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BMC Health Serv Res. 2017 Jun 19;17(1):411. doi: 10.1186/s12913-017-2364-3.

Applying the Plan-Do-Study-Act (PDSA) approach to a large pragmatic study involving safety net clinics.

Author information

Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
Kaiser Permanente Center for Health Research, 3800 N. Interstate Ave, Portland, OR, 97227, USA.
Lean HealthCare West, 315 SW 5th Avenue, Suite 900, Portland, OR, 97204, USA.
Multnomah County Health Department, 426 SW Stark St, 8th Floor, Portland, OR, 97204, USA.
Process of Care Research Branch, Behavioral Research Program, National Cancer Institute, Division of Cancer Control and Population Sciences, Rockville, MD, USA.
Group Health Research Institute, 1730 Minor Avenue, Suite 1600, Seattle, WA, 98101, USA.



The Plan-Do-Study-Act (PDSA) cycle is a commonly used improvement process in health care settings, although its documented use in pragmatic clinical research is rare. A recent pragmatic clinical research study, called the Strategies and Opportunities to STOP Colon Cancer in Priority Populations (STOP CRC), used this process to optimize the research implementation of an automated colon cancer screening outreach program in intervention clinics. We describe the process of using this PDSA approach, the selection of PDSA topics by clinic leaders, and project leaders' reactions to using PDSA in pragmatic research.


STOP CRC is a cluster-randomized pragmatic study that aims to test the effectiveness of a direct-mail fecal immunochemical testing (FIT) program involving eight Federally Qualified Health Centers in Oregon and California. We and a practice improvement specialist trained in the PDSA process delivered structured presentations to leaders of these centers; the presentations addressed how to apply the PDSA process to improve implementation of a mailed outreach program offering colorectal cancer screening through FIT tests. Center leaders submitted PDSA plans and delivered reports via webinar at quarterly meetings of the project's advisory board. Project staff conducted one-on-one, 45-min interviews with project leads from each health center to assess the reaction to and value of the PDSA process in supporting the implementation of STOP CRC.


Clinic-selected PDSA activities included refining the intervention staffing model, improving outreach materials, and changing workflow steps. Common benefits of using PDSA cycles in pragmatic research were that it provided a structure for staff to focus on improving the program and it allowed staff to test the change they wanted to see. A commonly reported challenge was measuring the success of the PDSA process with the available electronic medical record tools.


Understanding how the PDSA process can be applied to pragmatic trials and the reaction of clinic staff to their use may help clinics integrate evidence-based interventions into their everyday care processes.

TRIAL REGISTRATION: NCT01742065 . Registered October 31, 2013.


Colorectal cancer; Fecal immunochemical test; Plan-Do-Study-Act; Process improvement

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