PDSA Cycles: A Practical Guide to Testing Change in Healthcare

Why this topic matters

Healthcare is a complex and dynamic environment. Implementing changes, even seemingly small ones, without proper testing can lead to unintended consequences, resistance, and failure to achieve desired improvements. PDSA cycles provide a robust yet flexible framework for iterative learning and adaptation. They mitigate risk by encouraging small-scale tests, allowing teams to identify what works, what doesn't, and why, before committing significant resources to a particular intervention.

For junior doctors and trainees, mastering PDSA is not just about fulfilling QI project requirements; it's about developing a fundamental skill for continuous professional development and contributing meaningfully to service improvement. For QI leads, embedding PDSA thinking across teams fosters a culture of learning and innovation.

Practical explanation: What are PDSA cycles?

The Plan-Do-Study-Act (PDSA) cycle is a four-stage iterative model for testing changes. It's often visualised as a wheel, emphasising the continuous nature of improvement – one cycle builds on the last.

• Plan: This stage involves setting clear objectives for the test, formulating predictions about the outcome, defining the specific change to be tested, identifying who will carry out the test, when and where it will happen, and what data will be collected.
  • Key questions: What exactly are we trying to achieve? What change will we test? What do we expect to happen? How will we know it worked?
• Do: This is the stage where the planned change is carried out, typically on a small scale. Data collection, as outlined in the 'Plan' stage, occurs during this phase.
  • Key questions: Did we follow the plan? What observations did we make? What data did we collect?
• Study: In this stage, the data collected during the 'Do' phase is analysed, and the results are compared against the predictions made in the 'Plan' stage. The team reflects on what was learned.
  • Key questions: What did the data show? Did it match our predictions? What did we learn? What went well, and what didn't?
• Act: Based on the learning from the 'Study' phase, the team decides what to do next. This could involve adopting the change, adapting it and running another PDSA cycle, or abandoning the change if it wasn't effective.
  • Key questions: What will we do next? Adopt, adapt, or abandon? What is the next PDSA cycle?

PDSA cycles are rarely 'one and done'. They are designed to be run repeatedly, each cycle building on the knowledge gained from the previous one. This iterative approach allows for gradual refinement and optimisation of changes.

Common pitfalls

While PDSA is straightforward in concept, several common pitfalls can hinder its effectiveness:

• Lack of clear aims: Starting a PDSA without a well-defined problem statement and specific aims (often using SMART criteria) can lead to unfocused tests.
• Skipping the 'Plan' phase: Rushing straight to 'Do' without thorough planning often results in poorly designed tests, uncollected data, or unclear expectations.
• Making the 'Do' phase too large: Trying to implement a change across an entire ward or department in the first cycle is a common mistake. Start small – one patient, one shift, one clinician.
• Failing to collect data: Relying solely on anecdotal evidence rather than systematic data collection makes it difficult to objectively 'Study' the impact of the change.
• Not 'Studying' the data: Collecting data but not analysing it or comparing it to predictions means missing the opportunity to learn.
• Lack of 'Act' phase follow-through: Completing a cycle but not explicitly deciding on the next steps (adopt, adapt, abandon) wastes the learning.
• Confusing PDSA with project management: PDSA is a tool for testing changes, not for managing the entire QI project. It sits within a larger QI methodology.

Step-by-step approach: Running a PDSA cycle

Here’s a practical guide to running an effective PDSA cycle:

1. Plan

• Define the specific change: Clearly articulate the single, small change you intend to test. Be precise. (e.g., 'Introduce a standardised pre-shift huddle checklist' rather than 'Improve ward communication').
• State your predictions: What do you expect to happen? What are the desired outcomes? What are potential unintended consequences?
• Identify the participants and scope: Who will be involved? When and where will this test take place? Keep it small (e.g., one nurse, one patient, one day).
• Determine data collection: What data will you collect to measure the impact of your change? How will you collect it? (e.g., observe 3 huddles, count number of items missed, survey 2 nurses).
• Set a timeline: Establish a short, clear timeframe for the 'Do' phase (e.g., 2 hours, 1 shift, 1 week).

2. Do

• Carry out the test: Implement the change exactly as planned. Stick to the small scale you defined.
• Collect data: Record observations, measurements, and any unexpected events or challenges encountered. Use the data collection methods defined in the 'Plan' phase.

3. Study

• Analyse the data: Review the collected data. Did the change have the predicted effect? Did anything unexpected happen?
• Compare to predictions: How did the actual results compare to your initial predictions? Were your assumptions correct?
• Identify learnings: What worked well? What didn't? Why? What new questions arose?

4. Act

• Decide on next steps:
  • Adopt: If the change was successful, sustainable, and produced the desired outcomes, consider embedding it or rolling it out on a larger scale.
  • Adapt: If the change showed promise but needs modification, refine it based on your learning and plan the next PDSA cycle.
  • Abandon: If the change was ineffective, detrimental, or not feasible, discard it and consider testing a different intervention.
• Plan the next cycle: If adapting or adopting, immediately begin planning the next PDSA cycle, building on the knowledge gained.

Example in clinical practice: Reducing delayed discharges

Problem: High rates of delayed discharges impacting patient flow and bed availability. Overall Aim: To reduce the proportion of patients with delayed discharge by 10% within 6 months.

PDSA Cycle 1: Testing a new 'Expected Discharge Date' (EDD) sticker on patient notes.

• Plan:
  • Change: Introduce a bright orange 'EDD' sticker on the front of patient notes for all patients admitted to Ward X.
  • Prediction: Staff will more consistently document EDDs, leading to earlier discharge planning discussions.
  • Scope: All admissions to Ward X for one week (Monday-Friday).
  • Data: Count how many patient notes have an EDD sticker and a documented EDD by Tuesday morning ward round. Interview 3 nurses and 2 doctors about their awareness and use of the sticker.
• Do:
  • Nursing staff on Ward X are briefed and asked to apply stickers and document EDDs. Data collected as planned.
• Study:
  • Only 60% of patient notes had an EDD sticker, and only 40% had a documented EDD. Interviews revealed stickers were often forgotten or ran out. Some staff found them cumbersome.
• Act:
  • Adapt. The sticker alone isn't enough. We need to integrate EDD documentation into the daily ward round proforma and ensure stickers are readily available. Plan PDSA Cycle 2.

PDSA Cycle 2: Integrating EDD documentation into ward round proforma and introducing a morning 'EDD check' during safety brief.

• Plan:
  • Change: Incorporate EDD as a mandatory field in the ward round proforma. Introduce a specific 2-minute slot in the morning safety brief to review all EDDs and identify potential delays.
  • Prediction: EDD documentation will improve to >90%, and more proactive discharge planning will occur.
  • Scope: All admissions to Ward X for one week. The morning safety brief team for that week.
  • Data: Count documented EDDs on ward round proformas by Tuesday morning. Observe 3 morning safety briefs for EDD discussion. Interview 3 doctors and 3 nurses about the new process.
• Do:
  • Ward round proformas updated. Safety brief lead briefed. Data collected.
• Study:
  • 95% of proformas had EDDs. Safety briefs consistently included EDD discussion, leading to early identification of some potential discharge barriers. Staff reported feeling more 'on top' of discharge planning.
• Act:
  • Adopt this process for Ward X. Consider piloting across two more wards next month, then scaling up. Begin planning for further PDSA cycles to tackle specific discharge barriers identified.

This example illustrates how iterative cycles build learning and refine the change until it is effective and ready for wider implementation.

How Lazomis can help

Lazomis provides structured tools that can significantly streamline your PDSA cycles and overall QI project management:

• QI Project Setup: Our project templates include dedicated sections for outlining your PDSA cycles, ensuring clear objectives, predictions, and data collection plans for each iteration.
• Data Collection Tools: Customisable forms and dashboards within Lazomis can help you efficiently collect and visualise the data from your 'Do' phase, making the 'Study' phase more straightforward.
• Reporting and Documentation: Easily document the outcomes of each PDSA cycle, lessons learned, and your 'Act' decision, creating a clear audit trail of your improvement journey.
• Collaboration Features: Facilitate team communication and decision-making for your PDSA cycles, ensuring everyone is aligned on the plan, execution, and learning.

This resource supports, but does not replace, clinical judgement. Local policy, formulary and specialist advice should be followed.