Appendix D. PDSA Worksheet

AHRQ Safety Program for Long-Term Care: HAIs/CAUTI

The purpose of this worksheet is to develop, document, and test small changes, through the use of the Plan-Do-Study-Act (PDSA) cycle, that lead to improvement in areas that your team has identified. A circular diagram showing the cycle from plan, do, study and act.

Using PDSA To Improve Performance

Upon identifying opportunities for improvement, develop and execute a plan to improve performance using small tests of change. The following section provides a step-by-step example of a PDSA cycle as one of many valuable performance or process improvement tools you may implement to systematically address opportunities for improvement your team has identified. Visit AHRQ Web site for more detailed information on the PDSA cycle.

Below is a sample worksheet you may use as a reference to document a PDSA cycle:

Date: Name of organization: Cycle #:
Aim: What are you trying to accomplish?

Improvement in staff knowledge related to:

Indwelling urinary catheter (IUC)

☐ Clinical indications for an IUC

☐ Alternative supplies and procedures to using a IUC

☐ IUC removal

☐ IUC maintenance and care

☐ IUC insertion procedure

What is the measurable outcome that you want to see?

The plan should address your identified aim that is listed above. In this section, consider the steps in the plan as well as resources required—both people and materials—and how you will measure your implementation of your interventions.

What actions must be in place for you to achieve the above goal?
The plan is to:


What are the individual steps required for you to implement your plan?
The steps in the plan are:


Who needs to be involved in the different steps of your plan?
The people involved in the plan are:


How long will it take to implement the steps of the plan?
The steps in the plan will be implemented by (list dates for individual steps):


What will you measure to determine if the goal was achieved?
The knowledge questionnaire will be administered (list timeframe or date):



Once the plan is developed, it must be executed.

What did you observe?


What were some challenges and/or surprises during the process?



Spend some time analyzing your results. Monitor progress on each opportunity for improvement regularly.

How did the measured results compare to your predictions?


Why do you think we scored high or low in these areas? Do any of the results surprise you?


What ideas do you have for potential solutions?


What are some next steps we need to take to improve our knowledge and practice?



Based on your findings, adjust, adapt and/or implement on a larger scale. Once you have completed a cycle, take a look at the data and see what, if any, changes need to be made.

What are some adjustments that need to be made?


What did you conclude from this cycle?


What is the focus of the next cycle?



Page last reviewed March 2017
Page originally created March 2017
Internet Citation: Appendix D. PDSA Worksheet. Content last reviewed March 2017. Agency for Healthcare Research and Quality, Rockville, MD.