Key failure modes for the investigation/problem framing and plan steps
| PDSA stages | Key failure modes | Potential 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 21–25 | Time, 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 26 | A poor match between the design of the intervention and its intended impact; inability to assess success during ‘study’ phase | |
| Failure to identify key stakeholders22 27 | Important knowledge may be left out of the planning process | |
| Plan 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 outcomes28–31 | Poorly 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 33 | Underinvestment 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 answers26 | Impossible 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 35 | Proceeding 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 36 | Poor 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 options37–41 | Interventions 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 46 | Performance 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 47 | Interventions 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.