Appendix F. Sample Plan-Do-Study-Act Cycle Report Forms

Asthma Health Disparities Collaborative Coalition Guide

Asthma Initiative of Michigan/Asthma Health Disparities Collaborative: Draft Form

(Note: Adapted from Chronic Care Model, the Model of Improvement, and Their Application to Reducing Disparities in Pediatric Asthma: A Faculty Workshop—Training Workbook)

Chronic Care Model component [check the component that is being addressed]

__  Health Care Organization
__  Self-Management Support
__  Delivery System Design
__  Decision Support
__  Clinical Information Systems
__  Community Resources and Policies

Health Center:  ___________________ 
Asthma Coalition:  __________________

PDSA Cycle Number:  _____________ 
PDSA Cycle Timeframe:  _____________

Trimester Report:
__  First
__  Second
__  Third

Fiscal Year:  _________________________________________

Purpose of Cycle and Summary of Proposed Health System Change:
_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

_______________________________________________________________

PLAN:  The change, data collection, and predicted outcome

The Change

  • What are we testing?


  • Who are we testing the change on?


  • When are we testing?


  • Where are we testing?

Predictions

  • What do we expect to happen?

Data

  • What data do we need to collect?


  • Who will collect the data?


  • When will the data be collected?


  • Where will the data be collected?

STUDY: Complete analysis of data, summarize what was learned, and compare data to predictions


ACT: What adjustments to the change or the method of test should we make before the next test cycle?

What will the next test cycle be?

 

Are we ready to implement the change we tested?

 

Are we ready to spread the change we tested? If so, how?


PDSA Worksheet

(Note: Used by Michigan Primary Care Association, Michigan Asthma HDC Learning Lab, May 22, 2007)

Health Center: ___________________________________________________

Date: ___________________  Initiated by: ___________________  Cycle# ____________________

CARE MODEL COMPONENT: 

__ OrgHC
__ Comm
__ DelSysD
__ DecSupp
__ SelfMgt
__ CIS

Purpose of this cycle: ____________________________________

PLAN the change, prediction(s) and data collection
The Change:
What are we testing? 
On whom are we testing the change? 
When are we testing? 
Where are we testing? 
Prediction(s):
What do we expect to happen? 
Data:
What data do we need to collect? 
Who will collect the data? 
When will the data be collected? 
Where will data be collected? 
DO: Carry out the change/test, collect data, and begin analysis
What was actually tested? 
What happened? 
Observations: 
Problems: 
STUDY: Complete analysis of data. Summarize what was learned and compare to prediction
(Use back of form to elaborate.)
ACT
What adjustments to the change or method of test should we make before the next cycle?
Are we ready to implement the change we tested?
What will the next test cycle be? (use back of form to elaborate)

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Page last reviewed September 2007
Internet Citation: Appendix F. Sample Plan-Do-Study-Act Cycle Report Forms: Asthma Health Disparities Collaborative Coalition Guide. September 2007. Agency for Healthcare Research and Quality, Rockville, MD. http://archive.ahrq.gov/research/findings/nhqrdr/asthma-health-disparities/appendix-f.html