Appendix B: Implementation Plan Template

Appendix B: Implementation Plan Template

Improvement Strategy Name: ___________________________________________________________


1. Goals and Strategies

Problem Statement


Goal Statement


Strategy Description

2. Approach

Project Team Members



Barriers to Successful Implementation (actual or potential)


Method of Study Improvement (check one or more)

Plan, Do, Study, Act 


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

RoleNameNumber of hours per weekNumber of weeksTotal number of hours


Resources Needed for Implementation

ResourceEstimated expenditure ($)


Approvals Needed

NameIssue for ApprovalDate Approval
Date Approval


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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Page last reviewed October 2014
Internet Citation: Appendix B: Implementation Plan Template. October 2014. Agency for Healthcare Research and Quality, Rockville, MD.