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* 1. Practice Name:

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* 2. Please provide your last name:

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* 3. Date:

Date

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* 4. Desired Goal:

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* 5. Please report on your team meeting(s), if any, since your last PDSA report. For every team meeting, please report the date, the person leading the meeting, the team members who attended and a very brief description of the topics discussed.

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* 6. Meeting #1 Date:

Date

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* 7. Meeting #1 Leader

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* 8. Meeting #1 Attendees

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* 9. Meeting #1 Topics Discussed

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* 10. Meeting #2 Date:

Date

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* 11. Meeting #2 Leader

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* 12. Meeting #2 Attendees

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* 13. Meeting #2 Topics Discussed

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* 14. Meeting #3 Date:

Date

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* 15. Meeting #3 Leader

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* 16. Meeting #3 Attendees

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* 17. Meeting #3 Topics Discussed

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* 18. Plan: We plan to:

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* 19. Desired Outcome:

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* 20. How will we execute/steps to follow:

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* 21. Predictions:

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* 22. Do: Carry out the change or test. Collect data analysis. Describe observations:

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* 23. What, if any, barriers did you encounter during this action period? 

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* 24. What, if any, successes did you have during this action period?

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* 25. Study: Did you meet your measurement goal?

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* 26. What did you learn from this intervention?

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* 27. Did you achieve what you desired?

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* 28. Act: Will you adopt/adapt/abandon? Why?

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* 29. Are there any particular issues or topics you would like to have discussed during an ECHO session or directly with project leaders/staff?

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* 30. Please share any additional comments or suggestions.

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