Facility Name:
Date last updated:
Defining Your Goals and Selecting Your Initiative
| No. | Question | Answer |
|---|---|---|
| 1 | What areas do you want to focus on for improvement? | |
| 2 | What are your goals? | |
| 3 | What initiative will you implement? | |
| Notes or Comments | ||
Planning Your Initiative
| No. | Question | Answer | ||
|---|---|---|---|---|
| 4 | Who will be affected and how? | |||
| 5 | Who can lead the initiative? | |||
| 6 | What resources will be needed? | Types of Staff and Required Time | Estimated Costs | |
| Supplies, Materials, Equipment, and Other Resources Needed | Estimated Costs | |||
| Notes or Comments | ||||
| 7 | What are possible barriers and how can they be overcome? | Barriers | Strategies For Overcoming Barriers | |
| 1. | ||||
| 2. | ||||
| 8 | How will you measure progress and success? | Process Measures | Staff Responsible | |
| Outcome Measures | Staff Responsible | |||
| Notes or Comments | ||||
Timeline
| No. | Question | Task/Milestone | Start Date | End Date |
|---|---|---|---|---|
| 9 | What is the timeline? | |||
Communicating Your Action Plan
| No. | Question | Answer |
|---|---|---|
| 10 | How will you share your action plan and with whom? | |
| Notes or Comments | ||
