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Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study
  1. Chris McNicholas1,2,
  2. Laura Lennox1,
  3. Thomas Woodcock1,
  4. Derek Bell1,
  5. Julie E Reed1
  1. 1 NIHR CLAHRC NWL, Chelsea and Westminster Hosptial, Imperial College London, London, United Kingdom
  2. 2 Improvement Team, Office of Medical Director, Imperial College Healthcare NHS Trust, London, United Kingdom
  1. Correspondence to Dr Julie E Reed, NIHR CLAHRC NWL, Chelsea and Westminster Hopstial, Imperial College London, London SW11 3TN, UK; julie.reed02{at}


Background Although widely recommended as an effective approach to quality improvement (QI), the Plan–Do–Study–Act (PDSA) cycle method can be challenging to use, and low fidelity of published accounts of the method has been reported. There is little evidence on the fidelity of PDSA cycles used by front-line teams, nor how to support and improve the method’s use. Data collected from 39 front-line improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this over time.

Methods The fidelity of 421 PDSA cycles was reviewed using a predefined framework and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.

Results Although modest, statistically significant improvements in PDSA fidelity occurred; however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.

Conclusion This study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

  • quality improvement
  • PDSA
  • quality improvement methodologies
  • Plan-Do-Study-Act

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  • Contributors CM and LL collected the data, interviewed participants and carried out the analysis. While employed by NIHR CLAHRC NWL, they joined later in the programme and had no involvement in supporting or provision of training to project teams. TW supported PDSA cycle data extraction and quantitative analyses. JER and DB provided academic oversight and support to the study and review of analysis. JER and DB were involved in the development of the QI support strategies, teaching of PDSA and overall programme oversight, but not day-to-day project support. All researchers contributed to reflections and sense-making following initial analysis of results by LL and CM, and contributed to the development of the article.

  • Funding This article is based on independent research commissioned by the National Institute for Health Research (NIHR) under the Collaborations for Leadership in Applied Health Research and Care (CLAHRC) programme for North West London. JER and TW were also financially supported by Improvement Science Fellowships from The Health Foundation.

  • Disclaimer The views expressed in this publication are those of the authors and not necessarily those of The Health Foundation, the NHS, the NIHR or the Department of Health.

  • Competing interests None declared.

  • Patient consent Not required.

  • Provenance and peer review Not commissioned; externally peer reviewed.

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