One real cycle, start to finish
This is example data from a colorectal cancer screening cycle — the same structure your team fills in. Look at the whole thing before you decide whether MeasureWise is worth 14 days of your attention.
PDSA Cycle · Colorectal Cancer Screening
FIT kit outreach with a day-10 reminder call
Main Street site · Owner: QI Director · Started January 8
Aim (Plan)
Documented- Aim statement
- Increase colorectal cancer screening (CRC) among patients aged 45–75 from 38% to 50% by the end of Q3 at the Main Street site.
- UDS measure
- Colorectal Cancer Screening — baseline 38% (Jan), health center goal 50%
- Prediction
- Mailing FIT kits with a pre-call from the care team will convert 1 in 4 overdue patients within 60 days.
Action (Do)
Documented- What we tested
- Ran an overdue-patient list weekly, mailed 120 FIT kits per month with a reminder call at day 10 and a second call at day 21.
- Who did the work
- 2 MAs on the outreach list, 1 RN care manager on abnormal-result follow-up.
- Tasks logged
- 14 tasks — 12 complete, 2 open (result follow-up for August mailings).
Results (Study)
Documented- Measured result
- CRC screening rate moved 38% → 54% over 8 months (+16 points).
- SPC signal
- July and August sit above the upper control limit of 49% — this is special-cause variation, not month-to-month noise.
- What surprised us
- Kits mailed without the day-10 call returned at less than half the rate.
Decision (Act)
In progress- Decision
- Adopt — spread the mail-plus-call workflow to the two satellite sites in Q4.
- Next cycle
- Draft: test a texted reminder in place of the day-21 call to cut MA phone time.
Did the intervention work, or was it a good month?
MeasureWise calculates the control limits from your own measure history. Two consecutive points above the upper control limit is a real shift — that is the sentence you can defend in front of a site-visit reviewer, and it is the one that goes in your board report.
- Baseline 38% · current 54% · goal 50% (met in July)
- UCL 49% · mean 40% · LCL 31%, recalculated as data arrives
Colorectal Cancer Screening — SPC Chart
The HRSA Audit Binder this cycle produces
Nothing above was re-typed to make this export. It is the same record, printed in the order a surveyor reads it.
- Cycle log with every edit and date stamped
- Aim, prediction, measurement plan, and decision in HRSA-recognizable order
- Task evidence — who did what, and when it closed
- Baseline-to-result delta with the SPC chart attached
- Next-cycle linkage showing the improvement work continued
Sample binder with example data. Your exports reflect your health center's real QI activity.
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