Step 8: Implement Changes

“We are what we repeatedly do. Excellence therefore is not an act but a habit”

– Aristotle

Step 8 occurs after an improvement team has developed and tested a change using PDSA cycles and is convinced by evidence from these cycles that that the change will lead to sufficient improvement. Step 8 is about making the change a permanent part of the system.

tipToo often organizations skip testing and go straight to implementation of changes. The result frequently is problems with or failure of the newly implemented change. The learning that occurs with testing changes is vital to successful implementation. If you have not tested the changes, go back to step 7.


Implementation is a commonly used term in relation to change, with various definitions covering a spectrum of steps. Implementation in the context of quality improvement is a more narrow focus than how the term is commonly used: “The aim of this narrow scope of implementation is to make sure the infrastructure is in place to make the change long-lasting and successful. This includes issues such as training, documentation, standardization, adequate resources, and social considerations…”

“Testing is about learning if the change will result in an improvement.
Implementation is about how to make the change an integral part of the system.” (Improvement Guide).

As you did with developing and testing changes, implementation should be carried out as part of a PDSA cycle or series of cycles. However, assuming that testing has been effective, implementation PDSA cycles are expected to result in no failures. Here is a chart that can help you decide the scale of your PDSA cycles and whether the change is ready for implementation.

Step 8 Testing and Implementing a Change Idea 2 by 2 table

These following ideas are important in implementing complex changes

  • Managing implementation as a series of PDSA cycles
  • Providing supporting during and after the implementation to ensure that improvement is achieved and maintained
  • Recognizing and addressing the social aspects of implementing a change

Implementation as a Series of Cycles

Just like with testing changes, implementation should be managed as a series of PDSA cycles. In implementing the change, you will continue to run PDSAs: making predictions, collecting data, and documenting things that go wrong so that you learn from them and use them to plan the next test. However, compared to PDSAs in the pilot phase, these tests will require significantly more people, time, and resources — it’s why you must be very confident that your change is likely to lead to improvement.

Here’s a chart that summarizes the differences between PDSA testing during the pilot and the implementation phases:

Step 8 PDSAs v Implementation Comparison

Depending on the complexity and the risks involved, implementation can be conducted a number ways – all relying on the use of the PDSA cycle:

 Just Do ItParallel ApproachSequential Approach
When to Use ItSimple, low risk changeImplementing complex changes, while trying to satisfy normal operational demandsA change comprises multiple independent components
Implementation approachRunning a successful implementation PDSA cycle + one more cycle to ensure that the predicted results are achievedUsing PDSA cycles for implementation to plan and phase in the changes parallel with the existing systemRunning multiple PDSA cycles for implementing different components of a change sequentially over time.
Consequences of failureMaximizes the negative impact of unforeseen negative consequencesReduces some of the risks but will take longer to fully implementAfter the first few cycles, all the components of the change may not be implemented, but there is no risk of 100% failure

The Social Aspects of Implementing a Change


tipTo sustain a change that has been implemented, we need to create a structure that makes it easy for people to do the right thing (use the new process or system) and hard to do the wrong thing (go back to the old process or system)


Change is not only a technical issue, but the success of a change can largely be driven by organizational culture and social factors. The increased permanence of a change associated with moving from testing to implementation is usually accompanied by increased awareness of and reaction to change. Although testing a change prior to implementation reduces the risk of a problem or failure, a spectrum of reactions from impacted staff should be expected when a change is announced. Common behaviors include:

  • Resistance: impede change that is perceived as threatening
  • Apathy: showing little or no interest in the change
  • Compliance: publicly acting in accord while privately disagreeing with the change
  • Conformance: changing behavior as a result of real or imagined group pressure
  • Commitment: becoming bound emotionally or intellectually to the change

Leaders should not view people’s initial reactions as negative resistance; however, if these reactions are not properly dealt with, they can develop into full blown resistance (Improvement Guide).

Many of the ways in which people become motivated to support a change begin before implementation is started.

  • Create the will for people to adapt the change. Leaders can create will by communicating:
    • Dissatisfaction. People need to be unhappy about the current state of affairs. If unhappiness with the status quo isn’t there, create.
    • Direction. Relentlessly communicate what the change, why it is necessary, and what people out to be doing right now with as much clarity as possible.
    • Overconfidence (punctuated by self-doubt and updating). Express excessive faith that the change will succeed and be worth the pain, time, and money in the end. Create a self-fulfilling prophecy, regardless of the success rates anywhere else.
    • Embrace the mess. Accept that there will be errors, set-backs, miscommunication, frayed nerves, and frightening rumors when trying to do something new, no matter how well the change is planned.
  • Provide information on why the change is being made.
  • Reframe the change as an exciting opportunity, not something being forced on people
  • Offer specific information on how the change will affect people
  • Get consensus on solutions, resources, and other necessary support to implement the change
  • Publicize and promote the change in a positive light. Take advantage of significant events (good or bad) and tie the implementation of the change to these events.

Depending on the level of support or resistance, other measures may include:

  • Modifying the planned change to increase commitment
  • Using incentives
  • Using logical consequences
  • Demanding conformance as an expectation of continued employment


Infrastructure & Processes Needed to Make the Change an Integral Part of the System

  • Documenting the flow of the new process(es) — the new way of doing things
  • Providing training on the new process
  • Teaching people new skills that might be required of them
  • Making changes to job descriptions, policies, procedures, and forms
  • Addressing supply and equipment issues
  • Assigning day-to-day ownership for the improvement and maintenance of the new process
  • Having senior leaders remove any barriers that might allow slippage back to the old process
  • Measuring processes to ensure the changes implemented are being carried out and improvements are maintained over time.


Improvement Journey Exercise #8

Complete the Implementation Checklist


Once you have completed the implementation checklist, move on to Step 9: Spread Improvements.