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/