1. Foundations for Change 2017 Project Title
Fellow Name
Title/Dept
Hospital Name
City, State
Date

2. Aim and Background Aim Background How much improvement?
By when? For whom?
Why this project and why now?

3. Measures Outcome Measures: Process Measures: Balance Measures:
How is the system performing? What are the results?
(Suggested 1-2)
Process Measures:
Are the parts or steps in the process or system performing as planned?
(Suggested 3-5)
Balance Measures:
What happened to the system as we improve the outcome and process measures? (Suggested 1-2)

4. Driver Diagram
Paste in your Driver Diagram

5. Change Ideas
Please list the changes that you tested as part of this effort

6. Data
Paste in your Run Chart(s)

7. Reflections Lessons Learned
What were some of your key barriers and how did you overcome them?
Lessons Learned
What surprised you the most about this work?
What advice do you have for others?
Lessons Learned

8. Next Steps