PDSA cycles and quality improvement plans: how to plan, test and evidence each improvement

Regulation 17 (good governance) requires every registered provider to run systems that work in practice, not just on paper, so it can “assess, monitor and improve the quality and safety of the services provided”. It also requires you to seek and act on feedback “for the purposes of continually evaluating and improving such services”.

CQC’s guidance on the regulation spells out what that means for a plan. Providers “must monitor progress against plans to improve the quality and safety of services, and take appropriate action without delay where progress is not achieved as expected”. They must be able to show that improvements were made, and the system must include “scrutiny and overall responsibility at board level or equivalent”.

Three of CQC’s quality statements turn on improvement:

• Learning culture (Safe). Lessons are learned from safety incidents or complaints, “resulting in changes that improve care for others”.
• Governance, management and sustainability (Well-led). “Information is used effectively to monitor and improve the quality of care.”
• Learning, improvement and innovation (Well-led). “Staff and leaders have a good understanding of how to make improvement happen. The approach is consistent and includes measuring outcomes and impact.” People who use the service, their families and carers are involved in developing and evaluating improvement.

The framework is changing. CQC plans to replace the quality statements with key lines of enquiry in new frameworks for each sector. It planned to publish the final frameworks in summer 2026 and start using them at the end of the year; as at 6 November 2026, we haven’t seen them published. Our well-led guide covers what CQC looks for in governance.

If CQC finds a breach of the regulations but people aren’t at immediate risk of harm, it may ask you for a report. It now calls this an Action Plan Request; it used to call it a Requirement Notice. The report must show how you’ll comply and what action you’re taking, within a timeframe CQC judges reasonable. CQC can reject a plan that doesn’t address the issues, and not sending the report within its timescale is an offence.

When CQC asks for a report under Regulation 17(3), you have 28 days, starting the day after you receive the request, and the report covers your plans for improving the service. Adult social care services rated Requires Improvement more than once can be asked for an improvement action plan within 28 days. CQC’s adult social care guidance also asks providers to tell it in writing when they’ve completed the actions.

Rated Requires Improvement? Our recovery guide covers the steps from the draft report to the re-inspection.

A PDSA cycle tests a change on a small scale so you learn what works before you roll it out everywhere. NHS England’s improvement guide says PDSA cycles let you “test out changes on a small scale, building on the learning from these test cycles in a structured way before wholesale implementation”. The cycle began as Plan, Do, Check, Act, introduced by Walter Shewhart in the 1920s, and became the basis of W. Edwards Deming’s approach.

The Institute for Healthcare Improvement (IHI) names three choices at the Act stage on its PDSA worksheet: adapt (change the idea and test again), adopt (test it on a larger scale) or abandon (stop testing this idea). In the IHI’s usage, adopt means a bigger test; making a change permanent is what it calls implementing.

Start very small. NHS England’s example is to begin “with one patient or one clinician at one afternoon clinic and increase the numbers as you refine the ideas”. Most changes need several cycles in a row, and the guide asks you to record each one “to capture the learning and to demonstrate the improvement journey”.

A care home’s monthly medicines audit keeps finding gaps in the evening medication records.

• Plan. Will a second staff member checking the records at the end of the evening round cut the gaps? The prediction: fewer gaps on the unit that tries it. The team agrees to test it on one unit for two weeks and count the gaps each night.
• Do. The unit runs the check, counts the gaps and notes what got in the way, such as a busy handover.
• Study. The team compares the count with the two weeks before and with the prediction, and writes down what it learned.
• Act. If the check worked, the team tests it on more units (adopt). If it half worked, it changes the timing and tests again (adapt). If it didn’t help, it stops and tries another idea (abandon).

The IHI names three types of measure, and NHS England’s guidance adds a fourth:

The IHI suggests tracking a set of measures, typically 4 to 10. NHS England’s guide asks project teams to report progress monthly on charts over time, known as run charts or statistical process control (SPC) charts, and says the measures are “tools for learning and demonstrating improvement, not for judgement”.

Every US nursing home must “develop, implement, and maintain an effective, comprehensive, data-driven QAPI program” (quality assurance and performance improvement) under 42 CFR 483.75. It must present its QAPI plan to surveyors at each annual recertification survey, run at least one improvement project a year on a high-risk or problem-prone area, and have a quality assessment and assurance committee that meets at least quarterly and writes plans of action to correct quality deficiencies. The Centers for Medicare & Medicaid Services (CMS) describes QAPI in five elements, from design and scope to systematic analysis and systemic action. Hospitals have their own QAPI rule; our healthcare QMS guide covers it.

ISO 7101:2023, the international standard for quality management in healthcare organisations, is built on the same cycle. Its final draft maps Plan to clause 6, Do to clauses 7 and 8, Study to clause 9 and Act to clause 10, improvement: “take actions to continually improve”. Our ISO 7101 guide covers what it requires.