Table 1.

Examples of Abandoned Plan Do Study Act (PDSA) Cycles

Improvement PlannedStage of PDSA Cycle in Which Progress Was ArrestedParticipants InvolvedSymptoms Experienced
Design of new DM template for EHRPlanDiabetes improvement teamMultiple team members could not agree on the comprehensiveness of final template
BP medication complianceDoQI team, residentsCould not determine what to do; consensus
Pneumovax administration and trackingPlanQI team, one residentNot continued after resident champion graduated
Retinal screenings for diabeticsStudy, ActQI team, nursingCould not determine if first cycle worked or next plan of action
BP re-check reminder systemActQI team, one provider-nurse teamCould not expand to other providers
Advanced Access SchedulingStudyMedical director, QI teamCould not measure demand data reliably; quit trying after two attempts
Self management goal settingActQI team, nursingDid not spread beyond two physician/nurse teams
Microalbumin testing remindersPlanQI team, nursingNo agreement on standard protocol
A1c testing remindersStudyQI team, nursingNo follow-up data collection
BP Monitoring Standing OrdersPlanQI team, administration, nursingLack of consensus about roles, duties, content
Preclinic huddle participationActQI team, nursingSustainability was difficult and uneven

  • DM, diabetes mellitus; EHR, electronic health record; BP, blood pressure; A1c, hemoglobin; QI, quality improvement.