Evolving quality improvement support strategies to improve Plan–Do–Study–Act cycle fidelity: a retrospective mixed-methods study

Abstract

BackgroundAlthough widely recommended as an effective approach to quality improvement (QI), the Plan–Do–Study–Act (PDSA) cycle method can be challenging to use, and low fidelity of published accounts of the method has been reported. There is little evidence on the fidelity of PDSA cycles used by front-line teams, nor how to support and improve the method’s use. Data collected from 39 front-line improvement teams provided an opportunity to retrospectively investigate PDSA cycle use and how strategies were modified to help improve this over time.MethodsThe fidelity of 421 PDSA cycles was reviewed using a predefined framework and statistical analysis examined whether fidelity changed over three annual rounds of projects. The experiences of project teams and QI support staff were investigated through document analysis and interviews.ResultsAlthough modest, statistically significant improvements in PDSA fidelity occurred; however, overall fidelity remained low. Challenges to achieving greater fidelity reflected problems with understanding the PDSA methodology, intention to use and application in practice. These problems were exacerbated by assumptions made in the original QI training and support strategies: that PDSA was easy to understand; that teams would be motivated and willing to use PDSA; and that PDSA is easy to apply. QI strategies that evolved to overcome these challenges included project selection process, redesign of training, increased hands-on support and investment in training QI support staff.ConclusionThis study identifies support strategies that may help improve PDSA cycle fidelity. It provides an approach to assess minimum standards of fidelity which can be replicated elsewhere. The findings suggest achieving high PDSA fidelity requires a gradual and negotiated process to explore different perspectives and encourage new ways of working.

Quality improvement into practice

“…Employing an iterative process of testing change ideas— Adopting a theory of change which emphasises a continuous process of planning and testing changes, studying and learning from comparing the results to a predicted outcome, and adapting hypotheses in response to results of previous tests 89…”

Evaluating quality improvement at scale: routine reporting for executive board governance in a UK National Health Service organisation

“…Training should not overemphasise the conceptual simplicity of PDSA (Reed & Card, 2016). Achieving high fidelity in PDSA application as a QI method will require a gradual and negotiated process to explore different perspectives and encourage new ways of working (McNicholas, Lennox, Woodcock, Bell, & Reed, 2019). Collecting routine data on PDSA fidelity can aid conversations in this effort.…”

Enhanced Recovery after Intensive Care (ERIC): study protocol for a stepped-wedge cluster randomized controlled trial to evaluate the effectiveness of a critical care telehealth program on process quality and functional outcomes

“…These peer reviews conducted during mutual visits by colleagues promote the exchange of experience between professions and disciplines at ICU and focus on the systematic evaluation of the quality of an ICU's structure, its processes and outcome to secure the sustainability of the planned change processes in patient care. [35][36][37] Adherence to the intervention After the crossover date, the adherence to the intervention condition delivered by the ICU is monitored by the tele-ICU team. The login-times to the audio-visual communication are monitored by a distinct fleet management system resulting in an anonymous monthly performance report and show the connection times that enable to draw conclusions about the compliance of the caregivers both at the remote as well as at the tele-ICU.…”