You are visiting us from Virginia. You are located in HHS Region 3. Your Center is Central East ATTC.

Change Project 911: When Your Rapid-cycle PDSA is not Working

Change Project 911 logo

Mat Roosa, LCSW-R
NIATx Coach

Rapid-Cycle Plan-Do-Study-ACT (PDSA) is a powerful tool for improvement that can enable a team or organization to achieve its short-term goals and move toward long-term success. But sometimes, PDSA change cycles do not yield the desired results.

Here are a few questions to consider when your change project does not achieve the goal.

What are the lessons learned from “failure”?

Rapid-Cycle PDSA has been called a “no-fail” method. The lessons learned from change that does not achieve the desired result can yield as much information as a highly successful change project. Finding out what does not work enables a team to avoid future investments in ineffective strategies and focus on efforts with a high return on investment.

Was the goal realistic?

We often recommend a “stretch goal” for a project that pushes the team toward a result that might seem unattainable. Stretch goals can energize a team toward greater achievement. However, sometimes a lack of information or an overabundance of enthusiasm can result in an unattainable goal. Recalibrating the goal toward a more realistic expectation can clarify the level of success the change achieved. 

What does the early data tell us?

Some change teams make the mistake of waiting until the “Study” phase of PDSA to look at the data collected. However, an initial review of the data during the “Do” phase may uncover the need to restructure the change or reconsider the data plan. These adjustments can rescue some change projects from heading too far in the wrong direction.

Are we experiencing unexpected variables?

Confounding variables can have a big impact on change project results. Teams should conduct some form of environmental scan to consider factors such as seasonal events, economic trends, political or social events, changes in staffing, or other variables affecting the people being served or the people providing the service.

Was our aim statement hypothesis correct?

Increase A from B to C by date D through strategy E.

Teams can consider a number of assumptions related to this equation when a change project is not yielding the desired results:

  • Is E actually a primary driver of A? Perhaps other strategies will have a better impact on the thing that we are trying to change.
  • Is C too high? See our discussion of realistic goals above.
  • Do we need more time? An adjustment to D may allow the change to unfold in a manner that creates better understanding of the impact of the change, or achieves greater results.
  • Is A the key indicator of success? Are we measuring the right thing? Maybe there are better ways to understand the impact of strategy E. Maybe we are having an effect on a different goal.
  • Is our data source valid and reliable? Is our chosen measure giving us accurate information about the thing that we are seeking to change? Are all participants following the measuring and reporting process consistently? Sometimes participants in the data collection process have a different interpretation of the data collection rules. (Oh, I thought we were only counting attendance for people who showed up on time…etc.)   

Rapid-cycle change projects should always yield valuable results, even when they do not achieve the desired goal. Taking some time to consider the questions above will result in more reliable results that can serve as a compass to guide your ongoing change project journey.  


About Change Project 911

Change Project 911 is a monthly blog post series covering common change project barriers and how to address them. Has your change project hit a snag that you’re not sure to tackle? Share your issue in the comments section below, or email Change Project 911 at [email protected]’ll offer solutions from our team of change project experts!

About our Guest Blogger

Mat Roosa was a founding member of NIATx and has been a NIATx coach for a wide range of projects. He works as a consultant in quality improvement, organizational development and planning, and implementing evidence-based practices. His experience includes direct clinical practice in mental health and substance use services, teaching at the undergraduate and graduate levels, and human service agency administration. You can reach Mat (Change Project SOS) at [email protected].

Recent posts
Whether you're a seasoned NIATx expert or just beginning your NIATx journey, we have a challenge for you. Take this quick quiz to find out just how well you know this evidence-based process improvement approach!   Question 1:What does NIATx stand for? A) The Network for Improvement and Technical Excellence B) The Network for the […]
Information provided in this post comes from technical assistance provided by the Great Lakes ATTC in Manitowoc County, WI. Providers throughout the Great Lakes region and across the county have been making steady gains toward integrated mental health and substance use care. Providers have come to understand that co-occurring conditions (COD) are more the norm […]
The NIATx change model focuses on a sequence of four primary tools: After a walk-through, teams sometimes struggle to create a flowchart to map out the process they just examined. Whether you use a big sheet of paper and a marker, sticky notes on a dry-erase board, or any number of softwares, here are a […]
The Nominal Group Technique (NGT) is one of the essential tools that NIATx change teams use to implement successful change projects.

The opinions expressed herein are the views of the authors and do not reflect the official position of the Department of Health and Human Services (DHHS), SAMHSA, CSAT or the ATTC Network. No official support or endorsement of DHHS, SAMHSA, or CSAT for the opinions of authors presented in this e-publication is intended or should be inferred.