Part 1 BACKGROUND (about % page)
Briefly describe the clinical setting. Include patient services and/or environment where the planned change is
proposed to take place. Introduce the problem to be addressed with your change project and describe the
current state of the issue that supports the need for change. (e.g., Current patient falls at your organization are
higher than the national average, current HCAHPS scores are lower when compared to national data, current
CAUTI rates on your unit or in your hospital show you have a problem that is significant compared to national
rates or the CDC goal for CAUTI reduction). Comparison data should be referenced. Demonstrate the current
state and data by initiating a graph. For example, if your problem is CAUTI graph the national rates and rates for
your facility. Your data should be briefly discussed and referenced. You will use this graph to compare your data
at the end of the change. Attach graph in your Appendix
Part 1 PROBLEM STATEMENT (Two sentences) Succinctly state the problem that will be addressed. For
example, “Despite low or no cost immunizations for vulnerable children served at the XXX Clinic in Orange
County, CA, childhood immunization rates fell well below Healthy People 2020 target rates. The current system
of documentation and record keeping system does not provide a reliable process to remind parents and
clinicians when immunizations are due”.
Part 1 AIM STATEMENT (One sentence)
Identify the aim of the planned change: what are you going to improve, by how much, when. For example, “the
aim of the proposed planned change is to improve childhood immunization rates (the what), from 45% to 75%
(by how much) by May 10, 2019 (the when)”.
Sample Solution
