The problem with Plan-Do-Study-Act cycles

Quality improvement (QI) methods have been introduced to healthcare to support the delivery of care that is safe, timely, effective, efficient, equitable and cost effective. Of the many QI tools and methods, the Plan-Do-Study-Act (PDSA) cycle is one of the few that focuses on the crux of change, the translation of ideas and intentions into action. As such, the PDSA cycle and the concept of iterative tests of change are central to many QI approaches, including the model for improvement,1 lean,2 six sigma3 and total quality management.4 PDSA provides a structured experimental learning approach to testing changes. Previously, concerns have been raised regarding the fidelity of application of PDSA method, which may undermine learning efforts,5 the complexity of its use in practice5 ,6 and as to the appropriateness of the PDSA method to address the significant challenges of healthcare improvement.7 This article presents our reflections on the full potential of using PDSA in healthcare, but in doing so we explore the inherent complexity and multiple challenges of executing PDSA well. Ultimately, we argue that the problem with PDSA is the oversimplification of the method as it has been translated into healthcare and the failure to invest in a rigorous and tailored application of the approach. The purpose of the PDSA method lies in learning as quickly as possible whether an intervention works in a particular setting and to making adjustments accordingly to increase the chances of delivering and sustaining the desired improvement. In contrast to controlled trials, PDSAs allow new learning to be built in to this experimental process. If problems are identified with the original plan, then the theory can be revised to build on this learning and a subsequent experiment conducted to see if it has resolved the problem, and …