PDSA stages | Key failure modes | Potential consequence |
---|---|---|
Do Implement the plan (including both the QI intervention and the data collection plan) | Failure to implement the QI intervention as intended27 36 | Impossible to learn whether the planned QI intervention works as expected; wasted effort; disillusionment among staff involved with intervention design |
Failure to collect the data as intended27 36 | Undercuts the Study phase; may be difficult or impossible to tell whether the intervention worked as expected; difficult or impossible to learn about the effectiveness of the original data collection plan | |
Failure to capture unanticipated learning17 22 27 | Missed learning opportunities (especially for qualitative learning about how and why the intervention did/did not work); project failure; unnecessary PDSA cycles | |
Failure to abandon the Do phase despite manifest failure or severe negative side effects24 | Wasted effort; excessive disruption; adverse outcomes from side effects | |
Study Analyse data and compare results to the definition of success; distil and communicate what has been learned from the formal data analysis and unanticipated learning | Failure to conduct a study5 or inappropriate failure to follow the study plan | No/limited opportunity to learn whether the intervention works as intended; potential for biased and misleading results |
Failure to communicate what has been learned27 46 | Loss of stakeholder engagement; reinventing the same broken wheel in the service of other QI projects; loss of institutional knowledge if there is turnover among project leaders | |
Act Based on what has been learned, either:
| Failure to engage in ‘double loop learning’17 that questions the goals of the project in light of what has been learned | Wasted effort continuing to work on the wrong problem, or one that cannot realistically be solved; Excessive PDSA cycles spent trying to achieve a goal that is set too high, when a more realistic goal would deliver real improvement |
Moving too quickly from small-scale tests of change to full-scale implementation and sustainment5 | Failure to uncover barriers to broader use prior to implementation; project failure; disruption associated with deimplementation; wasted resources/goodwill |
PDSA, Plan-Do-Study-Act; QI, quality improvement.