ABOUT

Problem Statement

Aim / Overall Goal / Desired Result

Change Idea

PDSA Objective

PDSA Cycle Number:

Estimated PDSA Implementation Timeline

From to

What questions do you want answered for this change?

PLAN

Predict what will happen when this test is carried out:

List the tasks needed to set-up this change: (Please include the person responsible, when the task is to be completed, and where the task is to be completed for each task.)

Related Improvement Measure:

No related measure has been set yet. Please connect this Quality Improvement project to a raw data measure.

DO

Describe what happened when you ran the test:

STUDY

Describe the measured results, and how they compared to the predictions:

ACT

Describe what modifications in the plan will be made for the next cycle from what you learned:

Source: https://mygarrettcounty.com/groups/promoting-quitting-among-adults/qi.