Start by reviewing the possible root causes for the event described in your RCA. Come to a consensus on ONE of the possible root causes for application of the PDSA.

· Apply the steps of PDSA quality improvement framework to the selected root cause of the RCA.

Plan: The planning phase involves defining the problem and deciding on the desired outcome. The problem observed was the lack of visitation by friends and families to see their love ones in the nursing home. The plan of action would ensure that friends and families would be able to see their love ones more frequently, which would lead to improving the quality of life for the residents. Setting measurable goals is essential to be able to design your implementation and assess progress. Example: Residents will be able to see their loved ones once a week at least.

Do: In this phase, the plan is being carried out and making the desired changes to the process. Transportation was provided by the facility for the families and friends to visit their love ones. A schedule was implemented for various times throughout the day when friends and families were picked up by a designated driver who transported them to the facility to visit their loved ones.

Study: In this phase, the impact and outcome of the implemented changes are reviewed to find out the results of the changes and if the desired outcome was achieved. In this case, the facility used satisfaction surveys from the residents, families, and friends to track the performance measures. They also used a transportation statistics and kept a time line.

Act: The final phase involves making decisions whether to keep the changes implemented as is or to further make any necessary changes to improve the plan. In this case, the facility found out that the outcome of the initiative was very positive and has surpassed the initial goals. As a result, there was a 50% increase in family and significant other visitations and a 10% to 30% increase in customer satisfaction for residents, families, and the community. With such a success, the facility was able to develop and implement a long-term plan in order to reveal if there are any deteriorations affecting performance in the future.



Organization and Clarity

· Well-organized

· Easy to follow



· Definition of the PDSA model

· Clinical example clearly articulated

· Each area of the PDSA identified and discussed in the clinical example

· Group equal participation from members (affects individual members)


APA Format

· Conclusion includes synthesis of the main points

· Reference page with a minimum of three citations, must be from a peer reviewed journal 10 years old