PDSA
“The simple truth is that truth is hard to come by, and once found it may easily be lost again. Erroneous beliefs may
have an astonishing power to survive.” Conjectures and refutations: the growth of scientific knowledge. Karl Popper, 1959.
PDSA – Plan, Do, Study, Act – is the single most important element of continuous improvement. Everything else is
just a refinement of ‘how to’ do PDSA, or an element of enabling PDSA to take place.
We start with P for Plan.
A plan is an expression of a theory of the form ‘if we do X, then we expect the result Y’. We always have a theory –
but sometimes (often) it is not conscious. PDSA forces us to articulate our theory, to bring it into consciousness.
What are we trying to accomplish? And, importantly, how will we know if we have succeeded? The latter question
implies that we have some sort of way of measuring our present situation. The theory can range from the very
simple, that might take seconds to test (for example ‘if I ask the operator what is the biggest problem, I’ll get some
insight into an improvement opportunity’) through to the very complex (‘if we migrate our legacy IT systems into a
web based SOA platform, we’ll improve our flexibility and reduce our IT administration costs’) that may take years to
resolve.
D is for Do.
It is the stage for testing our theory. As far as possible, we want to test our theory before committing to large scale
action. This involves some classic quality tools that help us to understand our processes, and the analysis tools that
can help us to discriminate between assignable and common cause variation, and to stratify and tease apart the
various contributory factors to our outcomes.
S is for Study.
Study is where we process the information we have gathered. We are looking to see whether our theory holds
water. Noting the quote from Popper at the top of this page, it is powerful (but difficult) to focus our energies on
trying disprove our theories. Psychologically, we all have a tendency to look for evidence that confirms our theories.
This can lead to very costly errors when we come to implementation.
Freedom of expression in this stage is invaluable, but in most organisations it is a scarce resource. The IT analytics
folks refer to phenomenon of the HIPPO – the highest paid person’s opinion. The recent revelations around Toyota’s
woes points out that whilst Toyota espoused the credo that ‘No Problem’ is a problem, somehow the problem
persisted until they had to recall millions of vehicles.
A is for Act.
Act is the implementation point. We can apply a triage here to Adopt (theory validated, proceed with diligence),
Adapt (in the ball park, but needs refinement, cycle through and retest) or Abandon (oops, we got that one wrong,
back to square one). All of these outcomes are meaningful and honourable. What is dishonourable though, is to
adopt and invalidated theory, or to ignore the possibility to test the theory.
Further PDSA considerations
No one is saying you have to PDSA. There are no laws here. But if you don’t PDSA, you make it very hard to learn,
because you won’t be able to weed the beliefs out from your garden of truth.
Consider the following profoundly important implications for PDSA.

We will plan as well as we can, but we will inevitably miss things and make mistakes. PDSA is a commitment
to learn from things gone wrong.

PDSA creates a learning organisation. It is a system of continual study and adjustment. PDSA forgives a
mistake and prevents it from occurring over and over.

When studying a process that really exists, start with ‘Study’: How well is this working? What do the
customers say? What do the employees say? What does the data say?

PDSA can be applied to large efforts (annual strategic planning) or small efforts (purchasing office supplies).
It can be used on frequently turning cycles (opening up the building each day) to slow turning cycles (reacting to a once-in-a-hundred-years flood.
PDSA - CONTINUOUS IMPROVEMENT
ACT
Act
PLAN
ACT
Stud
STUDY
Do
DO
THIS APPLIES TO EVERYTHING WE DO
28/02/2013
PDSA - Tools and Techniques-05062011.pptx
The PDSA Approach To Continuous Process Improvement
1
Select an
improvement
opportunity
- Select, prioritise improvement
opportunity
- Review existing process goals
- Ensure process goal linked to
business strategy
2
4
3
Analyse
the current
situation
Form a team
- Select team members
- Establish rules
- Agree roles and responsibilities
- Adopt strategy
- Develop improvement plan
- Set objectives and measures
Take
improvement
action
- Develop action plan
- Re-design process
- Plan and implement action
- Agree and make process changes
- Create draft ‘To Be’ process map
- Select monitoring measures
- Describe (re-define) problemopportunity
- Identify immediate improvement
- Collect, analyse available data
- Develop ‘As Is’ process map
- Identify customer requirements
- Identify constraints
P
D
A
S
8
Plan for the
future
- Plan to address any further opportunities
- Review lessons learned
5
No
7
Review
7
improvement
strategy
- Review outcomes against objectives
- Review team and task processes
- Results documented
- Feedback given
6
Standardise
and
monitor
Yes
- Standardise procedures
- Plan for change and make it stick
- Establish clear process measures
- Everyone understands new process
- Establish periodic review points
Were
actions
taken
effective?
Study the
results
- Confirm actions achieved target
- Has process been improved?
- Degree of effectiveness?
- Reasons target not met understood
- Actions to be taken
Adapted from NIES Total Quality Management
The PDSA Approach To Continuous Process Improvement – Tools and Techniques
1
2
3
4
5
6
Identify -define
(redefine)
the problem
Collect data
- Select team
members
- Establish rules
- Adopt strategy
- Establish purpose
- Understand objectives
Analyse data
Establish causes
- Customer surveys
- Process map
- Pareto chart
- Check sheet
- Establish monitoring
- Pareto chart
- Control chart
- Cause and effect diagram
Prepare
Action plan(s)
Implement
Action plan(s)
- Action plan
- Force field analysis
- Cost-benefit analysis
- Training
- Cause & effect
diagram
- Histogram
- Scatter diagram
P
D
A
S
7
11
Collect data
Review outcomes
- Action plan
- Brainstorming
- Pareto chart
- Histogram
- Control chart
- Check sheet
- Standardise procedures
- Review team and Task processes
- Run chart
- Control system
No
10
Standardise and
Monitor solution
8
9
Yes
Were
actions
taken
effective?
Analyse data
1/03/2013
PDSA - Tools and Techniques-06192012.pptx
Act
We integrate the
lessons learned from
our Study. We reformulate
our theory. We adjust our
methods. We identify what
more we need to learn.
Study
We monitor the outcomes,
testing the validity of our
theory and plan. We study the
results for signs of progress
or success or unexpected
outcomes. We look for
new lessons to learn
and problems
to solve.
28/02/2013
Plan
We identify our
purpose and goals
We formulate our
theory. We define how
we will measure success.
We plan our activities.
Do
We execute our plan. We
undertaking the activities,
introducing the interventions,
applying our best knowledge
to the pursuit of our
purpose and goals.
PDSA - Tools and Techniques-06192012.pptx