Plan-Do-Study-Act (PDSA)A Step-by-Step Approach to Improve Quality, Work-Life, and Equity

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).

1. Plan: Develop the Initiative

2. Do: Implement Your Plan

3. Study: Analyze the Results

4. Act: Adjust the Plan or Process

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

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.

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.

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.

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.

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:

• Team-based Care of Type 2 Diabetes and Prediabetes

• Adult Vaccinations

• Social Determinants of Health

• Annual Prescription Renewal

• Pre-Visit Planning

• Team Documentation

• Team-Based Care

• Behavioral Health Integration into Primary Care

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.

Journal Articles and Other Publications

• Our DRIVE flu QI library. DRIVE, Center for Sustainable Health Care Quality and Equity. Published October 26, 2022. Accessed July 18, 2023. https://issuu.com/nmqf-shc/docs/flu_pdsa_library

• PDSA lupus DRIVE library. DRIVE, Center for Sustainable Health Care Quality and Equity. Published November 9, 2022. Accessed July 18, 2023. https://issuu.com/nmqf-shc/docs/lupus_pdsa_library

• DRIVE clinical research QI library. DRIVE, Center for Sustainable Health Care Quality and Equity. Published January 17, 2023. Accessed July 18, 2023. https://issuu.com/nmqf-shc/docs/drive_clinical_research_qi_library

• Christoff P. Running PDSA cycles. Curr Probl Pediatr Adolesc Health Care. 2018;48(8):198-201. doi:10.1016/j.cppeds.2018.08.006

• Shaikh U. Strategies and approaches for tracking improvements in patient safety. Agency for Healthcare Research and Quality (AHRQ) Patient Safety Network (PSNet). April 1, 2021. Accessed July 18, 2023. https://psnet.ahrq.gov/primer/strategies-and-approaches-tracking-improvements-patient-safety

• Fries Taylor E, Peikes D, Geonnotti K, McNellis R, Genevro J, Meyers D. Quality improvement in primary care: external supports for practices. Agency for Healthcare Research and Quality. Last reviewed November 2020. Accessed July 20, 2023. https://www.ahrq.gov/research/findings/factsheets/quality/qipc/index.html

• Fries Taylor E, Genevro J, Peikes D, Geonnotti K, Wang W, Meyers D. Building quality improvement capacity in primary care: supports and resources. Last reviewed August 2018. Accessed July 20, 2023. https://www.ahrq.gov/ncepcr/tools/capacity/brief2.html

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

Websites

• National Quality Forum. Accessed July 18, 2023. https://www.qualityforum.org/Home.aspx

• AHRQ evidence-based Care Transformation Support (ACTS). Agency for Healthcare Research and Quality. Accessed July 20, 2023. https://digital.ahrq.gov/acts

• Science of improvement: testing changes. Institute for Healthcare Improvement. Accessed July 19, 2023. www.ihi.org/resources/Pages/HowtoImprove/ScienceofImprovementTestingChanges.aspx

• Basics of quality improvement. American Academy of Family Physicians. Accessed July 2, 2023. https://www.aafp.org/family-physician/practice-and-career/managing-your-practice/quality-improvement-basics.html

• Workflow assessment for health IT toolkit. Agency for Healthcare Research and Quality. Accessed July 20, 2023. https://healthit.ahrq.gov/health-it-tools-and-resources/workflow-assessment-health-it-toolkit

• Tools and resources—type 2 diabetes. DRIVE, Center for Sustainable Health Care and Equity. Accessed July 18, 2023. https://shcdrive.org/tools-resources-diabetes/

• Tools and resources—flu vaccination. DRIVE, Center for Sustainable Health Care and Equity. Accessed July 18, 2023. https://shcdrive.org/tools-and-resources-flu-vaccination/

• Tools and resources—COVID-19. DRIVE, Center for Sustainable Health Care and Equity. Accessed July 18, 2023. https://shcdrive.org/tools-and-resources-covid-19/

• Quality tools. American Society for Quality. Accessed July 18, 2023. https://asq.org/quality-resources/quality-tools

• Run chart tool. Institute for Healthcare Improvement. Accessed July 20, 2023. www.ihi.org/resources/Pages/Tools/RunChart.aspx

• Quality improvement in healthcare: ACP resources and programs. Accessed July 20, 2023. https://www.acponline.org/practice-resources/quality-improvement-in-healthcare-acp-resources-and-programs

• Adult immunization. American College of Physicians. Accessed July 20, 2023. https://www.acponline.org/clinical-information/clinical-resources-products/adult-immunization

• Quality programs. American College of Cardiology. Accessed July 20, 2023. www.acc.org/tools-and-practice-support/quality-programs?w_nav=FN

• Quality improvement. American Society of Clinical Oncology (ASCO) Practice Central. Accessed July 20, 2023. www.instituteforquality.org

• Patient-centered medical home (PCMH). National Committee for Quality Assurance. Accessed July 20, 2023. www.ncqa.org/Programs/Recognition/Practices/PatientCenteredMedicalHomePCMH.aspx

• Quality measurement and quality improvement. Centers for Medicare & Medicaid Services. Last modified December 1, 2021. Accessed July 20, 2023. https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/MMS/Quality-Measure-and-Quality-Improvement-

• The Plan-Do-Study-Act (PDSA) cycle.The W.Edwards Deming Institute. Accessed July 18, 2023 https://deming.org/explore/p-d-s-a

• Maintaining certification (MOC). American Board of Internal Medicine. Accessed July 20, 2023. https://www.abim.org/maintenance-of-certification/

Related AMA STEPS Forward® Content

Education (Playbooks, Toolkits, MOC/CME)

• Saving Time Playbook

• Taming the EHR Playbook

• Digital Health Playbook

• LISTEN-SORT-EMPOWER Toolkit

• Change Initiatives Toolkit

• Appreciative Inquiry Toolkit

• Lean Health Care Toolkit

• Change Management and Organizational Development Toolkit

• Getting Rid of Stupid Stuff Toolkit

• Social Determinants of Health Toolkit

• Telehealth and Team-Based Care Toolkit

• EHR Inbox Management Toolkit

• Behavioral Health Integration Into Primary Care Toolkit

• Building Bridges Between Practicing Physicians and Administrators Toolkit

• Increasing Annual Prescriptions Renewal for Chronic Meds MOC IV AMA

• Removing Unnecessary EHR Inbox Messages MOC IV AMA

Podcasts

• Small interventions matter

• How to create a unified communication initiative using Epic Secure Chat

• One practice's success in implementing advanced team-based care

• Private Practice: Attending to Business, episode three—Practice efficiencies

Success Stories

• PDSA Case Report: University Physicians Group

Webinars and Videos

• Building Trust: Addressing Inefficiencies

• Crossing the divide: Building bridges between physicians and administration

• Social Determinants of Health

• BHI in practice: establishing efficient workflows

• Integrating psychopharmacology into Primary Care: When and How

• Priorities and Practical Strategies for Addressing Clinician Well-Being

• Implementing innovative solutions with an equity lens

• Cognitive workload: A modifiable contributor to physician burnout?

• Vaccinations: A Roadmap for Success

• Telehealth and Team-based Care: How to Engage Support Staff to Implement Team-based Care in Telehealth