Appendix B: Implementation Plan Template

Improvement Strategy Name: ___________________________________________________________

Date:_______________________________________________________________________________

1. Goals and Strategies

Problem Statement

Goal Statement

Strategy Description

2. Approach

Project Team Members
Role	Name	Title	Department

Barriers to Successful Implementation (actual or potential)

Method of Study Improvement (check one or more)
Plan, Do, Study, Act
Lean
Other

Implementation Steps
Activity (e.g., data collection, staff training, development of new forms, purchases)	Who is responsible?	Due Date

Communications Strategy
Who needs to know about the strategy?	What information do they need?	When do they need the information?	Who will provide the information?

3. Estimated Time and Expenses

Estimated Number of Hours for Implementation
Role	Name	Number of hours per week	Number of weeks	Total number of hours

Resources Needed for Implementation
Resource	Estimated expenditure ($)

Approvals Needed
Name	Issue for Approval	Date Approval Requested	Date Approval Obtained

4. Performance Measures

Performance Measures (check all that apply)
ED Arrival to ED Departure – Admitted Patients
ED Arrival to ED Departure – Discharged Patients
Admit Decision Time to ED Departure
Left Without Being Seen
ED Arrival to Bed
ED Arrival to Physician
Other Measure:
Other Measure:
Other Measure:

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Current as of October 2011

Internet Citation: Appendix B: Implementation Plan Template. October 2011. Agency for Healthcare Research and Quality, Rockville, MD. http://www.ahrq.gov/research/findings/final-reports/ptflow/appendix-b.html