1. Facilitation Tool: Goal to Action template
Anticipated result: ____________________________________________________________________________________
Cycle 5: ____________________________________________________________________________
Long Term Goal: ________________________________________________________________________Short – term Goal: ________________________________________________________________________
Cycle 4: ____________________________________
___________________________________________
Learning
Cycle 3: _________________________________________
________________________________________________
Cycle 2: : _______________________________________________
_______________________________________________________
Cycle 1: _____________________________________________________
____________________________________________________________

2. Example: Goal to Action
Anticipated result: Diabetes Flow Sheet used by all clinicians in the clinic within 3 months
Cycle 5: Final version implemented across clinic within 2 months and guideline driven measures of care tracked.
Long Term Goal: Improved Planned Care for patients with diabetes ______________________________________Short – term Goal: Implement a diabetes flow sheet to improve delivery of guideline-based care
Cycle 4: V4 discussed at monthly all staff meeting
and V5 tested with providers new to the process
Learning
Cycle 3: V3 test with 3 providers for one week with 30
patients. Data on number of care gaps addressed is tracked
Cycle 2: : Revise flow sheet and test V2 with same provider on Thurs.
Cycle 1: Download CDA diabetes flow sheet and test with one provider
on Tuesday using all patients with diabetes coming in that day

3. Facilitation Tool: Multiple Goals Template
Cycle 5: _________
Cycle 5: _________
Cycle 5: _______
Learning
Cycle 4: ________
Cycle 4: ________
Cycle 4: _________
Learning
Learning
Cycle 3: _________
Cycle 3: _________
Cycle 3: _________
Cycle 2: _________
Cycle 2: _________
Cycle 2: _________
Cycle 1: _________
Cycle 1: _________
Cycle 1: _________

4. Example: Multiple Goals
Goal 1: Increase foot exams
Goal 2: Group Visits
Goal 3: Self care goals
Cycle 5: Implement protocol
Cycle 5: Increase recruiting
Cycle 5: Implement
protocol
Cycle 4:
MA removes shoes/socks
Cycle 4: Community resource added
Cycle 4:
Info in waiting room-RN sets BAP
Learning
Cycle 3: Remind MD about foot exam
Cycle 3: Healer added
Cycle 3:
RN sets BAP end of visit
Cycle 2:
Sign in exam room
Cycle 2:
MD added when on site
Cycle 2:
MA sets BAP rooming pt.
Cycle 1:
Check-in reminder about socks/shoes
Cycle 1:
RN visit
Cycle 1:
MD sets BAP w/1 pt.

5. Facilitation Tool: Multiple PDSA Template
Goal 1: __________________________________________________________
Cycle 5: _________
Cycle 5: _________
Cycle 5: ______
Learning
Cycle 4: ________
Learning
Cycle 4: _______
Learning
Cycle 4: ________
Cycle 3: _________
Cycle 3: _________
Cycle 3: _________
Cycle 2: _________
Cycle 2: _________
Cycle 2: _________
Cycle 1: _________
Cycle 1: _________
Cycle 1: _________

6. Example: Multiple PDSAs
Goal 1: Proactive Outreach to Targeted Populations Using Registry
Cycle 5: Implement protocol
Cycle 5: Multi med rec strategy implemented
Cycle 5:
2 pronged care mgt strategy
Cycle 4:
MD calls non-responders
Cycle 4:
RN does med rec on phone
Cycle 4: MD visits home bound
Learning
Learning
Learning
Cycle 3:
RN calls lost to follow up
Cycle 3:
Pt. Re-scheduled if no meds
Cycle 3:
RN recruits pts at visit
Cycle 2:
MA calls lost to follow up
Cycle 2:
Front office calls to bring in meds
Cycle 2:
Letter to complex pts
Cycle 1:
Front office mails letter to lost to FU
Cycle 1:
Letter to bring in meds
Cycle 1:
Complex care risk identifier tested