Plan Do Study Act (PDSA) Form by Blue Cross NC

Spring 2019

Please fill out the below form for each quality metric requiring a PDSA. For additional information on how to do a PDSA and fill out the form, please use this link:

https://www.ahrq.gov/professionals/quality-patient-safety/quality-resources/tools/literacy-toolkit/healthlittoolkit2-tool2b.html

Practices will be required to provide results of their first PDSA cycle within the next 6 months.

Question Title

* 1. Practice Information

Practice Name

Practice NPI

Practice Contact Person

Practice Email

Question Title

* 2. Please list out the Quality Metrics needing a PDSA for your practice. (All metrics scoring 50th percentile or below).

PDSA 1:

PDSA 2:

PDSA 3:

PDSA 4:

PSDA 5:

Question Title

* 3. PLAN: Please fill out your practice's plan for each quality metric needing a PDSA. Define the objective, state the desired outcome, and outline a plan on how to improve (needs to include who, what, how)

PDSA 1:

PDSA 2:

PDSA 3:

PDSA 4:

PDSA 5:

Question Title

* 4. DO: Please fill out your practice's approach for measuring success of the PLAN, when the PLAN will be implemented and for how long, and how the practice will track and record its successes and failures.

PDSA 1:

PDSA 2:

PDSA 3:

PDSA 4:

PDSA 5:

Question Title

* 5. STUDY: Please fill out your practice's approach for measuring and analyzing success of the PLAN, how will the practice "study" the results? How does the practice plan to summarize what is learned and share with providers/staff?

PDSA 1:

PDSA 2:

PDSA 3:

PDSA 4:

PDSA 5:

Question Title

* 6. ACT: How will the practice prepare for changes that need to be made based on the results of the PDSA cycle? Will the practice plan to run another cycle, will additional help be brought in etc? How will the practice maintain success if the practice succeeded in its goal?

PDSA 1:

PDSA 2:

PDSA 3:

PDSA 4:

PDSA 5: