Title

Primary Contact Name

Job title
Name of practice site
Street address
City, state zip
Phone
Email

Primary Intended Outcome(s)

1. Example

2. Example

Relevant PAI Recommendation(s) - EXAMPLE

B26. Every pharmacy department should:

B26a. Identify drug‐therapy management services that should be provided consistently

by its pharmacists.

B26b. Develop a plan to reallocate its resources to devote significantly more pharmacist
time to drug‐therapy management services.

Situation Analysis

Narrative form, less than 600 words.

Service Description

Narrative form, less than 300 words.

Key Elements for Success

1. Example

2.

3.

4.
Resource Utilization

Personnel:

IT and other infrastructure:

Supply Expense:

Return on Investment:

Recognized Intangible Benefits

Narrative description.

Outcome Measures

1. Example. Include measures that worked and measures that didn’t work.

2. Etc.

Lessons Learned

1. Example.

2. Etc.

3.

Other Considerations

Narrative description.

Suggestions for Other Hospitals/Health Systems

Narrative description.

Helpful References

1. Citation

2. Citation