Up for Lunch: One Plan-Do-Study-Act Cycle Testing Chair Meals for Hospitalized Adults Over 70
Student Name
American College of Education
NUR4063: Leadership and Management in Healthcare
Module 6 Assignment
Instructor Name
October 12, 2026
The Problem and the Aim
Many patients over 70 go home from a hospital stay weaker than when they came in. Covinsky et al. (2011) describe hospitalization-associated disability, a loss of the ability to perform basic activities of daily living, and estimate that it occurs in about one-third of patients older than 70, sometimes even when the illness that led to admission is successfully treated. Low mobility is one of the main contributors. Brown et al. (2009) monitored older patients continuously during their hospital stays and found that, on average, 83 percent of their time was spent lying in bed, even though most of them were able to walk a short distance independently. The median time spent standing or walking was 43 minutes a day.
On the 28-bed medical unit described in this paper, a composite written for this assignment, a one-day observation found that of 14 patients aged 70 or older who were able to sit in a chair with help, three ate lunch sitting up in a chair and eleven ate in bed. The unit's improvement team set a specific aim: within eight weeks, 70 percent of eligible patients aged 70 or older will eat lunch sitting in a chair. Lunch was chosen because it is the one meal of the day when staffing, patient alertness and the absence of shift change line up.
Plan
The Model for Improvement opens every project with three questions, asking in turn for the goal, for the evidence that would show progress toward it and for the specific change expected to produce that progress (Langley et al., 2009). The team's answers were the aim above, a daily count of eligible patients sitting in a chair at lunch, and a change idea: at 1115, the nursing assistant on each hallway would help every eligible patient into the chair with the nurse's approval, before trays arrived at 1145.
The test was deliberately small. It would run on one hallway of ten beds, on weekdays only, for one week, with one nursing assistant and two nurses who had volunteered. Eligibility was defined in advance: age 70 or older, able to sit in a chair with the assistance of one person according to the morning mobility assessment and without an order restricting activity. The team recorded one prediction before starting: that at least 60 percent of eligible patients would be in a chair for lunch on each test day and that the task would add no more than fifteen minutes to the assistant's late morning.
Do and Study
Over five weekdays, the hallway had 26 eligible patient-days. On 15 of them, the patient ate lunch sitting in a chair, 58 percent overall. The daily figures, however, were uneven: 80 and 75 percent on the first two days, 33 percent on Wednesday, and 60 and 50 percent on Thursday and Friday. The nursing assistant recorded the time spent each day, which ranged from ten to twenty-five minutes. Nurses recorded the reason for each eligible patient who ate in bed. Of the eleven misses, five occurred because the patient was off the unit for tests or therapy at 1115, three because the patient declined, two because the patient had just received pain medication and was drowsy, and one because the assistant was pulled to help with a fall on another hallway.
Comparing the results with the prediction was the most useful part of the cycle. The overall figure was close to the prediction of 60 percent, which might have suggested success. The daily variation and the reasons for missed patients told a different story. Wednesday was the day most patients on the hallway were scheduled for imaging or physical therapy in the late morning, and the unit had no way of knowing that at 1115. The average hid the problem; the reasons for each miss revealed it. Taylor et al. (2014) reviewed published accounts of plan-do-study-act cycles in health care and found that fewer than 20 percent documented a sequence of iterative cycles, and that few used frequent data to guide the next cycle; recording the reason for every miss gave this team exactly the kind of data those accounts lacked.
The time measure also mattered. On the three days when fewer patients were eligible or several were off the unit, the assistant spent ten to fifteen minutes on the task, within the prediction. On the two days with six eligible patients present, it took twenty to twenty-five minutes, which pushed her late morning vital signs past their scheduled time. That finding does not argue against the change, but it does mean that a second assistant or a different division of tasks would be needed before extending it to a full unit of 28 beds, where on a typical day twelve to fifteen patients might be eligible.
Act
The team chose to adapt the change rather than adopt or abandon it. Two changes were made for the second cycle. First, the unit secretary would print the day's scheduled tests and therapy sessions for the hallway at 1030 and give the list to the assistant, who would help those patients into the chair on their return or, where possible, before they left. Second, nurses would coordinate as-needed pain medication for eligible patients so that a dose due in the late morning was given by 1030 rather than at 1115. Patients who declined would be asked again at 1130 with a family member present if one was visiting, since two of the three refusals had come from patients who said they were waiting for relatives.
The second cycle will run on the same hallway for another week, with a new prediction of 70 percent on every day, not just on average. If the second cycle meets that prediction, the third cycle will extend the change to a second hallway, testing whether it works with a different assistant and a different mix of patients before any unit-wide change.
What the Small Test Prevented
If the unit had launched chair lunches across all 28 beds at once, the first week's results would likely have looked acceptable on average and poor on the days when tests and therapy clustered. Staff would have experienced the change as unreliable, the Wednesday failures would have been blamed on the assistants, and the most likely outcome would have been a quiet return to trays in bed within a month. The small test cost one hallway and five days. It revealed a scheduling problem outside nursing, a medication timing problem inside it and a simple fix for some refusals, all before the change had a chance to fail publicly. That is the purpose of testing small: the failure happens where it is cheap, and the learning arrives in time to use it.
Conclusion
Low mobility is common, harmful and easy to overlook in older hospitalized adults, and a change as simple as sitting up for lunch addresses part of it. A single plan-do-study-act cycle on one hallway showed that the change was feasible, that its average result was close to the prediction and that the average concealed a predictable failure. By recording the reason for each miss, the team found two fixes it could make before expanding. The next cycles will show whether those fixes hold, one hallway at a time.
References
Brown, C. J., Redden, D. T., Flood, K. L., & Allman, R. M. (2009). The underrecognized epidemic of low mobility during hospitalization of older adults. Journal of the American Geriatrics Society, 57(9), 1660-1665. https://doi.org/10.1111/j.1532-5415.2009.02393.x
Covinsky, K. E., Pierluissi, E., & Johnston, C. B. (2011). Hospitalization-associated disability: "She was probably able to ambulate, but I'm not sure." JAMA, 306(16), 1782-1793. https://doi.org/10.1001/jama.2011.1556
Langley, G. J., Moen, R. D., Nolan, K. M., Nolan, T. W., Norman, C. L., & Provost, L. P. (2009). The improvement guide: A practical approach to enhancing organizational performance (2nd ed.). Jossey-Bass.
Taylor, M. J., McNicholas, C., Nicolay, C., Darzi, A., Bell, D., & Reed, J. E. (2014). Systematic review of the application of the plan-do-study-act method to improve quality in healthcare. BMJ Quality & Safety, 23(4), 290-298. https://doi.org/10.1136/bmjqs-2013-001862
How this NUR 4063 Module 6 example is structured
NUR 4063 Module 6 often closes on quality improvement and how a small test avoids a large failure; your classroom's instructions decide whether the paper describes a completed cycle, a planned one or a critique. This example states the aim and the evidence behind it, then reports the cycle in its four stages, including the prediction made before the test, because a plan-do-study-act cycle without a prediction cannot show learning. The study stage compares results with the prediction, the act stage decides what to change, and a final section explains what a unit-wide launch would have cost if the test had been skipped.
NUR4063 Module 6 questions, answered
What does NUR4063 Module 6 usually ask for?
NUR4063 Module 6 often focuses on quality improvement, and many sections ask students to plan or describe a plan-do-study-act cycle, with a clear aim, measures and a small test of change. Your classroom's instructions decide whether the cycle must be carried out, only planned, or critiqued from a published example, and which quality improvement model to use.
Why does a PDSA cycle need a prediction?
The prediction is what turns a trial run into a test. Writing down what you expect before you start lets you compare results with expectations in the study stage and see what you learned. Without a prediction, almost any result can be described as a success, and the cycle teaches nothing about why the change worked or failed.
How small should the first test of change be?
Small enough that failure is cheap and fast: one hallway, one shift, a few patients or a few days. The first cycle is meant to show whether the change is workable and what goes wrong, not to prove it works everywhere. Scale up in later cycles once the change works reliably under the conditions you tested.
Write yours, or have the desk draft it
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