Introduction The Plan-Do-Study-Act cycle method is a common approach taken in improvement initiatives to test changes in a pragmatic and scientific fashion. The effectiveness and application of the method, however, is varied with a recent systematic review outlining a lack of adherence to key functions of the methods approach. To understand how to achieve good quality use of the method it is necessary to assess the attainment of these key functions of its use in frontline improvement initiatives, opening the method's “black box”. This research aims to further develop and apply a theoretical framework to assess the conduct of improvement initiatives: understanding both the conduct of the PDSA method and the improvement context of an organization that supports its use.

Methods A qualitative study of three separate healthcare organizations is underway to assess the PDSA cycle conduct of improvement initiatives, including iterative development, prediction-based tests of change, use of regular data over time, starting on a small scale and collaborative working. Semi-structured interviews with improvement initiative members and senior organizations leaders are being conducted and complemented with participant observation and document analysis of initiatives' day-today work to gain an in-depth understanding of how PDSA methods are applied and perceived by healthcare professionals and to gain an understanding of broader organizational context for improvement work.

Results The study is due for complete in early 2014, however, initial findings can be highlighted.

Whilst the recognition of the functions of PDSA is widespread in the improvement initiatives observed, be it implicitly or explicitly, the achievement of these is varied. The utilization of regular data over time to influence progression of PDSA cycles is a key challenge when using the PDSA cycle approach, both in collecting the data and collaboratively critiquing it to iterate a change. This leaves teams stuck in the Plan-Do stages of the cycle and prevents effective cycle completion. Whilst the concept of testing change is supported by most individuals involved directly in improvement initiatives not all participants are necessarily aware or engaged with the PDSA cycle approach and tests of change of occur without using the 4 stages or are retrospectively documented as PDSA cycles.

Discussion This work presents a framework to assess the effective application and supporting context for improvement initiatives using the PDSA cycle approach. Whilst the benefit of testing change in a scientific and pragmatic manner is evident in the views of healthcare staff the improvement of organizational learning mechanisms to support this is necessary. Both internal and external support to an organization can benefit from reflecting on the framework and address data and staff training needs to ensure patient care is improved in an effective and efficient manner.

Declaration of competing interests None.