You Are Here: AHRQ Home > Quality & Patient Safety > Quality Information & Improvement > Asthma Health Disparities Collaborative Coalition Guide > Appendix F

Asthma Health Disparities Collaborative Coalition Guide

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

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)

Return to Contents

Current as of September 2007
AHRQ Publication No. 07-0056-EF

Internet Citation:

Asthma Health Disparities Collaborative Coalition Guide. Final Contract Report. AHRQ Publication No. 07-0056-EF, September. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/qual/asthmadisparities/