How to Fill Out a PDSA Form: Template, Questions, and Run Charts

To fill out a PDSA form, work through its four sections in order: Plan (describe the change, predict what will happen, and set out who will do what, when, and how you’ll measure it), Do (run the test on the small scale you defined and record what actually happened), Study (compare the measured results against your prediction), and Act (decide whether to adopt, adapt, or abandon the change). Before you touch the four-phase worksheet, the Centers for Medicare & Medicaid Services (CMS) template asks you to answer three framing questions about your aim, your measure, and the change you want to test. Those answers set the boundaries for everything that follows.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

Where to Get a Template

CMS publishes a free PDSA cycle template as part of its Quality Assurance and Performance Improvement (QAPI) resources. The Institute for Healthcare Improvement (IHI) publishes a similar one-page worksheet that condenses the same structure into a more compact format often used in training. Both are available as downloadable PDFs at no cost, and the underlying fields are the same whether you work from one of these templates or from a version your organization has built into its own quality management software.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

The Three Framing Questions

Answer these at the top of the form before you move into the cycle itself.

What are we trying to accomplish? Write a clear aim statement. A strong aim is specific, measurable, and time-bound: not “reduce falls” but “reduce patient falls on Unit 3B by 20 percent within 90 days.” The Administration for Children & Families recommends structuring aims around five elements: the direction of change (increase or decrease), the baseline, the target, the deadline, and the population or process affected.2Administration for Children & Families. Guiding CQI with SMART Goals

How will we know that a change is an improvement? Identify the specific metric you will track. It should be something you can collect reliably at regular intervals: a rate, a count, a percentage, a time measurement. Vague indicators like “staff satisfaction” need to be pinned to something countable, such as the score on a specific survey question.

What change can we make that will result in improvement? The CMS template prompts you to map your current process first, spot where breakdowns or delays happen, and then describe the single change you want to test. Resist testing multiple changes at once. You will not be able to tell which one caused the result.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

Plan

The Plan section is where most of the intellectual work happens, and where teams most often cut corners. You are building a miniature experiment, so treat it like one.

Start by writing the specific change you are testing in this cycle. Then write your prediction: what do you expect will happen, and why? Predictions force you to articulate your theory of cause and effect. A cycle without a prediction is just observation; you cannot learn whether your thinking was right if you never committed to a guess. Teams that skip this step tend to rationalize whatever result they get rather than genuinely learn from it.

Next, fill in the logistics. The CMS template asks: who will be involved, how long the test will take, what resources are needed, and what data will be collected.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form The IHI frames this as “who, what, where, when” plus a separate plan for data collection.3Institute for Healthcare Improvement. Model for Improvement: Testing Changes Either way, be concrete. “We will collect data” is not a plan. “Nurse Jones will record the time between call-light activation and room entry for every call on the day shift, Tuesday through Thursday” is a plan.

Finally, list your action steps in order, with the person responsible for each step and the timeline. This chronological list makes the test reproducible. If someone else picks up your form and tries to replicate the cycle, they should be able to follow the steps without calling you.

Keep the Test Small

Early PDSA cycles should be scoped as small as possible. The IHI recommends starting with one provider and one patient, or a handful of cases on a single shift, rather than rolling a change across an entire department.3Institute for Healthcare Improvement. Model for Improvement: Testing Changes Small tests fail cheaply and teach quickly. If your first cycle involves 200 patients and three departments, you have skipped testing and jumped straight to implementation, and if the change does not work the disruption is much harder to unwind.

Do

The Do section captures what actually happened when you ran the test. Carry out the plan on the small scale you defined, collect the data you committed to, and then write a narrative account of the experience. The CMS template asks you to describe what actually happened when you ran the test and to document observations, including any problems and unexpected findings.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

Two things deserve special attention. First, record any deviation from the original protocol. If you planned to test on the day shift but a staffing shortage pushed the test to the evening shift, write that down. It changes the conditions and therefore changes what the data means. Second, capture qualitative observations that the numbers alone would miss: a staff member’s workaround, a patient’s confusion about a new process, a piece of equipment that behaved differently than expected. These details often explain why the numbers came out the way they did.

This section works best as a straightforward chronological account. Do not interpret results here. That belongs in Study. Just document what happened with enough detail that someone reading the form months later can reconstruct the experience.

Study

Study is where you sit down with the data from the Do phase and compare it against the predictions you wrote in Plan. The CMS template asks you to determine whether the change produced the expected outcome, describe the measured results, and summarize what you learned, including unintended consequences, surprises, successes, and failures.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

Be honest about discrepancies. If you predicted a 20 percent reduction and got 5 percent, say so and explore why. The explanation matters more than the number. Maybe the change worked but only during certain hours, or maybe the measurement method was flawed. A “failed” prediction that generates a clear insight is more valuable than a “successful” one that teaches nothing.

Using Run Charts to Spot Patterns

If your test ran over multiple data points, a run chart (a simple line graph of your measure over time with a median line) can reveal patterns that summary statistics hide. Standard interpretation rules flag non-random variation worth investigating:

  • Shift: six or more consecutive data points all above or all below the median.
  • Trend: five or more consecutive points all increasing or all decreasing.
  • Astronomical point: a single data point that is obviously different from the rest, identified by judgment rather than a fixed rule.4NHS England. A Guide to Creating and Interpreting Run and Control Charts

You do not need sophisticated statistical software for this. A hand-drawn chart or a basic spreadsheet graph works for the small data sets typical of early PDSA cycles. Attach the chart to your form or paste it into the Study section so future readers can see the pattern you are describing.

Act

The Act section requires a decision about what to do next. The CMS template offers three options:

  • Adopt. The change worked as hoped. You are ready to expand it to additional staff, patients, shifts, or units.
  • Adapt. The change showed promise but needs modification. Describe the specific modifications and plan the next PDSA cycle to test the revised version.
  • Abandon. The change did not produce useful results or caused problems. Change your approach and test a different idea in the next cycle.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form

Whichever you choose, document your reasoning. A well-written Act section prevents the next team from repeating a test that already failed, or from re-debating a change that already proved effective. If you are adapting or abandoning, describe what modifications you plan to make for the next cycle. If you are adopting, outline the next steps for broader implementation. Even after a successful first test, the IHI recommends a series of progressively larger PDSA cycles rather than jumping to organization-wide rollout, varying the conditions each time to confirm the improvement holds.3Institute for Healthcare Improvement. Model for Improvement: Testing Changes

Common Mistakes

A few errors show up on PDSA forms repeatedly, and they are worth knowing before you start.

  • Confusing the aim with the cycle objective. The aim is the big-picture goal of the project (reduce falls by 20 percent in 90 days). The cycle objective is the specific learning goal of one test (find out whether a new rounding schedule reduces call-light frequency on the day shift). Each cycle should have its own objective tied to a specific learning question.
  • Skipping predictions. Without a prediction, the Study phase has nothing to compare against, and you end up describing data instead of analyzing whether your theory of change held up.
  • Testing too big. If the first cycle involves an entire department or lasts a month, it is not a test but an uncontrolled implementation. Start with the smallest meaningful sample and expand from there.
  • Not planning data collection in advance. Deciding what to measure after the test is over leads to scrambling for data that may no longer be available. Specify the metric, the collection method, and the responsible person in the Plan section before the test begins.1Centers for Medicare & Medicaid Services. Plan-Do-Study-Act (PDSA) Form
  • Rushing from Do to Act. Teams under time pressure sometimes skip Study entirely, jumping from “we ran the test” to “let’s implement.” The analysis phase is where the learning happens. Without it, the cycle is just trial and error.

Storing the Completed Form

Keep completed PDSA forms in a centralized location: a quality improvement database, a shared drive, or a binder in the QI office. The point is retrievability. When a team proposes a new test, the first thing they should do is check whether someone already ran a similar cycle. When an auditor asks how you documented a process change, you need to find the form quickly.

No single federal rule dictates how long you must retain PDSA worksheets specifically, but related CMS guidance offers useful benchmarks. Quality Improvement Organization review documentation must be retained for six years from the date services were furnished for confirmed quality concerns and negative determinations.5Centers for Medicare & Medicaid Services. Quality Improvement Organization Manual State record retention requirements for healthcare facilities vary, with most falling in the range of five to ten years for administrative quality records. Your organization’s compliance or records management office can confirm the applicable retention schedule. When in doubt, keep them longer. Storage is cheap, and a missing form during an audit is not.