1. [Organization Name]:[insert]Collaborative
Insert Key Driver Diagram

2. [Organization Name]:[insert]Collaborative
Insert process map

3. [Organization Name] – [insert] Collaborative
PDSA cycle #
Start Date:
End Date:
Measure
Intervention 
Plan
Objective for cycle: What do you expect to accomplish? What key driver/need does it address.
Prediction: What did you expect to happen
Plan: What questions will be answered (Who, What, When, Where)?
What data will be collected (Who, What, When, Where)? Do
Carry out the plan.
Document observations.
Record data.
Study
Analyze the data.
Compare prediction to results of PDSA cycle.
Summarize what was learned (challenges, accomplishments, unintended consequences).
Act
Utilize the learning from this PDSA cycle and incorporate into next PDSA cycle.
Should the team implement the findings from this PDSA cycle?
Is the team ready to make a change?
Consider next PDSA cycle—what additional cycles need to be run?

4. [Organization Name]- [insert] Collaborative
Insert data graph