1. Having patients set self-management goals will improve care.
Aim: Improve care of patients with cardiovascular disease by involving patients in their care.
10% have SMG
Improved care D S P A
DATA A P S D
Cycle 5: All staff oriented in use of SM goal sheet. D S P A
0% have SMG A P S D
Cycle 4: All patients work with RN.
This is an example of real PDSA cycles from Catahoula Parish Community Health Center. The change that they are testing is that involving patients in their care will improve it. This test is based on a powerful concept that outcomes in chronic illness care are dependent on patient’s ability to be managers of their own care. This example also shows how the data changed over time.
The tests begin with working out the system of doing goal setting within their team and in the flow of the office visit. You can see that having the MD wasn’t a sustainable system. After two PDSAs with the MD doing goal setting, they moved to the RN doing it during rooming, and they eventually settled on making sure all staff could do goal-setting. After making refinements in the new system, the team is ready to use the system throughout the clinic and trained all of their providers in the use of the goal sheet. A P S D
Cycle 3:
RN introduces goal-setting during room- ing, MD follows up.
Having patients set self-management goals will improve care.
Cycle 2:
MD uses form with all patients for one week.
Cycle 1: MD tries self-management goal form with 3 patients
Catahoula Parish CHC, Apr. 2003

2. Aim: Improve care of patients with cardiovascular disease by involving patients in their care.
70% have SMG
Improved care D S P A
DATA A P S D
Cycle 8: MD does follow- up of SMG as found in chart. D S P A
10% have SMG A P S D
At this time they have begun to implement a change. (Staff training is an indicator of implementation) they still had only 10% of patients with a self-management goal. Since the team was monitoring their data, they knew they had to take a different approach to help more patients become involved in their care.
The team then decided to use their clinical information system and reach out to patients who were missing a key clinical activity, a test for lipid levels in the blood (cholesterol.) They adapted their process to this outreach method, and by the end of that series of tests, 70% of patients had self-management goals. A P S D
Cycle 7:
Patients in for lipid tests given SM goal sheet by RN.
Using outreach will increase the patients who have opportunities to set goals.
Cycle 6: Using registry, query patients without lipid test, call in
proactively for free lab work.
Catahoula Parish CHC, Apr. 2003