Qsource Blog

Using the PDSA Cycle to Drive Practical Improvement in Nursing Homes

Written by Qsource | Feb 26, 2026 2:00:51 PM

Quality improvement in nursing homes works best when it is structured, measurable, and grounded in daily operations. One of the most effective tools for this work is the Plan Do Study Act cycle, often referred to as PDSA. This simple framework helps facilities test changes, evaluate results, and refine processes without disrupting care or overwhelming staff.

What the PDSA Cycle Is

The PDSA cycle is a continuous improvement method designed to test small changes in real time. It breaks improvement work into four clear steps:

  • Plan: Identify a problem, define a goal, and decide what change will be tested. This step includes determining who is involved, what data will be collected, and how success will be measured.
  • Do: Carry out the plan on a small scale. This may involve one unit, one shift, or a limited group of residents.
  • Study: Review the results. Compare outcomes to expectations, identify trends, and determine whether the change addressed the underlying issue or revealed new contributing factors.
  • Act: Decide next steps. The change may be adopted, adjusted, or abandoned based on what the data shows.

CMS expects nursing homes to use systematic, data-driven methods to identify, monitor, and improve care processes under the QAPI regulations (F865). The PDSA cycle is one of the primary tools facilities use to demonstrate ongoing performance improvement and leadership oversight.

 

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How Nursing Homes Apply PDSA

In nursing homes, PDSA cycles are commonly used to address clinical, operational, and regulatory challenges. Examples include reducing falls, improving infection control practices, strengthening documentation accuracy, or addressing repeat survey citations. Facilities often apply PDSA as part of their Quality Assurance and Performance Improvement (QAPI) work, testing changes on a small scale with real data before broader implementation.

This method supports interdisciplinary collaboration. Small-scale testing may include resident groups, CNA assignments, shifts, or hallways, allowing teams to learn quickly without disrupting facility-wide operations. Nursing, therapy, dietary, and administrative staff can participate in identifying issues and reviewing outcomes, which builds shared accountability and a sense of ownership in improvement work.

Benefits of the PDSA Process

The strength of the PDSA cycle lies in its practicality. It does not require large-scale changes or complex technology to be effective. Benefits include:

  • Encourages data-driven decision making rather than assumptions
  • Allows facilities to test changes without placing residents at risk
  • Supports staff engagement by involving frontline teams in problem solving
  • Creates documentation that demonstrates an active quality improvement program
  • Helps identify root causes instead of treating symptoms

Surveyors often look for evidence that a facility understands its challenges and is actively working to improve systems. Documentation of each PDSA cycle- including the goal, data reviewed, decisions made, and follow-up actions- helps demonstrate an active and effective QAPI program during survey. Even brief summaries can show meaningful improvement work over time. Well-documented PDSA cycles show thoughtful analysis, follow-through, and leadership oversight.

 


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Where the PDSA Cycle Fits in QAPI

PDSA is a central tool within a strong QAPI program, which is required for nursing homes and emphasizes data collection, performance measurement, and sustained improvement. Qsource supports facilities in developing or strengthening QAPI programs by providing tools, frameworks, and coaching that integrate PDSA and other performance improvement methods into daily operations. These resources help nursing homes formalize written plans, identify gaps in systems, and track improvements over time so they can consistently monitor results and sustain change. With a well-designed QAPI program, PDSA cycles become a foundation for measurable quality gains rather than isolated efforts.

How Qsource Helps Facilities Use PDSA and Improve Care

As a long-standing partner to nursing homes, Qsource offers practical support that aligns directly with quality improvement goals. Our consultants work collaboratively with facility teams to bring structure and clarity to improvement efforts.

  • QAPI Assistance: We help nursing homes design and implement effective QAPI programs that embed PDSA cycles into routine processes. Facilities get access to tools and templates that make planning, data collection, and trend analysis more manageable.
  • Clinical and Quality Improvement Consulting: When teams struggle to translate PDSA cycles into meaningful changes, our clinical experts provide guidance on choosing the right measures, interpreting data, and scaling successful tests across the facility.
  • Education and Training: Building competency in quality improvement methods is essential. Qsource offers tailored education that reinforces PDSA methodology and connects improvement tools to real regulatory and resident care expectations.
  • Root Cause Analysis and Strategic Planning: Many PDSA cycles begin with a deep look at why an issue exists. We guide facilities through structured root cause analysis and help translate insights into well-focused PDSA plans.

Our approach is collaborative, not one-size-fits-all. We work with facility leadership and frontline staff to build systems that fit the culture and capacity of the organization. This partnership fosters greater engagement and accountability, which are critical for long-term success.

 

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Long-Term Benefits of a Strong PDSA Practice

When used consistently and with support, the PDSA cycle becomes part of how a nursing home operates. Facilities that embed this process into meetings, performance dashboards, and staff routines are better prepared to respond to changing regulations, resident needs, and workforce challenges.

Over time, PDSA helps move facilities away from reactive responses. Teams gain confidence in testing solutions, reviewing outcomes, and making informed adjustments. This leads to stronger compliance, improved resident outcomes, and a culture of continuous improvement.

Improvement does not happen overnight, and PDSA is not about perfection. It is about structured learning. With the right support and tools, nursing homes can use this simple cycle to make steady, measurable progress toward safer, higher-quality care.