Article Text

This article has a correction. Please see:

other Versions

Download PDFPDF
The problem with Plan-Do-Study-Act cycles
  1. Julie E Reed1,
  2. Alan J Card2,3
  1. 1NIHR CLAHRC NWL, Imperial College London, London, UK
  2. 2Department of Management, University of Notre Dame, Notre Dame, Indiana, USA
  3. 3Evidence-Based Health Solutions, LLC, Notre Dame, Indiana, USA
  1. Correspondence to Dr Julie E Reed, NIHR CLAHRC NWL, Imperial College London, Chelsea and Westminster Hospital, 369 Fulham Road, London SW10 9NH, UK; julie.reed02{at}

Statistics from


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 value of PDSA in healthcare improvement

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 …

View Full Text


  • Twitter Follow Julie Reed at @julie4clahrc and Alan Card at @AlanJCard

  • Competing interests None declared.

  • Disclaimer This article presents 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. The views expressed in this publication are those of the author(s) and not necessarily those of the NHS, the NIHR or the Department of Health.

  • Provenance and peer review Commissioned; internally peer reviewed.

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

Linked Articles