1. [Title of QI Project] Resident name: Faculty Advisor: Start date: End date:

2. PLANNING PHASE

3. Background Title: [Repeat title here] Background: [Reason for the effort. Why is the effort important? How will this improvement benefit patients? What is the potential downside of this effort for patients? What background information (data/analysis/literature review) supports the choice? Who is responsible for literature review?]

4. Select all IOM aims that apply to your aim:

5. Aim [My aim statement here] [ What? How good? By when? For whom?]

6. Team

7. CURRENT STATE ANALYSIS GAP ANALAYSIS

8. Drivers List ‘primary drivers’ identified by team of your project’s aim Specify the ‘secondary drivers’ related to your primary drivers above that are the focus of your team’s QI efforts List change solutions

9. [Aim statement Here] [Driver 1] [Driver 2] [Driver 3] [Driver 1] [Driver 2] [Driver 3] 1.Idea 2.Idea 3.Idea 4.……

10. Current state analysis [Insert at LEAST one of the following*:] Fishbone/Ishikawa diagram Pareto diagram Flow chart/process analysis Walkthrough observations Failure-modes-effects-analysis *Some templates on Blackboard

11. Metrics [Specify your key metrics that you will be tracking on your QI project]

12. PDSA CYCLES

13. List of interventions [Based on drivers & current state analysis, list AT LEAST three (3) planned interventions]

14. Data display 1.[Create a data collection tool, for example an excel spread sheet, a survey, a rubrik etc.] 2.[Plan how to best display your data- if applicable, use a run chart or control chart] 3.[For rare events, can plot time to next event rather than number of events over time]

15. Prediction [write down a numeric estimate/prediction of the problem. This could be based on experience of the team members or literature]

16. Baseline [Show here the baseline data] [For run/control charts: try to display at least 20 baseline data points]

17. PDSA cycle 1 [List 1 st improvement intervention] [Date(s) tried] [Display new data in collection sheet/chart] Lessons learned: [Discuss here why this intervention succeeded or failed. What did you observe happening during the implementation? How do these observations inform modification of this improvement intervention or choice of another intervention? What is the next improvement step and why?]

18. PDSA cycle 2 [List 2 nd improvement intervention] [Date(s) tried] [Display new data in collection sheet/chart] Lessons learned: [Discuss here why this intervention succeeded or failed. What did you observe happening during the implementation? How do these observations inform modification of this improvement intervention or choice of another intervention? What is the next improvement step and why?]

19. PDSA cycle 3 [List 3 rd improvement intervention] [Date(s) tried] [Display new data in collection sheet/chart] Lessons learned: [Discuss here why this intervention succeeded or failed. What did you observe happening during the implementation? How do these observations inform modification of this improvement intervention or choice of another intervention? What is the next improvement step and why?]

20. Data [Show data that are annotated with 1) your changes tested and 2) dates of these change tests]

21. SUMMARY

22. Dates Start date: End date:

23. Improvements Made

24. Barriers that remain

25. Reflection How was this QI experience for you? What went well? What could be improved? What did you take away from this experience?

26. Abstract Title: Authors: Background: Materials & Method: Results: Conclusion: