PDSA Project Pack: Charter, Measures, and Runbook

Welcome

This PDSA Project Pack gives you the practical pieces you need to run focused improvement cycles that produce measurable change. Use the templates as a starting point — adapt wording, measures, and cadence to your team and context. The goal is reliable learning and repeatable improvement, not paperwork.

What’s included

• Project Charter template (fields + short sample)
• Measurement plan: examples of outcome, process, and balancing measures + simple data collection sheet
• PDSA worksheet: a one-page cycle template with prompts
• Weekly reporting card: concise status, run-chart snapshot, and next-step commitments
• Runbook: roles, cadence, meeting agenda, escalation paths
• Communication checklist: who, what, when, how
• Sustainment checklist: how to lock in gains and hand off standard work
• Quick tips and common pitfalls

How to use this pack

Start with a short charter to agree scope and purpose. Select 1–2 clear outcome measures plus 1–2 process measures and one balancing measure. Run short, time-boxed PDSA cycles (1–4 weeks depending on the change). Use the weekly reporting card to keep the team aligned and make decisions from the data.

Project Charter (template + sample)

Use this one-page charter to align the team quickly.

Template fields:

• Project Title: (concise)
• Problem / Hunger: (briefly describe the problem and why it matters)
• Aim Statement: (specific, time-bound, measurable — e.g., reduce average ED door-to-provider time from 52 to 35 minutes within 12 weeks)
• Scope: (what’s included / excluded)
• Owner / Sponsor:
• Team Members & Roles:
• Key Stakeholders:
• Start / Review Dates:

Sample (brief): Reduce missed medication reconciliation on discharge from 18% to under 5% for general medicine patients within 10 weeks. Owner: Dr. K. Sponsor: CNO. Team: pharmacy lead, RN discharge coordinator, IT analyst.

Measures: outcome, process, balancing

Good measurement is simple, visible, and tied to decisions.

• Outcome measures — tell you if the system is improving (example: % of discharges with completed med reconciliation).
• Process measures — track whether your change is being implemented as intended (example: % of discharges where pharmacist reviewed reconciliation before discharge).
• Balancing measures — check for unintended consequences (example: average time to discharge).

Practical advice: For rapid experiments choose one primary outcome and one primary process measure. Limit the number of measures to what the team can reliably collect weekly.

Simple data collection sheet (suggested layout)

Columns: Date | Patient ID (or batch) | Outcome measure value | Process measure value(s) | Balancing measure value | Notes/Exceptions

Keep it on a single page or spreadsheet tab. Enter data weekly. Preserve raw rows so you can create a run chart.

PDSA worksheet (one-page cycle)

1. Plan: Describe the change to test, who will do what, where and when. State the prediction.
2. Do: Carry out the test, collect the agreed measures, note observations and unexpected events.
3. Study: Summarize the data (attach run chart), compare to prediction, capture learning.
4. Act: Decide next steps: adopt, adapt, abandon, or scale. Assign actions and owners.

Keep each cycle small and time-boxed. The worksheet should be completed within 24–48 hours of the study meeting while observations are fresh.

Weekly reporting card (one side)

Keep updates to 10 minutes using the card:

• Headline metric(s): primary outcome + key process
• Run-chart thumbnail or latest weekly values
• Progress vs aim (percent of target)
• Top 3 risks or barriers
• Next cycle commitments (who does what by when)

Use the card to focus conversations on decisions supported by data, not narrative status reports.

Runbook: roles & cadence

Suggested structure:

• Weekly team huddle: 15–30 minutes, review card and PDSA outcomes.
• Data owner: responsible for collecting and updating the weekly card.
• Process owner: runs the PDSA cycles, ensures tests are designed.
• Sponsor: unblock resources and make decisions on scope changes.
• Escalation: If blocking issues persist for more than two cycles, escalate to sponsor with a concise brief.

Communication checklist

• Who needs to know (staff, patients, executives)?
• What is the single sentence update this week?
• When and how will we share progress (weekly email, dashboard, huddle)?
• How will we capture feedback from frontline staff?

Sustainment checklist

• Confirm standard work and documentation for successful changes.
• Integrate measure into operational dashboards or handoffs if sustained.
• Assign ongoing owner for long-term monitoring.
• Plan a 30/60/90 day check-in after adoption to ensure stability.

Quick tips & common pitfalls

• Keep PDSA cycles small — large tests delay learning.
• Measure what matters: avoid long lists of vanity metrics.
• Collect data at the cadence you’ll actually use (weekly is usually enough).
• Document learning concisely — what we learned and what we’ll try next.
• Aim statements that are vague cause scope drift; make them specific and time-bound.

Example scenario (brief)

Problem: High percentage of discharge medication errors.

Charter aim: Reduce medication reconciliation errors from 18% to <5% in 10 weeks.

Measures: Outcome = % errors; Process = % discharges with pharmacist sign-off; Balancing = median time to discharge.

PDSA idea: Pharmacist reviews reconciliation for high-risk patients during morning discharge huddle for 2-week test. Collect process and outcome weekly and adapt.

Suggested attachments & templates

• Charter.docx / Charter.pdf (one-page)
• PDSA-worksheet.xlsx (one row per cycle)
• Weekly-reporting-card.pdf (one-page printable)
• Data-collection-sheet.csv (simple columns as described above)

These can be adapted into your team’s preferred tool (spreadsheet, EHR extract, or the platform’s interactive forms).

Next steps

1. Fill the charter with the team and confirm aim.
2. Select measures and set up the data collection sheet.
3. Run a first, small PDSA cycle and use the weekly reporting card to review.
4. Make decisions from data and iterate quickly.

Where this could get better with platform capabilities

Consider adding interactive forms for the charter, repeatable PDSA worksheet entries, and automated weekly reporting cards that persist data and plot run charts. These changes reduce friction and create a reusable team-owned improvement record.

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