Tuesday, 10 January 2012

Time to retire the PDSA cycle?

We are told that the Deming (or Shewhart) cycle of Plan-Do-Study-Act, originally described in 1950 as a quality improvement tool, can help in the following ways:

"Using PDSA cycles enables you to test out changes before wholesale implementation and gives stakeholders the opportunity to see if the proposed change will work." NHS Institute of Innovation and Improvement

"The Plan-Do-Study-Act (PDSA) Worksheet is a useful tool for documenting a test of change." Institute for Healthcare Improvement

It is sold as a 'scientific method' dating back to Galileo and Francis Bacon.

I beg to differ.

I think it is not fit for its wider purpose promoted by its proponents as part of a culture of overall quality improvement in healthcare.

It is good at improving the issue that it is targetting but only when it is in isolation. Seeing healthcare as an industrial process that consists of conveyor belts of treatment pathways that are separate from each other is not how I see the world. This PDSA cycle is good for manufacturing where the process can be controlled and isolated but healthcare is more complex. There are uncertainties about which patients should be on which pathways. Patients have more than one condition or require more than one treatment and the simple view of a PDSA cycle (which is good at improving car manufacture) is too simple for the real world of clinical medicine. Yes it can be used as a strategy for a single focussed task in medicine but it is not fit for using more widely as it is too dumb a tool for the job. In short it is a good 'in vitro' tool but not so good an 'in vivo' tool.

Also, the PDSA cycle may have unintended consequences. If, for example, on an emergency medicine unit we use PDSA cycles to improve our quality of care for community-acquired pneumonia patients this may have the unintended consequence of reducing quality (by de-prioritising) in other conditions such as acute stroke or anything that does not have its own PDSA cycle.

Is it time to recognise PDSA cycles for what they are; useful tools for focussed tasks but too simple an intervention to be used widely in medicine where it may do more harm than good?

1 comment:

  1. do you have any suggesetions for a better tool?