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QI case study: Testing the selected QI intervention using PDSA

Part two of a hypothetical case study illustrating how a NICU team applies the PDSA cycles to address problems with ROP screening.
Illustration of the Plan-Do-Study-Act cycle beside an ROP screening being carried out
© London School of Hygiene & Tropical Medicine CC BY-NC-SA 4.0

In this step we return to our hypothetical case study of a neonatal intensive care unit (NICU) team’s quality improvement (QI) project to resolve problems with their process for retinopathy of prematurity (ROP) screening.

Last week we followed the early stage where the QI team came together to identify and analyse the issues, and consider the action needed. The team concluded that, to improve the ROP screening rate from 33%, they would test two priority activities:

  • Training the neonatal nurses on ROP

  • Increasing the role of neonatal nurses in counselling parents about ROP in the NICU and step down units before discharge.

In this activity, we review what the team learned in the next stage of their quality improvement project, where they tested their intervention idea using a Plan-Do-Study-Act cycle. Below is the key information the team recorded at each stage of their PDSA using a template. If you are a healthworker you can download a similar PDSA template to use in your own setting.

Before you start, you might want to refresh your memory of this case study by revisiting step 1.20

QI case study: Reporting on the first PDSA cycle

Project aim (what are we trying to accomplish?): To improve ROP screening at the NICU.

SMART objective: To increase the ROP screening rate* from 33% to 60% by the end of the eight weeks.

* Note: The screening rate is the percentage of neonates screened out of the total number listed for first screening.


Description of the intervention

The QI team will create:

  • A training resource for nurses to improve their knowledge about ROP and the importance of counselling parents.

  • An information poster on ROP screening to remind nurses and for counselling parents.

Two resident doctors to provide individual training to all 40 neonatal nurses on ROP screening over a two week period and on a shift basis, so as not to disrupt routine care. Posters on ROP screening will be displayed appropriately to remind nurses to discuss this issue with the parents. A neonatal nurse in the NICU and another in the step down unit will be assigned to 1) Collect feedback from nurses and parents, and 2) Supervise the implementation of the task to counsel parents and list babies for ROP screening.

What change should the intervention cause?

  • Improve all the neonatal nurses’ knowledge of ROP screening and the importance of their active involvement in counselling parents on screening.

What improvement should the change lead to?

  • All neonatal nurses apply their knowledge by implementing the ROP protocol to look out for high risk cases, provide empathetic support for parents and ensure first ROP screening takes place.

How we will know if the change does lead to improvement?

  • Over the eight weeks data on numbers of babies screened will be tracked for the NICU and the step down units.

  • Qualitative feedback from parents will also be collected during screening events on what they have been told about ROP screening and what they should expect afterwards.

Plan of tasks to deliver the intervention (over eight weeks)

Task / person responsible / when and where to be done:

  1. Training material and poster to be developed by head neonatal nurse and resident doctors before the start of project. The materials should be shown to a sample of the neonatal nurses and doctors not involved in the development of the materials, to make sure the messages are clear and unambiguous.

  2. Training to be delivered to all 40 nurses as individual 30 minute training sessions with one of the resident doctors over two weeks during their shifts.

  3. ROP screening awareness posters to be placed in strategic locations by the head nurse in the first week.

  4. Feedback on training and counselling sessions to be collected by neonatal nurse supervisors.

  5. Qualitative feedback on ROP counselling to be collected from parents by the neonatal administrator.

  6. ROP screening data to be collected on ROP screening days by the neonatal administrator.

  7. Weekly QI meetings for updates on progress to be coordinated by the head neonatologist.


Was the cycle carried out as planned? Yes

What were the recorded data and observations?

  • Quantitative ROP screening data were collected during screening events.

  • A self-administered test of ROP screening knowledge was completed by all the neonatal nurses at the end of the eight weeks.

  • Qualitative feedback was collected from 30 parents.

  • Qualitative feedback was collected from 10 nurses in the NICU and 10 nurses from the step down clinic.

What did you observe that was not part of the plan?

  • Nurses in the night shift could not be trained on time and training period was extended to 4 weeks.

  • Nurses in the step down units had to consider ROP screening during discharge and this caused some difficulties for parents.


Did our results match the prediction? Yes

How do the results compare to previous performance?

  • ROP screening rate increased from 33% to 50%

  • Nurses’ ROP median test score increased to 10 / 10

  • Qualitative feedback from nurses indicates they feel empowered and informed to undertake the task of counselling the parents and even to remind the neonatologist.

  • Qualitative feedback from parents is positive. They have raised concerns on what happens when baby in the step down clinic is discharged on the same day as their scheduled ROP screening.

What did we learn?

  • Empowering the nurses has resulted in improved parental awareness and acceptance of ROP screening.

  • Some changes need to be considered in the step down unit to schedule ROP screening before discharge.

  • Parents remain unsure of what to do about ROP after discharge.


Decision is to: ADAPT the intervention

We will extend the project and run a new PDSA cycle which includes:

  • A new register for ROP screening in the NICU and step down units.

  • Adding all ROP screening details and dates to babies’ discharge notes.


This team found that using PDSA helped them to improve their practice without the need for investment. In your view what are the strengths and weakness of the PDSA approach?

© London School of Hygiene & Tropical Medicine CC BY-NC-SA 4.0
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Retinopathy of Prematurity: Practical Approaches to Prevent Blindness

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