1. Community Health Board Name Health Departments within CHB

2. Optional – picture of locations and/or counties Optional – picture of locations and/or counties Could add text about agency/agencies overview – location, county population, how many health departments, etc.

3. Improvement Team Members Who are your team members? – Names, titles, and roles – Team photo (optional, but photos are nice)- MDH has team photos originally sent – would be happy to send them

4. PLAN Problem Statement Aim Statement

5. PLAN - Current Process Process map or list of the process Information you have about the process Any data collection you did about the current process – check sheet examples, charts, surveys, etc. 5

6. PLAN - Root Cause Analysis Root Cause analysis – fishbone diagram, 5 why’s, etc. 6

7. PLAN - Improvement Theories Brainstorm list of change ideas Prioritizing matrix of solutions if have Improvement theories generated 7

8. DO - Tests of Change – List any PDSA cycles you implemented – Data collected during DO 8

9. Study What did you find as a result of the PDSA’s – Any findings including charts, graphs, check sheets, etc.

10. Act – Adapt, Adopt or Abandon What changes have you made as a result of your findings? – What did you adapt, adopt or Abandon of your improvements? – List or provide pictures of the key improvements your team made – List or provide pictures of your revised tools, forms, etc. that you created – Include before and after photos – Include quotes from clients/staff about improvements What measurable results have you seen? – List them or show the graphs, charts, etc.

11. Key Learnings What are some of the lessons your team has learned by doing the QI process? − Aha moments − Challenges you overcame − Advice you would give to others

12. Future Plans What does your team plan to do next to spread and sustain QI? – Examples: Additional changes, ways to involve more staff, new QI projects, training, performance management development, etc.