Tribal Continuous Quality Improvement Collaboratives

OMB #: 0970-0531

Expiration Date: 07/31/2022

P lan-Do-Study-Act (PDSA) Planning Tool

Please complete the following PDSA Planning Tool for each PDSA cycle your team charters for your Continuous Quality Improvement Collaborative (CQIC) Activities.

Grantee Name:	Collaborative Topic:	Date: Click or tap to enter a date.
Primary Driver:	Secondary Driver:
Change and change number (if applicable):	Cycle number:
What are you trying to accomplish with this PDSA cycle?
Improvement Theory (If/then Statement):
If we…
Then…

PLAN Stage

Plan for Test:

What will take place?

Who will test the change?

Who will the change be tested with?

Start and end date (Month/Day/Year) of test? Click or tap to enter a date. to Click or tap to enter a date.

Where will this test occur?

What are the tasks/resources needed to support the change?

Plan for Data Collection:

What quantitative (% or count) or qualitative (question(s) asked) data will be collected?

Who will collect the data and who are the subjects?

Start and end date of data collection? Click or tap to enter a date. to Click or tap to enter a date.

Where will data be collected and stored?

What tools are needed to support data collection (e.g. form, Excel file for tracking data, etc.)?

DO Stage

Was the test carried out as planned? ☐ Yes ☐ No

If no, why not and what happened?

STUDY Stage

What did the data tell you? What did you learn?

Did your results match your prediction?

What surprised you?

ACT Stage

Please check the box that applies:

☐ Adapt the change & test again

☐ Scale up the change & test again

☐ Adopt the change for your program

☐ Abandon the change & test a new change

Please explain your next steps:

Did you team develop any resources to support this PDSA cycle? ☐ Yes ☐ No

If yes, what did your team develop? (Please attach the resource(s) developed when sharing this PDSA Planning Tool with your TEI TA Provider. The resource(s) may be shared with the collaborative to support other grantees improvement efforts.)

1