Table 1

Key failure modes for the investigation/problem framing and plan steps

PDSA stagesKey failure modesPotential consequence
Investigation and problem framing
Define the problem; determine its causes/contributing factors; identify stakeholders; set the criteria for success
Poor definition of the problem and its causes/contributing factors1 5 21–25Time, money and goodwill may be wasted trying to solve the wrong problem or solve it in the wrong way
Failure to clearly define the criteria for success and how performance will be measured5 22 26A poor match between the design of the intervention and its intended impact; inability to assess success during ‘study’ phase
Failure to identify key stakeholders22 27Important knowledge may be left out of the planning process
Design an intervention and data collection plan; specify how the intervention will be implemented (Do), evaluated (Study) and sustained (if successful)
No theory of change/programme theory connecting the intervention to its intended outcomes28–31Poorly targeted interventions that may be inefficient or may fail altogether. Poor buy-in due to a perceived lack of legitimacy
Planned intervention, implementation plan and study protocol that are not in proportion to one another and the problem to be solved22 32 33Underinvestment leading to projects that do not achieve their goals or that cannot be proven to have achieved their goals; Overinvestment leading to wasted resources
Designing a data collection and analysis plan that is incapable of providing the required answers26Impossible to know if the intervention was effective; excessive PDSA cycles required; aggravation among frontline staff that the administrative burden of data collection was wasted
Not consulting key stakeholders during the planning stage21 27 34 35Proceeding with an intervention that is predictably doomed to fail; disengagement among frontline staff
Not planning for the ‘who, what, where, when, and how’ of implementation (the ‘do’ phase)5 22 36Poor understanding of resource requirements and cost-effectiveness; poor execution of the ‘do’ and ‘study’ phases
Adopting weak interventions (eg, administrative controls, such as training and policies) without considering more robust options37–41Interventions that do not achieve their goals or do not sustain them
Not assessing cultural and structural barriers/facilitators related to the intervention14 21 42–44‘Fish out of water’ interventions put in place without attention to the broader changes required to make them successful; systemic issues not tackled and only superficial change attempts made
Failure to plan for how the intervention will be sustained in practice, if successful16 7 38 45 46Performance reverts to previous standards, staff frustrated with unsuccessful change effort and disengage from future attempts
Failure to consider the intervention's failure modes and potential side effects (positive and negative)21 45 47Interventions that are designed to fail or that create more problems than they solve; failure to select the most cost-effective solutions
  • PDSA, Plan-Do-Study-Act.