Newsletter Article

Aug 5, 2022



What is the Plan-Do-Study-Act (PDSA)?

Quality Improvement efforts are intended to support clinics in the delivery of care that is safe, timely, effective, and efficient. However, the QI process can prove to be daunting, labor-intensive, and burdensome at times. Sometimes key players are left out of discussions and decisions regarding improvement efforts. By involving staff, we allow all who are involved to feel empowered by better understanding the “WHY.” When we help them understand the “WHY,” they tend to be more invested and engaged.

The PDSA method is an organized way to test a change that is implemented to improve processes and quality. The 4-step PDSA protocol guides us to break down the task, evaluate the outcome, improve on it, and then repeat if necessary or adopt the changes we have made. If you think about it, we often use this methodology in our personal lives and don’t even realize it.

Let’s get into the details:

Plan: (this is where the bulk of your efforts are spent)

  • I plan to:
  • I hope this produces:
  • Steps to execute:
  • What is the time frame?


  • What did you observe?


  • What did you learn?
  • Did you meet your measurement goal?


  • What did you conclude?
  • Will you adopt, adapt, or abandon this cycle?

A well-conducted PDSA promises learning, but it does not and cannot promise that you will achieve your desired outcomes. That is the beauty of the flexibility and adaptability of this model. If at first you don’t succeed, adapt your plan, and try again.

Now that you know what PDSA is, you may be asking yourself, “How do I start?”

First, you need to involve the team in a discussion about what needs to change or improve in your clinic. Get buy-in by gathering feedback and ideas. You will find out just how valuable the input from your team can be. Don’t set unattainable goals!

Once you choose your initiative, measure your baseline, and set a goal. Keep this initiative small in scale and your goals achievable. Consider any improvement a WIN! There are many resources available to help you get started on this new journey to quality improvement, including a PDSA worksheet, available on our website –  Login to the provider section and the worksheet will be under Accreditation Programs Documentation/PCMH.

We also have information on our website about a platform called LAKE (Learning and Knowledge Exchange) that provides wonderful guidance and a template library. If you need more direction or have questions, contact Kristen Ogden, Director of Quality Improvement at or by phone at 417-631-2942.

IMPORTANT: Existing providers with PCMH Accreditation, please take note that there have been significant changes to PCMH 4.0 and 6.0. Starting in the third quarter of 2022, you will no longer be required to submit data to TCT through the website. Instead, we will be reviewing your quarterly PDSA projects upon reaccreditation.  For the most updated version of the standards, download the standards from the website.

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