you are well-prepared to implement your QI project. During this phase of the PDSA cycle, it is crucial to remain adaptable and make necessary adjustments as you progress.

Here are some guidelines to follow:

  1. Check-in frequently

    Maintain regular communication with your team and leadership throughout the implementation process. By discussing the new process or approach during huddles and meetings, you can gauge whether the undertaking is going smoothly. Identify any challenges or breakdowns that may have occurred and highlight the aspects functioning exceptionally well. Conducting brief real-time check-ins will provide valuable insights for making adaptations.

  2. Share stories to inspire and motivate

    Keep the team engaged and enthusiastic about the change by sharing inspiring stories. For example, if your effort aims to save time, remind the team that saving 1 hour each day translates into 260 hours or 32 workdays saved each year. Motivating examples can serve as a powerful reminder of the positive impact your project can have.

  3. Stay agile and make necessary adjustments

    Recognize that some changes will proceed smoothly while others may require tweaks along the way. You may not realize something isn't working until you have invested significant time and effort into the QI project. In such cases, rely on your team and leadership to guide you through obstacles. Keep an open mind and be receptive to feedback and suggestions for improvement.

By remaining nimble and adapting as needed, you can optimize the success of your QI project and ensure that it continues to align with the goals and needs of your organization.


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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STEP 3 Study: Analyze the Results

Evaluate success with the process or outcome measures the PDSA team chose during the planning phase. A classic technique to visualize changes over time is a run chart, which can be displayed in a team area or shared during meetings with the team or leadership.

Other analysis tools include

  • A fishbone diagram to show cause and effect9

  • A Pareto chart to identify the most influential cause(s) of a problem10

  • A scatter plot to reveal causal relationships11

  • A check sheet for easy data collection and to show patterns12

Your PDSA team should consider the factors that contributed to the findings. You may discover that your change was very successful. Or you do not see the expected or desired improvements. Together, the PDSA team can identify how and why you achieved the observed results.


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
STEP 4 Act: Adjust the Plan or Process

You and your practice determine whether to adopt, adapt, or abandon the process during the final phase of the PDSA cycle (Table 1). The PDSA cycle is meant to be continuous; even your best processes can be improved and become more consistent. Refine your effort by repeating the cycle.

No matter what the results were, celebrate completing your first PDSA cycle. Consider this a chance to learn and grow and an opportunity for personal development and advancement. The work, time, and commitment that your team put into the process qualify for American Board of Medical Specialties (ABMS) Maintenance of Certification (MOC) Part IV points—even if your QI project didn't result in improvement.

Table 1. Adopt, Adapt, or Abandon? Rationale to Inform Action
Image description not available.

You can use the table below to help identify your PDSA goals, improvement areas, implementation changes, and measures.

Other real-world examples of PDSA cycles and QI projects can be found in many of the STEPS Forward toolkits, including:

Box Section Ref ID


  • 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 a brief summary describing the QI initiative and the results generated, and share it widely by:

    • Publishing it in your organization's newsletter

    • Sending it in a congratulatory email to the team members; ensure leadership is copied

    • Presenting it during a lunchtime meeting

    • Posting it on a bulletin board in a common area

    • Celebrating your successes

    Create a data wall or dashboard to track all initiatives and showcase practice goals. Regularly highlight run charts to provide updates prominently. Foster teamwork and sustained quality improvement with positive communication and recognition of team member contributions. Boost morale and celebrate success by awarding a recognition pin to outstanding clinic members.

  • How should I communicate the results to patients?

    Engage patients and caregivers as valuable contributors and an integral part of your QI efforts. Utilize surveys to collect outcomes data, monitor the patient experience, and identify other areas for enhancement. By emphasizing your practice's dedication to providing high-quality care for all patients, you foster confidence in your medical team. Telling patients that they contributed to the QI efforts will encourage them to continue to offer feedback through patient surveys.


Any practice team can be empowered to undertake a QI project if they start small and plan ahead. Cultivate internal assets to build more robust and reliable systems for enhancing care. Carefully considering each aspect of the PDSA cycle, maintaining an open dialogue, and paying close attention to metrics will help you achieve your goals—leading to improved care for all your patients.

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Graphic Jump Location
AMA Pearls

AMA Pearls

Start small

Try using the PDSA framework on a simple initiative first so you can gain familiarity and comfort with the method. 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 next flu season. Take what you learn to make improvements to your approach during next year's flu season.

Further Reading

Journal Articles and Other Publications

Videos and Webinars

  • Small changes, big impact: creating thriving physician practices. American Medical Association. Published December 11, 2015. Accessed July 19, 2023. www.youtube.com/watch?v=XDNDq76sMfw


Related AMA STEPS Forward® Content

Education (Playbooks, Toolkits, MOC/CME)


Success Stories

Webinars and Videos

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Article Information

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.

About the AMA Professional Satisfaction and Practice Sustainability Group

The AMA Professional Satisfaction and Practice Sustainability group is committed to making the patient–physician relationship more valued than paperwork, technology an asset and not a burden, and physician burnout a thing of the past. We are focused on improving—and setting a positive future path for—the operational, financial, and technological aspects of a physician's practice. To learn more, visit https://www.ama-assn.org/practice-management/ama-steps-forward.

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Consumer Assessment of Healthcare Providers & Systems (CAHPS). Centers for Medicare & Medicaid Services. Updated January 25, 2023. Accessed July 18, 2023. https://www.cms.gov/research-statistics-data-and-systems/research/cahps
Types of health care quality measures. Agency for Healthcare Research and Quality. Last reviewed July2015. Accessed July 18, 2023. https://www.ahrq.gov/talkingquality/measures/types.html
Chapter 4. Selecting and defining outcome measures for registries. Gliklich  RE, Leavy  MB, Dreyer  NA, eds.  Registries for Evaluating Patient Outcomes: A User's Guide [Internet].4th ed. Agency for Healthcare Research and Quality (US); 2020. https://www.ncbi.nlm.nih.gov/books/NBK562576/
Fishbone diagram. American Society for Quality. Accessed July 18, 2023. https://asq.org/quality-resources/fishbone
What is a Pareto chart? American Society for Quality. Accessed July 18, 2023. https://asq.org/quality-resources/pareto
Check sheet. American Society for Quality. Accessed July 18, 2023. https://asq.org/quality-resources/check-sheet
Uyeki  TM.  High-risk groups for influenza complications.  JAMA. 2020;324(22):2334. doi:10.1001/jama.2020.21869Google ScholarCrossref
Stevens  ER, Mazumdar  M, Caniglia  EC,  et al.  Insights provided by depression screening regarding pain, anxiety, and substance use in a veteran population.  J Prim Care Community Health. 2020;11:2150132720949123. doi:10.1177/2150132720949123Google Scholar
Eschenroeder  HC, Manzione  LC, Adler-Milstein  J,  et al.  Associations of physician burnout with organizational electronic health record support and after-hours charting.  J Am Med Inform Assoc. 2021;28(5):960–966. doi:10.1093/jamia/ocab053Google ScholarCrossref
Sinsky  CA, Rule  A, Cohen  G,  et al.  Metrics for assessing physician activity using electronic health record log data.  J Am Med Inform Assoc. 2020;27(4):639–643. doi:10.1093/jamia/ocz223Google ScholarCrossref
The Joint Commission.  New requirements to reduce health care disparities.  The R3 Report. 2022;36. https://www.jointcommission.org/-/media/tjc/documents/standards/r3-reports/r3_disparities_july2022-6-20-2022.pdfGoogle Scholar

Disclaimer: AMA STEPS Forward® content is provided for informational purposes only, is believed to be current and accurate at the time of posting, and is not intended as, and should not be construed to be, legal, financial, medical, or consulting advice. Physicians and other users should seek competent legal, financial, medical, and consulting advice. AMA STEPS Forward® content provides information on commercial products, processes, and services for informational purposes only. The AMA does not endorse or recommend any commercial products, processes, or services and mention of the same in AMA STEPS Forward® content is not an endorsement or recommendation. The AMA hereby disclaims all express and implied warranties of any kind related to any third-party content or offering. The AMA expressly disclaims all liability for damages of any kind arising out of use, reference to, or reliance on AMA STEPS Forward® content.

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