Step 6.

9 – Change and Measure

PDSA Cycle Worksheet

Example
This completed PDSA Cycle Worksheet demonstrates how your team can use this tool to help plan,
conduct, and monitor progress with tests of change conducted to help you meet your aim. Refer to
Case Study 1.2. For instructions on how to use this tool, refer to 6.8 PDSA Cycles Worksheet.

Model for Improvement: Three questions for improvement

1. What are we trying to accomplish (aim)?
Over the next six months, we will redesign the way we schedule and communicate therapy
appointments to ensure that residents are attending all scheduled therapy appointments.
2. How will we know that change is an improvement (measures)?
Reduce the percentage of missed therapy appointments on the transitional care neighborhood
by September 1, 2014. Baseline for missed appointments is currently 32%. Target is 10% or
less.
3. What change can we make that will result in an improvement?
Therapy schedule will be updated using the electronic health record, retrieved on the
Transitional Care neighborhood, and made available to each nursing assistant at the beginning
of AM and PM shifts.

Step 6 Change and Measure—PDSA Cycle Worksheet Example - 1

 Plan List your action steps along with
person(s) responsible and time line.
What change are you testing with the 1. Therapy manager, therapy assistant,
PDSA cycle(s)? Copy of electronic version transitional care clinical manager,
of therapy schedule will be attached to each and transitional care nursing
nursing assistant assignment sheet at the assistant will meet by
start of the AM and PM shifts. month/date/year to review and revise
current therapy scheduling process.
What do you predict will happen and why? 2. Therapy manager will train therapy
More residents will be attending their assistants by month/date/year on
scheduled therapy appointments because the how to use therapy scheduling
nursing assistant will know their schedule and software
ensure that they are available. 3. Therapy manager will train transitional
care health unit coordinator by
Who will be involved in this PDSA? month/date/year on how to retrieve
Therapy manager, therapy assistant, therapy schedule using electronic
Transitional care clinical manager, health record
Transitional care nursing assistant, 4. 5 day trial will begin with one resident
Transitional care health unit coordinator on the transitional care
neighborhood on month/date/year:
PDSA will be carried out for one resident on  Therapy assistant will upload
the transitional care neighborhood for 5 therapy schedule for
days. following day to electronic
health record by 5:00 PM
How long will the change take to  Health unit coordinator will
implement? 5 days make copies of therapy
schedule and attach them to
each nursing assistant’s
What resources will they need? Time to train assignment sheets each day
staff on new process prior to the beginning of the
AM and PM shifts
 Nursing assistants will refer
What data need to be collected? Number of to therapy schedule
missed and scheduled therapy appointments attached to their assignment
during the test period sheet and ensure all
residents are ready for
therapy at their scheduled
time
 Therapy manager will track
therapy appointments for
test resident – were any
appointments missed?
 Transitional care clinical
manager will meet with the
team to review the test results

Step 6 Change and Measure—PDSA Cycle Worksheet Example - 2

 Do
Data indicated that of the 8 therapy
 Carry out the test on a small scale appointments this resident had scheduled
 Document observations, including any from month/date/year to month/date/year, the
problems and unexpected findings resident missed two of these appointments.
The two missed appointments were due to the
 Collect data you identified as needed
resident not wanting to attend therapy due to
during the “plan” stage.
complaints of pain. The missed appointments
were not due to a communication error – the
nursing assistants were aware of the therapy
appointments. The nursing assistants did
report that the therapy schedule was attached
to their assignment sheets each day.

The process for retrieving the therapy schedule

from the electronic health record went well.
There was a question about how this will work
on the weekends since the health unit
coordinator isn’t available to print off the
assignment worksheets prior to the AM and
PM shifts.

Step 6 Change and Measure—PDSA Cycle Worksheet Example - 3

 Study
Describe the measured results and how
 Study and analyze the data. Determine they compared to the predictions.
if the change resulted in the expected
outcome. The test resident missed 25% of her therapy
appointments during this test period.
 Were there implementation lessons? However, the missed appointments were
not due to communication issues. The
 Summarize what was learned. Look for: change resulted in what we expected – no
unintended consequences, surprises, missed therapy appointments due to the
successes, failures. nursing assistant not being aware of the
therapy schedule.

However, to make a bigger impact on

decreasing the number of missed
appointments and to ensure that the
resident is receiving as much benefit as
possible from therapy, we need to work on
our action plan/other PDSAs for these
issues that were identified as contributing
factors:
 Pain management interfered with the
resident’s ability to attend the
scheduled therapy. Individualized pain
management interventions need to be
established for each resident to assure
pain does not interfere with therapy
attendance.
 Rehab plans are not discussed with the
family and resident on admission.
Goals and interventions are not
identified in a timely manner.
 Not enough therapy staff or equipment
to meet therapy needs. Would more
staff and/or more equipment allow
therapy to accommodate unanticipated
needs and be more flexible with
scheduling?

Step 6 Change and Measure—PDSA Cycle Worksheet Example - 4

 Act
Describe what modifications to the plan
Based on what was learned from the test:
will be made for the next cycle from what
Adapt – modify the changes and
you learned.
repeat PDSA cycle.
 Will educate transitional care staff on
Adopt- consider expanding the
new process during neighborhood
changes in your organization to
meeting
additional residents, staff, and units.
Abandon – change your approach  Will implement the new process for
all residents in transitional care
and repeat PDSA cycle
neighborhood
 The transitional care health unit
coordinator will continue to print the
therapy schedules and attach them
to the nursing assistant assignment
sheets Monday-Friday and the night
supervisor will do this task on the
weekends
 Therapy manager will continue to
track missed appointments
 Nursing director will schedule a
meeting with the team to see how
things are going
 Changes will be made as necessary
 Team will continue to meet to plan
further actions related to contributing
factors

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Step 6 Change and Measure—PDSA Cycle Worksheet Example - 5