Action-Oriented Learning: Plan–Do–Study–Act
No plan survives its first contact with reality, particularly those that aim high. And especially in a complex environment like a hospital there will always be unforeseen glitches when trying something new. But you can start small and scale quickly by using rapid cycles of action-oriented learning. A great way to do this is by using the popular plan–do–study–act (PDSA) model.
Start by planning (plan) your intervention, and then test (do) it. The next step (study) is critical. Observe the test yourself, paying close attention to competing demands and physical space. Most important, ask those involved in the test what worked, what did not, and listen carefully. Ask them for alternative ideas, pitch your own, and talk it out. The idea is to get a read on what could or should be done differently from how your team originally planned it. The last step is to set things up to do better next time (act).
The following table highlights the advantages of PDSA and provides principles for doing it well.
Advantages of PDSA and Principles for Success
Advantages of PDSA |
- Allows valuable modifications to improve effectiveness or preserve productivity.
- Allows “failures” to come to light without undermining performance and momentum.
- Identifies areas of resistance that might undermine spread to other units.
- Allows costs and side effects of the change to be assessed.
- Increases certainty that change will result in improvement.
- Allows for detailed documentation of improvement.
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Principles for Success |
- Start new changes on the smallest possible scale, such as one patient, one nurse, one doctor.
- Run just as many PDSA cycles as necessary to gain confidence in a change, then spread incrementally.
- Spread incrementally to more patients, then more nurses, then doctors, and finally units.
- Balance changes within the overall system to ensure other processes are not adversely stressed.
- Pay special attention to preserving productivity and work flow.
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Whoever observes and studies the test should record lessons and the suggested tweaks. These should be shared at the next multidisciplinary team meeting.
The IHI has a preprinted PDSA Worksheet you may find helpful to download.
Plan–Do–Study–Act Worksheet for Testing Changes
Aim — Describe the aim of this project
— Every aim will require multiple smaller tests of change
— Describe your first (or next) test of change
— Person Responsible
— When to be done
— Where to be done
Plan — List the tasks needed to set up this test of change
— Person Responsible
— When to be done
— Where to be done
— Predict what will happen when the test is carried out
— Measures to determine if prediction succeeds
Do — Describe what actually happened when you ran the test
Study — Describe the measured results and how they compared
to the predictions
Act — Describe what modifications to the plan will be made for the
next cycle from what you learned
On to Specific Interventions
As we continue this section, we will assist you in constructing a series of algorithms and protocols for your institution, addressing subcutaneous insulin regimens, IV insulin infusion, transitions, perioperative settings, monitoring programs, and educational programs that will support your efforts. Return to these introductory sections on interventions periodically to make sure you are leveraging the algorithms and protocols to the fullest extent possible.
On the next several pages, we’ll start picking a preferred subcutaneous insulin strategy for several different situations and begin building an algorithm for your institution. We will be presenting acceptable options for each situation (excerpted from an excellent ADA technical review on inpatient diabetes care) to help you as you flesh out your own algorithm.
*Adapted from Clement S, Braithwaite SS, Magee MF, et al. Management of diabetes and hyperglycemia in hospitals. Diabetes Care. 2004;27:553–591.
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