Use of PDSAs in healthcare

Why use PDSAs in healthcare?

In this article we are going to take a look at why the ‘Plan-Do-Study-Act’ or PDSA cycle is so widely used within healthcare organisations. We’re going to delve into the benefits – and any disadvantages – of using PDSAs in healthcare and how you can use them to drive Quality Improvement.

The PDSA - a four-step model for improvement - has been used to support improvement in healthcare for many years now. The Institute for Healthcare Improvement (IHI) describe it as ‘shorthand for testing a change — by planning it, trying it, observing the results, and acting on what you learn. It is the scientific method, used for action-oriented learning in real-life situations. It is common to all improvement methodologies.’

Although the PDSA cycle was originally developed, introduced and tested in industrial settings, the first reported usage of PDSAs in healthcare was in 2000. It has been ‘formally proposed in healthcare’ within the Model for Improvement method set out in 'the improvement guide' by Langley et al in 1996.

Healthcare organisations and quality experts such as the IHI recommend the use of PDSAs as part of QI ‘to support the delivery of care that is safe, timely, effective, efficient, equitable and cost effective.'

The PDSA is regarded - and recommended by many healthcare organisations - as a key method for testing change. The fact that the changes can be small – and indeed sometimes, the smaller the better - means that you can implement change in a healthcare setting without causing major disruption for patients or clinicians or co-workers alike.

Benefits of PDSA cycles in healthcare

There are many benefits of using PDSAs within a healthcare organisation or healthcare setting as part of an improvement programme. The scientific methodology upon which PDSAs are based ensures that by planning, trying and observing the results of your PDSA, you can act on what you learn, and implement new changes quickly and easily.

PDSAs have a range of benefits that make them work well for healthcare organisations:

Cost-effective. Although the changes to test within PDSAs can sometimes be small and simple to implement, the results can be really impressive.

Easy to implement. Smaller ideas mean less bureaucracy to wade through.

Minimal disruption. Smaller changes have a lower risk of disrupting patients and staff, with less chance of a negative impact if the idea fails.

Well received. As the testing phase in PDSA cycles is so short, it means that alterations to everyday practices are usually well-received.

The Health Foundation report 'Skilled for improvement? Learning communities and the skills needed to improve care,’ gives an example of an unnamed trust using QI methods - including PDSAs - to drive improvement across the organisation, which demonstrates good results focusing on ‘small, rapid tests of change.’

The article 'The problem with Plan-Do-Study-Act cycles' states the method’s flexibility as a key benefit within healthcare organisations. ‘In the complex social systems of healthcare, this flexibility and adaptability of PDSA are important features that support the adaption of interventions to work in local settings.’

Later in this blog, we will be taking a look at good examples of using PDSAs within healthcare.

Disadvantages of using PDSA cycles in healthcare

Although there are many benefits to using PDSA cycles in healthcare organisations, it is important that you don't see them as a ‘magic bullet’ to any issue that a healthcare organisation may have.

The article 'The problem with Plan-Do-Study-Act cycles' looks at potential disadvantages of the PDSA cycle within healthcare organisations. It states that: ‘The intended output of PDSA is learning and informed action … but it does not, and cannot, promise that users will achieve their desired outcomes.'

Another issue associated with the PDSA in healthcare is the misconception that it can be used as a ‘standalone’ method. PDSAs really need to be part of a group of QI methods or ‘a suite of QI methods, the exact nature of which may be influenced by the broader methodological approach that is being followed (e.g. Model for Improvement, Lean).’

The Health Foundation report 'Safer Clinical Systems: evaluation findings' found that ‘Designing and implementing interventions to address these problems proved very challenging. Teams struggled to choose the right interventions – and right number of interventions.’ They also identified a need for more clarity ‘about when improvement approaches based on PDSA cycles are appropriate and when they are not.’

Examples of applying PDSAs to drive quality improvement in healthcare organisations

There are many examples of healthcare organisations applying PDSAs to drive QI within their organisations.  The NHS Improvement report 'Quality improvement: Theory and practice in healthcare' looks in detail at the PDSA and its collaborative approach.

The Health Foundation report 'Skilled for improvement? Learning communities and the skills needed to improve care: an evaluative service development' also gives an example of an unnamed trust using QI methods including PDSA to drive improvement across the organisation, which demonstrates good results.

East London NHS Foundation Trust (ELFT)

Another great example of the use of PDSAs in healthcare is demonstrated within the East London NHS Foundation Trust (ELFT) who are leading experts in QI in healthcare. The team at ELFT have written guides to running PDSAs and have created a range of resources to help support team members in their quality improvement efforts.

ELFT has a great example of how team members have used PDSAs to drive improvement. This demonstrates how the Early Years Speech and Language Therapy team used PDSA testing in order to reduce referral to treatment time in Early Years Speech and Language Therapy.

If you take a look at the article, you will see how using PDSA cycles led them to implement text message reminders to encourage uptake.  ‘By using PDSA rigorously this team arrived at a high degree of belief in this change idea, that it will help them to achieve their aim. They are now prepared to implement this change idea, to make sending text message reminders a part of the day-to-day operation of the system.’

A fantastic example of how you can test and implement relatively small changes to benefit people across the healthcare system.

So, as we have seen with these great examples, PDSAs can be an excellent way of testing and implementing change within a healthcare setting.  If you want to read more about the benefits of using PDSAs in healthcare, take a look at our blog.

Good luck in your Quality Improvement journey!