Project Lead(s) clarify the aim, desired impact, and resource needs: 

• Aim statement – Why are we addressing this Problem/Idea/Need/Suggestion?
• Desired impact – How will addressing it positively impact or benefit the team, our patients, or the organization?
• Resource needs – What resources (time, budget, supplies, etc.) do we think we will need to be successful?

Shared Governance: Check-in with your mentor before getting started. They can help answer questions and lobby for resources you might need.

During team huddle or a separate meeting, the Project Team works together to outline:

• Objective – What do we want to achieve?
• Key result(s) – What changes can we make that will help us achieve it?
• Measure(s) – How will we know if we achieved it? (Is there a unit of measurement for comparison? Think before and after—how will you measure change?)
• SMART Goal – write a first draft of a Specific, Measurable, Attainable, Relevant and Time-bound goal. (e.g., We plan to improve [what] by [doing what] [measured how] from [baseline/starting point] to [goal] by [MM/DD/YY].)

Shared Governance: Share what the team develops at next Team Board huddle. Seek feedback from the expanded team and make updates as needed.

Identify your baseline, which is a summary of the current state or approach:

• Obtain existing baseline data, or create and execute a data collection plan
• Obtain input from stakeholders (What do people impacted by the change think about the data?)
• Analyze and display baseline data on the Task List
• Determine root cause(s) or problem(s)
• Revise objective and SMART goal (if needed)

Once you know your baseline, identify a potential solution:

• Identify all potential solutions based on the root cause(s)
• Review evidence and/or local best practices to identify potential improvements
• Identified solution: Pick the best solution (the one most likely to accomplish your objective)

• Improvement theory – develop a theory for improvement (a prediction using “if…then” approach)
• Develop a strategy to test the theory

Shared Governance: Share baseline, identified solution and theory at next huddle. Get fedback from the team and adjust plan as needed.

• Implement your plan on a small scale (test it)
• Document observations, including any problems and unexpected findings
• Outcome – collect data you identified as needed during “plan” stage

Summarize your findings – was the test successful?

• Compare results against baseline data and measures of success
• Did results match the theory/prediction?
• Were there unintended side effects?
• Was there an improvement?
• Do you need to test the improvement under other conditions?

Data tells you?  Describe what you learned based on implementing the change.

Assess the results of the “Do” and “Study” phases to determine whether to:

• Adopt: standardize the change
• Adapt: adjust the change process for improved results
• Abandon: drop unsuccessful theories and start again with a new theory

Take steps to preserve gains and sustain accomplishments (if any)

Next steps: Make long-term plans for additional improvements (if needed)

Conduct iterative PDSA cycles (when needed)

Shared Governance: Share what you learned during the next Team Huddle and close out the PINS.

• Celebrate your success – every completed PIN is a big team win!
• Communicate what you did/learned at a Council meeting (Mentor/Excellence).
• For significant results, consider sharing your project externally.