Implementation and Improvement are two fields of science that overlap and have unique characteristics and language. 

When a new practice or program doesn’t seem to be working as hoped, organizations may find it tempting to change course as quickly as possible to “fix it.” All too often, changes are enacted without careful planning – ultimately leading to confusion, frustration, and sometimes prematurely abandoning an innovation altogether. Plan-Do-Study-Act (PDSA) cycles are a tool used in both implementation and improvement science with the power to rapidly identify an issue and a needed change, measure the impact, and make an informed plan to improve.  

Those in the fields of both implementation and improvement science may consider:  

• How can we come together in partnership to help organizations use implementation and improvement research to strengthen use of both sciences?
• The fundamental functions of PDSA cycles so that the unique language and terms do not hinder their understanding and effective use. 

PDSA Cycles: Function and Use

What is a PDSA cycle exactly? It is an iterative model for continuous improvement that aims to identify barriers and needed changes in implementation and outcome efforts. PDSA cycles allow implementation teams to think critically about a program or practice and plan for improvements that will lead to better outcomes. The cycle consists of four steps repeated over time: 

• Plan: During the planning stage, the implementation team uses multiple data points to identify challenges, desired outcomes, necessary changes, and methods to measure progress.
• Do: The team carries out the activities in the plan to test the proposed changes in action.
• Study: After carrying out the plan, the team examines data collected by their identified measurement methods to study what happened and assess progress. 
• Act: The team then makes subsequent changes to the next iteration of the plan, and the PDSA cycle begins again.

While there are notable differences, both fields of science actively engage people with direct experience of an issue on the ground with champions who have the authority to resource systems-change for sustainability.  

Three common ways to use PDSA cycles by implementation and improvement scientists and specialists are outlined below. 

Improvement Cycles (NIRN, 2022)	Improvement Guide (Langley et al., 2009)
1. Rapid Cycle Problem Solving is used to address immediate and pressing problems quickly. The process is transparent The information is sufficient to measure, identify, and solve problems within the system  To remove barriers and improve resources for implementation  resource improvements of team and practitioner practice.	1. Build knowledge to answer any one of the three Model for Improvement questions: What are we trying to accomplish?  How will we know that a change is an improvement?  What change can we make that will result in improvement?
2. Usability Testing to measure the feasibility and impact of a new way of work on a small scale. A planned series of sequential tests (3-5), to inform policies and procedures to enable practice, prior and during implementation to successfully roll it out more broadly in the larger system.	2. Test a change sequentially, in a small scale in a learning loop  using broad concepts to set the context for all of the smaller cycles in the larger system.
3. Practice Policy Feedback Loops to provide organizational leaders and policymakers policy makers with information about implementation barriers and successes from practice. A method for scaling or extending the reach of a practice?	3. Implement a change in a narrow sense, activities after the testing shows change is positive and leads to improvement Before spreading and to support the more permanent nature of the effort.

In the field, there are people and organizations that strongly hold to one discipline or another; others that want to blend the two sciences. We believe at NIRN that it is critical to success of implementation, to use the science of improvement. Within improvement work, the intentional use of PDSA testing is to learn if a change resulted in improvement of the identified aim or outcome. When using PDSA cycles in implementation work, we focus on how to make the change an integral part of the system, simultaneously measuring implementation outcomes e.g., (measuring training, coaching, and fidelity to practice) and improvement of identified aim or population outcome. Within both improvement and implementation the approach is to start small with a narrow scope to ensure infrastructure is in place to support sustained change and improvement with a system ready to support spread/scale.

For example, at NIRN, when a problem/opportunity and its contributing factors are identified based on data, we know an organization can't keep pushing on, they have to stop and solve the barrier.  At NIRN we integrate the use of implementation research and PDSA Cycles from day one using the Active Implementation Frameworks (AIFs) to determine the missing ingredients in a small, representative slice of the system, to test a change using implementation and outcome factors, before scaling it more broadly. 

We ask:

• Are teams developed and fully functioning at the required levels of the system?
• Are champions visible and active for implementation of the needed change?
• Do we have a communication plan developed and being used to gain acceptability for adopting and spreading the process at the local level?
• Are the practice and system for improvement clearly defined and operationalized so it can be measured and monitored?
• Are the systems for participant selection, training, coaching, and data use developed and continuously improved; and,
• Are we attending to what activities are needed when in the implementation process to ensure readiness of the community, individual staff, and the organization?  

Here is an example from Improvement Science. Numerous tools are available to support the use of PDSA cycles such as planning forms, data visualization tools to support decision making, and many more. Two data visualization tools we find particularly useful are Shewart and Run Charts. These charts are used intentionally in a structured process to use data to determine if a change is an improvement to:

• Monitor variation over time
• Look for patterns
• Help assess whether a change is an improvement to distinguish a signal vs noise in the data using four rules:
  • Shifts: 6 or more points above or below the median
  • Trends: 5 consecutive data points all going up or down
  • Too many or few runs: a random pattern in the data
  • Astronomical data point: a data point blatantly different

Chart 1: Sample Run Chart

In both sciences we ask, if a change was not an improvement, why not using three simple questions?

• What are we trying to accomplish? 
• How will we know that a change is an improvement? 
• What change can we make that will result in improvement?

Knowing the basic similarities and differences between the two sciences can foster an honest discussion regarding how PDSA Cycles can be used in your organization to continuously improve implementation systems, fidelity of practice, and population outcomes. Listening empathetically and observing what is already in place and what is needed for improvement can lead to actionable steps and a collective commitment to a disciplined approach for using PDSA Cycles in your organization.

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Resources

To learn more about Run Charts and how to present your data visit: Creating a Run Chart: How to Present your Data

Learn more about the history of PDSA Cycles:

• The History and Evolution of the PDSA Cycle
• The origins and theory of PDSA cycles

If you are interested in learning more about Improvement Cycles, check out the book, The Improvement Guide: A Practical Approach to Enhancing Organizational Performance. Langley et al. provide a PDSA Form and Checklist (pg, 446-451) for each component of the PDSA process. A project planning form describes the change and objective (learn, test, implement). Then a checklist for each phase is provided specific to the phase activities.

Check out more from NIRN to continue your learning:

• NIRN PDSA Planning Template: Plan-Do-Study-Act (PDSA) Cycles are used for rapid cycle problem solving in active implementation. Use of this PDSA Planning Template will help ensure there is clear communication, the plan is enacted, you begin to collect data to study, and you act on what was learned from that data.
• Identifying Champions and Cultivating Leadership: The importance of champions and leadership to implementation efforts cannot be understated. This lesson and template will support teams to identify and cultivate leadership and champions for change efforts.
• Communication: A carefully designed and used Dissemination (communication) Plan validates how stakeholders are included in the development of the organization's implementation capacity for systemic change “so everyone can see they have a role to play.”
• NIRN Active Implementation Hub - Lesson 6: The PDSA Cycle