Pdsacycledebedits PDF
Pdsacycledebedits PDF
Directions: Use this Plan-Do-Study-Act (PDSA) tool to plan and document your progress with tests of change
conducted as part of chartered performance improvement projects (PIPs). While the charter will have clearly
established the goals, scope, timing, milestones, and team roles and responsibilities for a project, the PIP team
asked to carry out the project will need to determine how to complete the work. This tool should be
completed by the project leader/manager/coordinator with review and input by the project team. Answer the
first two questions below for your PIP. Then as you plan to test changes to meet your aim, answer question 3
below and plan, conduct, and document your PDSA cycles. Remember that a PIP will usually involve multiple
PDSA cycles in order to achieve your aim. Use as many forms as you need to track your PDSA cycles.
Define the processes currently in place; use process mapping or flow charting
Identify opportunities for improvement that exist (look for causes of problems that have occurred
see Guidance for Performing Root Cause Analysis with Performance Improvement Projects; or identify
potential problems before they occur see Guidance for Performing Failure Mode Effects Analysis with
Performance Improvement Projects) (see root cause analysis tool):
Points where breakdowns occur
Work-a-rounds that have been developed
Variation that occurs
Duplicate or unnecessary steps
Decide what you will change in the process; determine your intervention based on your analysis
Identify better ways to do things that address the root causes of the problem
Learn what has worked at other organizations (copy)
Review the best available evidence for what works (literature, studies, experts, guidelines)
Remember that solution doesnt have to be perfect the first time
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Plan List your action steps along with person(s) responsible and
What change are you testing with time line.
the PDSA cycle(s)?
What do you predict will happen and
why?
Who will be involved in this PDSA?
(e.g., one staff member or resident,
one shift?). Whenever feasible, it
will be helpful to involve direct care
staff.
Plan a small test of change.
How long will the change take to
implement?
What resources will they need?
What data need to be collected?
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Study Describe the measured results and how they compared to the
Study and analyze the data. predictions.
Determine if the change resulted in
the expected outcome.
Were there implementation
lessons?
Summarize what was learned. Look
for: unintended consequences,
surprises, successes, failures.
Act Describe what modifications to the plan will be made for the
Based on what was learned from the test: next cycle from what you learned.
Adapt modify the changes and
repeat PDSA cycle.
Adopt consider expanding the
changes in your organization to
additional residents, staff, and units.
Abandon change your approach
and repeat PDSA cycle.
Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.