Step Four: Track Improvement

As PDSAs are conducted, track the measure(s) that are associated with the aim. For example, the PDSAs to improve adolescent depression screenings, should track the percentage of SBHC clients aged 12-20 years who had a depression screening in the last 12 months.

The measure for the aim is usually not the same data collected for each PDSA. PDSA data are more specific to the change strategy tested. For example, perhaps depression screens are not being done because the provider runs out of time during an annual well visit. Your team wants to test whether having the medical assistant administer the depression screen before every well visit increases screenings. In this case, the data for the PDSA would be the percentage of youth seen for well adolescent visit during that week who were also administered the Patient Health Questionnaire (PHQ-9) by the medical assistant.

If possible, track the measure(s) monthly during the aim’s six to 12 month timeframe. Determine the following before tracking the measure:

  • frequency of data collection,
  • source(s) of data,
  • who will collect data,
  • when data collection will begin,
  • what day/date data will be collected,
  • where data will be entered, and
  • any additional tools or training needed to collect the data.

Common Tracking Tools

Use run charts to determine if the change in the measure you are tracking is statistically significant or attributed to regular variation over time.  Use the process map to chart current clinic workflow and determine where there are potential roadblocks. Use the Cause and Effect Diagram (Fishbone Diagram) to visualize potential causes of problems or variation.

Go to Step Five

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