PDSA Practice Improvement Plan: Plan (Problem, Literature, PICOT, Process), Do, Study and Act, With a Worked Example
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How to write a PDSA (Plan-Do-Study-Act) practice improvement plan: Part I, Plan (problem identification, review of literature, PICO(T) question and the process); Part II, Do; Part III, Study; and Part IV, Act. A worked example, reducing catheter-associated urinary tract infections (CAUTI) on a medical unit, runs through every part.
What is a PDSA practice improvement plan?
The Plan-Do-Study-Act (PDSA) cycle is a quality improvement method for testing a change on a small scale, learning from the results, and refining the change before spreading it. It grew out of the work of Walter Shewhart and W. Edwards Deming and is the testing engine of the Model for Improvement (Langley et al., 2009). That model begins with three questions:
- What are we trying to accomplish? (the aim)
- How will we know that a change is an improvement? (the measures)
- What change can we make that will result in improvement? (the change idea)
A PDSA plan is not a one-off event. Improvement usually comes from several rapid, small cycles, each building on what the last one taught. Reviews of PDSA use in healthcare show that the method works best when cycles are small, iterative, and supported by data collected over time (Taylor et al., 2014).
Problem, evidence, PICOT, aim, process and predictions
Test the change on a small scale; collect data
Analyze the data; compare with predictions
Adopt, adapt or abandon; plan the next cycle
Part I: Plan
The Plan stage is the longest and most important part of the paper. A weak plan produces an unclear test and unusable data.
1. Problem identification
Describe the practice problem clearly, show that it is real and significant, and explain why it matters to patients, staff and the organization.
- State the problem in one or two sentences: who is affected, where, and how big the gap is.
- Use local data, such as unit dashboards, incident reports and audits, and compare it with national benchmarks or targets.
- Explain the significance: patient harm, costs, regulatory requirements, and nurse-sensitive indicators.
- Analyze root causes with a fishbone diagram, process map or “5 Whys” with frontline staff.
- Identify stakeholders, such as nurses, the nurse manager, providers, infection prevention, quality and patients, and secure leadership support.
Worked example: On a 32-bed adult medical unit, the CAUTI rate over the last two quarters was well above the hospital’s target, and an audit found that many indwelling urinary catheters stayed in place without a documented indication. A fishbone analysis identified no daily review of catheter need, unclear authority for nurses to remove catheters, and catheters placed in the emergency department for convenience. CAUTIs cause patient discomfort, longer stays and extra costs, and they are a publicly reported hospital-acquired condition.
2. Review of literature
Summarize the best current evidence on interventions for your problem. Do not simply list articles: synthesize them by theme and state the level of evidence.
- Search CINAHL, PubMed and the Cochrane Library, plus guidelines from the CDC, AHRQ and professional organizations.
- Appraise each source, and summarize the findings in an evidence table that includes author and year, design, level, sample, intervention, outcomes and limitations.
- Identify the intervention best supported by the evidence and feasible in your setting.
Worked example: CDC guidelines recommend inserting catheters only for appropriate indications and removing them as soon as they are no longer needed (Gould et al., 2010). A systematic review and meta-analysis found that reminder systems and stop orders, including nurse-driven removal protocols, reduced CAUTI rates by about half and shortened catheter duration (Meddings et al., 2010). This evidence supports a nurse-driven catheter removal protocol with a daily review of indications.
For help finding and appraising evidence, see our guide on developing a clinical question, levels of evidence and search strategy.
3. PICO(T) question
Turn the problem and the evidence into a focused, answerable question.
| Element | Worked example |
|---|---|
| P: Population | Adult patients with indwelling urinary catheters on a medical unit |
| I: Intervention | Nurse-driven catheter removal protocol with a daily review of indications |
| C: Comparison | Current practice (removal only on a provider order) |
| O: Outcome | Catheter utilization ratio and CAUTI rate |
| T: Time | Over 8 weeks |
PICOT: In adult medical patients with indwelling urinary catheters (P), does a nurse-driven catheter removal protocol (I), compared with provider-ordered removal (C), reduce catheter utilization and CAUTI rates (O) over 8 weeks (T)?
For more examples, see 114 PICOT question examples.
4. The process
Describe exactly how the change will be tested: who, what, where, when and how. Include your aim, measures, predictions and data plan.
| Component | What to include | Worked example |
|---|---|---|
| SMART aim | Specific, measurable, achievable, relevant, time-bound goal | Reduce the catheter utilization ratio on Unit 5 West from 0.30 to 0.20 or lower within 8 weeks |
| Change to test | The evidence-based intervention | Nurse-driven removal protocol, a daily indication checklist at 10 a.m., and a bladder scanner protocol after removal |
| Team and roles | Project lead, champions, stakeholders | Student or project lead, two RN champions, nurse manager, infection preventionist, hospitalist |
| Setting and scale | Start small | Cycle 1: day shift on one unit for 2 weeks |
| Education | How staff will learn the change | A 10-minute huddle education session, a laminated protocol at each workstation, and an EHR reminder |
| Outcome measure | Did patients benefit? | CAUTI rate per 1,000 catheter days |
| Process measures | Was the change carried out? | Catheter utilization ratio; percentage of catheters with a documented indication; checklist completion rate |
| Balancing measure | Did it cause new problems? | Re-insertion rate, urinary retention episodes, staff workload perception |
| Prediction | What you expect to happen | Utilization will fall by about a third with no increase in re-insertions |
| Data collection | Who collects what, when and how | Champions record daily catheter counts and indications; infection prevention provides CAUTI data; results are plotted weekly |
| Timeline and resources | Gantt chart; costs | 2 weeks of preparation, 8 weeks of testing; printing and staff time |
| Ethics and approval | Approvals and privacy | Facility QI approval and an IRB determination of non-research; de-identified, aggregate data only |
Part II: Do
In the Do stage, you carry out the test as planned, on a small scale, and document everything, including problems and surprises.
- Implement the change for the agreed period and setting.
- Collect data on the outcome, process and balancing measures exactly as planned.
- Keep a log of observations: what went well, barriers, staff feedback and unexpected events.
- Note any deviations from the plan and the reasons for them.
Worked example: During the first two weeks on day shift, champions reminded nurses at the 10 a.m. huddle to complete the indication checklist. Nurses removed 14 catheters without an appropriate indication. Two barriers emerged: night shift did not know about the protocol, and some catheters placed in the emergency department had no documented indication. One patient needed a straight catheterization for retention after removal, which was managed with the bladder scanner protocol.
Part III: Study
In the Study stage, you analyze the data, compare results with your predictions, and summarize what you learned.
- Plot data over time on a run chart, the standard QI tool for seeing whether a change led to improvement (Perla et al., 2011).
- Apply run chart rules, such as a shift of six or more consecutive points on one side of the median, or a trend of five or more points steadily rising or falling, to detect non-random change.
- Compare outcome, process and balancing measures with your predictions.
- Reflect on why the results occurred: barriers, facilitators and staff feedback.
Worked example (illustrative results): The catheter utilization ratio fell from a baseline median of 0.30 to about 0.20 by week 8, meeting the aim. Checklist completion rose to 85% on day shift but stayed lower at night. No CAUTIs occurred during the test period. Over a short period, however, CAUTI is a rare event, so the process measure is the more sensitive indicator. Re-insertions did not increase. The prediction was largely confirmed, and the learning was that night shift and the emergency department needed to be involved.
Part IV: Act
In the Act stage, you decide what to do next based on what you learned:
| Decision | When to choose it |
|---|---|
| Adopt | The change worked as predicted: standardize it and spread it |
| Adapt | The change partly worked: modify it and test again in a new cycle |
| Abandon | The change did not work or caused harm: stop and test a different idea |
Then plan the next PDSA cycle. Successive cycles typically increase the scale (more shifts, more units), the confidence in the change, and its integration into routine practice.
Worked example: Adapt and expand. Cycle 2 will add night shift, with the protocol added to shift handoff, and partner with the emergency department to require a documented indication at insertion. If results hold, Cycle 3 will spread the protocol to a second medical unit. For sustainability, the protocol will be written into unit policy and the EHR order set, unit champions will continue monthly audits, and results will be shared at staff meetings and the quality committee.
PDSA plan template
| Section | Key prompts |
|---|---|
| Plan: problem identification | What is the problem? Where is the evidence it exists (local and national data)? Why does it matter? What are the root causes? |
| Plan: review of literature | What does the best evidence recommend? What is the level and strength of that evidence? |
| Plan: PICO(T) | What is the focused question guiding the change? |
| Plan: the process | What is the SMART aim? What change will be tested, by whom, where and when? Which outcome, process and balancing measures? What do you predict? How will data be collected? |
| Do | Was the test carried out as planned? What problems and observations occurred? |
| Study | What do the data show (run chart)? How do results compare with predictions? What was learned? |
| Act | Adopt, adapt or abandon? What will the next cycle test? How will the change be sustained and spread? |
Common mistakes to avoid
- Starting with a large, organization-wide change instead of a small test.
- Skipping predictions, which makes it impossible to learn from the Study stage.
- Collecting data only before and after, instead of over time on a run chart.
- Measuring only outcomes and ignoring process and balancing measures.
- Stopping after one cycle. Improvement usually needs several linked cycles.
- Not involving frontline staff and stakeholders from the start.
- Calling a QI project “research.” Use QI language and obtain the appropriate approvals.
Conclusion
A PDSA practice improvement plan turns evidence into real change through small, rapid, data-driven tests. In the Plan stage, identify and validate the problem, review the literature, write a focused PICO(T) question and design the process, with a SMART aim, measures and predictions. In Do, carry out the test and document what happens. In Study, analyze the data on a run chart and compare it with your predictions. In Act, adopt, adapt or abandon the change and plan the next cycle. Repeated cycles build the evidence and staff buy-in needed for lasting improvement. Write up your final project using the SQUIRE 2.0 guidelines (Ogrinc et al., 2016). See also our guides on the Quadruple Aim and its measures and developing a capstone project from practicum experience.
References
Gould, C. V., Umscheid, C. A., Agarwal, R. K., Kuntz, G., Pegues, D. A., & Healthcare Infection Control Practices Advisory Committee. (2010). Guideline for prevention of catheter-associated urinary tract infections 2009. Infection Control & Hospital Epidemiology, 31(4), 319–326. https://doi.org/10.1086/651091
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Meddings, J., Rogers, M. A. M., Macy, M., & Saint, S. (2010). Systematic review and meta-analysis: Reminder systems to reduce catheter-associated urinary tract infections and urinary catheter use in hospitalized patients. Clinical Infectious Diseases, 51(5), 550–560. https://doi.org/10.1086/655133
Ogrinc, G., Davies, L., Goodman, D., Batalden, P., Davidoff, F., & Stevens, D. (2016). SQUIRE 2.0 (Standards for QUality Improvement Reporting Excellence): Revised publication guidelines from a detailed consensus process. BMJ Quality & Safety, 25(12), 986–992. https://doi.org/10.1136/bmjqs-2015-004411
Perla, R. J., Provost, L. P., & Murray, S. K. (2011). The run chart: A simple analytical tool for learning from variation in healthcare processes. BMJ Quality & Safety, 20(1), 46–51. https://doi.org/10.1136/bmjqs.2009.037895
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan–do–study–act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290–298. https://doi.org/10.1136/bmjqs-2013-001862
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