PDSA Cycles in Practice: Real-World Examples for Junior Doctors

Why PDSA Cycles Matter for Junior Doctors

Junior doctors are uniquely positioned to identify areas for improvement within their clinical teams and systems. Often on the front lines of patient care, they encounter inefficiencies, safety concerns, and opportunities for better practice daily. PDSA cycles provide a structured yet flexible framework to:

• Test changes safely: By starting small, potential negative impacts are minimised.
• Learn rapidly: Each cycle offers insights into what works and what doesn't, fostering continuous learning.
• Build evidence: Accumulated cycles provide data to support the effectiveness of a change.
• Engage teams: PDSA encourages collaboration and ownership of improvements.
• Meet portfolio requirements: Demonstrating active participation in QI is often a requirement for postgraduate training.

This approach aligns with NHS England's focus on embedding QI skills across the workforce, recognising that iterative testing is key to sustainable change.

Practical Explanation of the PDSA Cycle

The PDSA cycle, often visualised as a wheel, involves four interconnected stages:

P: Plan

This stage involves defining the objective of the change, predicting the outcome, and planning the 'Do' phase. Key questions to ask:

• What are we trying to achieve? (e.g., specific aim statement).
• What change are we testing? (e.g., a new process, a revised document).
• What do we expect to happen? (prediction).
• How will we measure it? (data collection plan – who, what, when, how).
• Who will be involved? (team members, stakeholders).
• What is the timeframe? (usually short – days or weeks).

D: Do

This is where the planned change is carried out, typically on a very small scale, and data is collected as per the plan. It's crucial to observe the process and document any unexpected issues or observations.

S: Study

In this stage, the collected data is analysed, and the results are compared against the initial predictions. The team reflects on what worked, what didn't, and why. Discussion points include:

• Did the change lead to the predicted outcome?
• Were there any unintended consequences?
• What problems or facilitators were encountered?
• What did we learn?

A: Act

Based on the learning from the 'Study' phase, the team decides on the next steps. This could involve:

• Adopting the change (if successful and sustainable).
• Adapting the change (modifying it based on learning and running another PDSA cycle).
• Abandoning the change (if it was ineffective or harmful).
• Scaling up the change (if multiple small cycles have proven efficacy and sustainability).

This cyclical nature allows for continuous refinement and improvement.

Common Pitfalls to Avoid

While PDSA cycles are powerful, several common missteps can hinder their effectiveness, especially for those new to QI:

• Skipping the 'Plan' phase: Insufficient planning often leads to unfocused or poorly measured interventions.
• Too large a 'Do' phase: Testing a change across an entire ward or hospital department too soon can be risky and difficult to manage or reverse if problems arise.
• Failing to 'Study' properly: Not analysing data, or not discussing what was learned, negates the purpose of the cycle. Without reflection, it's just 'doing', not 'improving'.
• Not acting on learning: Having a 'Study' phase but failing to adjust the approach based on the findings makes the cycle pointless.
• Expecting perfection in the first cycle: PDSA is iterative; it's about learning and refining, not achieving a perfect solution immediately.
• Lack of engagement: Not involving relevant team members can lead to resistance or missing crucial perspectives.

Step-by-Step Approach for Junior Doctors

1. Identify an Opportunity: Look for a problem or inefficiency in your daily work. This could be anything from delays in blood results to inconsistent handover practices. Start with something small and manageable.
2. Formulate an Aim: Clearly state what you want to achieve. Use SMART principles (Specific, Measurable, Achievable, Relevant, Time-bound).
   • Example: "To reduce the time from venous blood sampling to result availability for ward patients by 15% within the next four weeks on Ward X."
3. Brainstorm Changes: With your team, identify potential changes that could address your aim. These are your hypotheses for improvement.
4. Plan your First PDSA (P): Choose one small, specific change to test. Define:
   • What: The exact change (e.g., implementing a new 'stat bloods' tray at the nursing station).
   • Who: Who will implement it (e.g., one junior doctor, two nurses).
   • When: The specific timeframe (e.g., for three patients on Tuesday afternoon).
   • How to measure: What data you will collect (e.g., time stamps from sampling to lab receipt for these three patients vs. previous average).
   • Prediction: What you expect to happen.
5. Carry out the Plan (D): Implement the change as planned. Record observations, challenges, and data.
6. Analyse and Reflect (S): Compare your data to your baseline and prediction. Discuss with your team: What did you observe? What worked? What didn't? Why?
7. Decide on Next Steps (A):
   • If successful on a small scale, can you refine and test it with more patients or over a longer period (another PDSA cycle)?
   • If it didn't work, what did you learn? How can you modify the change or try a different approach (another PDSA cycle)?
   • If it caused unexpected problems, should you abandon this idea?
8. Repeat: Continue cycling through Plan-Do-Study-Act, refining your change with each iteration until you achieve your aim or determine a different approach is needed. This incremental learning is key.

Example in Clinical Practice: Improving Consultant Review Times

Context: On a busy medical ward, junior doctors often find patients are awaiting consultant review for discharge decisions, leading to delays and extended lengths of stay. The aim is to reduce the average time from a patient being 'ready for review' to consultant review for discharge patients.

Initial Observation: Junior doctors note that consultants aren't always aware of which patients are ready for review until the ward round, or through ad-hoc requests, leading to delays.

QI Aim: To reduce the average time from a patient being 'ready for consultant review for discharge' to the actual review by 20% within four weeks on Ward Y.

PDSA Cycle 1: Pilot 'Discharge Review Flag' System

• P (Plan):
  • Change: Implement a visible 'Discharge Review' sticker/flag on patient boards for patients ready for consultant review for discharge.
  • Prediction: Consultants will notice the flag and prioritise these patients, reducing review time.
  • Measure: For 5 patients identified as 'ready for review' on Monday morning, record time of flag placement and time of consultant review. Compare to average review times from previous week (baseline).
  • Who: One FY2 doctor, two ward nurses, one consultant.
• D (Do):
  • Implement stickers for 5 patients. FY2 doctor observes ward rounds and records times. Notes any consultant or nursing feedback.
• S (Study):
  • Results: Average review time for flagged patients was 1 hour shorter than baseline. Consultants noted the flag was helpful but sometimes missed if on the 'wrong' side of the board or obscured. Nurses found it easy to apply.
  • Learning: The flag has potential, but visibility is an issue. The idea is sound, but the execution needs refinement.
• A (Act):
  • Adapt: Refine the flag system. Design a larger, more prominent, brightly coloured magnet for the main patient board with a dedicated section for 'Awaiting Consultant Review for Discharge'. Proceed to PDSA Cycle 2.

PDSA Cycle 2: Refined 'Discharge Review Magnet' System

• P (Plan):
  • Change: Introduce a prominent, pre-printed magnet for the ward patient board, placed in a designated area. Junior doctor adds patient name to magnet when ready for review.
  • Prediction: Improved visibility will further reduce review times and increase consistency.
  • Measure: For 10 patients across Tuesday and Wednesday, record time of magnet placement and consultant review. Compare to baseline and PDSA 1 results.
  • Who: All junior doctors on the ward, ward manager, consultants.
• D (Do):
  • Implement magnets. Junior doctors and ward manager educate team. Data collected.
• S (Study):
  • Results: Average review time reduced by a further 30 minutes, now 1.5 hours shorter than baseline. Consultants consistently noticed the magnet. Some junior doctors occasionally forgot to update it immediately.
  • Learning: System is effective, but compliance with updating needs improvement. Reminders needed.
• A (Act):
  • Adapt/Adopt: Implement daily morning handover prompt for junior doctors to update the discharge review magnet. Consider standardising this across the department if successful in Ward Y. Continue to monitor review times. Proceed to PDSA Cycle 3 (optional: scale up to another ward or refine compliance). This ongoing cycle ensures continuous improvement.

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

How Lazomis Can Help

Lazomis provides structured tools and templates to facilitate your QI journey, making it easier to plan, track, and report on your PDSA cycles.

• QI Project Setup: Our platform guides you through defining your project aim, measures, and initial changes, helping you establish a robust 'Plan' phase.
• PDSA Cycle Templates: Access ready-to-use templates that prompt you through each stage of the PDSA cycle, ensuring you capture all necessary information for 'Plan', 'Do', 'Study', and 'Act'.
• Data Collection & Visualisation: Easily log data from your 'Do' phase and visualise trends over multiple cycles, making your 'Study' phase more efficient and insightful.
• Collaboration Features: Share your PDSA cycles and project progress with your team and supervisors, fostering engagement and facilitating feedback, crucial for the 'Act' phase.
• Reporting Tools: Generate clear reports of your QI work for portfolio submission, departmental review, or wider dissemination, highlighting the impact of your iterative testing.

By streamlining the administrative aspects of QI, Lazomis allows you to focus more on the clinical changes and learning, helping you meet your portfolio requirements and drive meaningful improvements within your NHS setting.