Disclaimer: Use of this tool is not mandated by CMS, nor does its completion ensure regulatory compliance.
Directions: Use this Plan-Do-Study-Act (PDSA) tool to plan and document your progress with tests of change
conducted as part of chartered performance improvement projects (PIPs). While the charter will have clearly
established the goals, scope, timing, milestones, and team roles and responsibilities for a project, the PIP team
asked to carry out the project will need to determine how to complete the work. This tool should be
completed by the project leader/manager/coordinator with review and input by the project team. Answer the
first two questions below for your PIP. Then as you plan to test changes to meet your aim, answer question 3
below and plan, conduct, and document your PDSA cycles. Remember that a PIP will usually involve multiple
PDSA cycles in order to achieve your aim. Use as many forms as you need to track your PDSA cycles.
Model for Improvement: Three questions for improvement
1. What are we trying to accomplish (aim)?
State your aim (review your PIP charter – and include your bold aim that will improve resident health
outcomes and quality of care)
2. How will we know that change is an improvement (measures)?
Describe the measureable outcome(s) you want to see
3. What change can we make that will result in an improvement?
Define the processes currently in place; use process mapping or flow charting
Identify opportunities for improvement that exist (look for causes of problems that have occurred –
see Guidance for Performing Root Cause Analysis with Performance Improvement Projects; or identify
potential problems before they occur – see Guidance for Performing Failure Mode Effects Analysis with
Performance Improvement Projects) (see root cause analysis tool):
Points where breakdowns occur
“Work-a-rounds” that have been developed
Variation that occurs
Duplicate or unnecessary steps
Decide what you will change in the process; determine your intervention based on your analysis
Identify better ways to do things that address the root causes of the problem
Learn what has worked at other organizations (copy)
Review the best available evidence for what works (literature, studies, experts, guidelines)
Remember that solution doesn’t have to be perfect the first time
PDSA Cycle Template
