Action Planning Tool for the AHRQ Surveys on Patient Safety Culture

Develop Your Action Plan

This Action Planning Tool offers guidance about the key questions you need to answer when developing an action plan for your organization, facility, unit, or department. You can use the Action Plan Template at the end of the tool to document your answers to the questions, including details about your:

  • Goals.
  • Planned initiatives.
  • Needed resources.
  • Process and outcome measures.
  • Timelines.

Answer Ten Key Questions

You will need to answer the following questions. You do not have to address them in this exact order, but you will need to answer all of them to complete your action plan.

Keep the following points in mind as you build your action plan:

  • You may need more time to answer some questions in this tool and may need input from others in your facility.
  • You will probably develop several drafts before you are ready to implement your action plan.
  • After you begin implementing your action plan, you may need to change it. Your action plan should be flexible to accommodate any needed changes.

Defining your goals and selecting your initiatives:

  1. What areas do you want to focus on for improvement?
  2. What are your goals?
  3. What initiatives will you implement?

Planning your initiatives):

  1. Who will be affected, and how?
  2. Who can lead the initiative?
  3. What resources will be needed?
  4. What are possible barriers, and how can they be overcome?
  5. How will you measure progress and success?
  6. What is the timeline?

Communicating your action plan:

  1. How will you share your action plan and with whom?

Defining Your Goals and Selecting Your Initiatives

Survey User's Guides

1. What patient safety culture areas do you want to focus on for improvement?

Your patient safety culture survey scores can help you identify opportunities to improve. Focus on survey results with low scores or scores that are low relative to other benchmarks, such as scores in other units or other organizations. If you administered the survey more than once, look at changes in your scores over time. (For more information about how to analyze your safety culture survey results, see the AHRQ Surveys on Patient Safety Culture User's Guidesi).

After reviewing your survey data, identify one or two areas for improvement. Develop an action plan for each improvement area you identify. To prioritize among several potential improvement areas, consider selecting ones that align with:

  • Your facility's mission, or regulatory or accreditation requirements.
  • Past or current initiatives to improve patient safety or quality of care.
  • Priorities that staff and leadership would support.
  • The expected positive impact that improvement in an area would have on patient safety culture and patient outcomes.
  • The potential for success, given available resources and time.

Arrow Complete Item 1 in the Action Plan Template.


2. What are your goals?

Describe your goals for each improvement area. Your goals could be at the organization or facility level, or if applicable, in a unit or department. Your goals need to be easily understood by leaders, staff implementing the change, and staff who will be affected by the change. For each improvement area that you identify, you may have one main goal or several goals. Remember to set "SMART" goals.

SMART goals should be:

  • Specific.
  • Measurable.
  • Achievable.
  • Realistic.
  • Time bound.

Setting SMART goals will help you see the gap between where you are and where you want to be.

Arrow Complete Item 2 in the Action Plan Template.


3. What initiatives will you implement?

Resource Lists

Identify potential initiatives

Consider the following methods to identify initiatives to achieve your goals:

  • What others are doing. Find out what initiatives other health care organizations, or high-performing units in your organization, are implementing to improve patient safety culture. Be sure to capture their lessons learned. You may want to consult the AHRQ Surveys on Patient Safety Culture Resource Lists,ii which reference initiatives that health care organizations can use to improve patient safety culture and patient safety.
  • Brainstorming sessions. Hold brainstorming sessions to gather as many improvement activity ideas as possible. Encourage everyone to speak up. Don’t let senior staff or more forceful personalities dominate the sessions. Consider allowing people to provide suggestions anonymously. Do not analyze or criticize the usefulness of any particular idea. Just write down all the ideas that people offer.
    • Include individuals whose work may be directly affected by the potential changes. Understanding their perspectives will help you identify better solutions and develop stronger staff engagement when you implement your action plan.
    • Consider an icebreaker activity to get the group talking, particularly if the members of the group do not know each other well.
    • Hold brownbag feedback sessions with staff (and provide food, if possible).
  • Walkarounds or safety huddles. Conduct walkarounds, safety huddles, or one-on-one talks with clinicians and staff, to learn more about their concerns and potential solutions.
  • Short surveys. Develop and administer short surveys to staff in selected positions or departments/offices to capture their views about potential initiatives, and follow up with staff after reviewing the results. The surveys can be 3 to 5 survey items or open-ended questions that ask for written responses.
Evaluate each initiative

After generating a list of potential initiatives, evaluate each initiative by asking the following questions:

  • What is the evidence that the initiative will be effective in achieving your desired goals?
  • How well does it align with your facility's mission?
  • How much support will leaders, stakeholders, providers, and staff provide for it?
  • How long will it take to implement?
  • What will it cost to implement?
  • Are the benefits likely to justify the cost of the initiative?
  • What is its overall likelihood of success?
Select the initiatives you will implement and define their scope

For each improvement area, identify the potential initiatives that have the highest chance for success. Consider whether each initiative should be started on a small scale first before expanding it on a broader scale. Conducting a small-scale pilot allows you to learn from the results and make modifications before investing a large amount of resources. Discuss the list of potential initiatives with your action planning team to select what you will implement and where you will implement it.

Arrow Complete Item 3 in the Action Plan Template.


Planning Your Initiatives

Gather information about how your initiatives should be implemented:

  • Find out what specific activities are required and document what it will take to implement the initiative.
  • Consider whether the initiative will involve training.
  • Talk with other health care organizations that have implemented the same initiative to find out how they did it and identify their lessons learned. You may need to customize the initiative before implementing it.

4. Who will be affected, and how?

Identify key people who will be affected by your initiative. Consider the providers and staff who will be directly affected by changes in processes or policies. Also, changing one thing often has a domino effect in other departments or work areas. Make sure you consider such possible indirect effects of the initiative.

Arrow Complete Item 4 in the Action Plan Template.


5. Who can lead the initiative?

It is essential to identify a leader and/or champion for your initiative. The leader should have the skills needed to manage the project and should be accountable for timely deliverables. This person should be enthusiastic about the initiative and have the energy to see it through, despite difficulties. The person also should be respected by others. A leader or champion might be:

  • A person in a high-level position whose strong support can make it easier to get resources and implement the initiative.
  • A person who may not be in a high-level position but has demonstrated interest in the initiative, would be an enthusiastic supporter, and has influence with other staff.

Arrow Complete Item 5 in the Action Plan Template.


6. What resources will be needed?

What staff will you need and how much of their time will be needed?

In addition to action planning team members, what other staff will you need to help with the initiative? Think about administrative support, information systems, trainers, or outside consultants who may need to be hired. Estimate how much of each person’s time will be needed for the initiative (e.g., hours per week, percentage of time, or hours per month) and how long they will be needed.

What supplies, materials, equipment, or training will be needed?

Think about the required resources and the costs that will be incurred. If things need to be purchased, consider how you will justify the need for them.

If your initial cost estimates seem high:

  • Consider reducing staffing costs or other expenses.
  • Build a strong rationale or business case for why funding the initiative will ultimately benefit the facility and be worth the upfront costs.
  • Investigate additional public or private sources of funding, including grants, within and outside your facility.

Arrow Complete Item 6 in the Action Plan Template.


7. What are possible barriers, and how can they be overcome?

Barriers are things that will make it difficult to implement your initiative. Senior leadership support will be needed to remove barriers and provide resources such as staff time. It is also useful to identify other barriers that could stall the initiative. Develop strategies for overcoming or minimizing them. Consider the following questions.

What are potential reasons the initiative might not get the support it needs?

People within your facility might not support the initiative for several reasons, including:

  • Satisfaction with things the way they are and not seeing a need for change.
  • Inability to fully understand the proposed initiative or its goals.
  • Experience with previous failed attempts at change or with failure to sustain change.
  • Inadequate plans for training or inadequate preparation of staff for the change.
  • Competing priorities.
  • Lack of management or senior leadership support.

Strategies for overcoming these barriers include sharing details about your initiative and listening to staff who have expressed concerns. Their opinions and experiences may give you insights and bring to light the reasons that previous efforts may have failed. Analysis of past failures can help you avoid making similar mistakes in implementing your initiative.

What other possible barriers should you think about?

Other potential barriers could be more basic issues, such as meeting logistics (e.g., ensuring that staff can leave their work area to attend training or meetings or selecting meeting locations that are convenient for team members, including those who are offsite). Draw on the experiences of those within your facility to help you identify other possible barriers and develop strategies for dealing with them.

Arrow Complete Item 7 in the Action Plan Template.


8. How will you measure progress and success?

Action plans should clearly state the process measures you will use to monitor the implementation of your initiative and the outcome measures you will use to assess whether you have met your goals. You should develop these measures before implementation. Keep the measures simple. Make sure that data collection on these measures can fit into daily work processes.

What process measures will you use to monitor the implementation of the initiative?

You need to assess whether your initiative is being implemented according to plan. Is the initiative progressing as scheduled? Are actual costs in line with budgeted costs? The information you collect may include quantitative data as well as qualitative data such as stories or anecdotes.

Examples of process measures include:

  • Number of staff trained.
  • Interim results for the activities, processes, or behaviors you are trying to encourage.
  • Status of implementation progress at specified times.
  • Results from short surveys asking staff how the initiative is going.
  • Information provided during walkarounds, safety huddles, focus groups, or interviews with those involved.
What outcome measures will you use to assess the success of the initiative?

Outcome measures help you assess whether your initiative has been successful in achieving its goals and answer the question, "What were the effects of making this change?" In many cases, goal achievement cannot be assessed immediately after implementing an initiative because it takes time to see the effects of change. Think about when it will be best for you to measure outcomes, and then plan accordingly. Measures can focus on immediate or short-term, intermediate, and longer term outcomes.

Examples of outcome measures include:

  • Change in the number of patient safety events reported from time X to time Y.
  • Reduction in the amount of time it takes to do or accomplish something.
  • Reduction in the number of unsafe conditions, near-misses, or errors.
  • Reduction in the use of shortcuts that put patient safety at risk.
  • Data you already collect for other purposes, such as infection rates and other quality measures.
  • Your facility's scores from the AHRQ Surveys on Patient Safety Culture.

Arrow Complete Item 8 in the Action Plan Template.


9. What is the timeline?

Develop an overall timeline for your action plan that includes time to assess whether goals have been met and to enable you to tell an informative story about what you did and how well it worked. If you plan to implement multiple initiatives, set a timeline for each.

  • Make your timeline realistic. Include start dates and the expected time it will take to complete the initiative.
  • Break down your timeline into steps.
  • Flag the major milestones to help you easily see when target dates should be met.
  • Adjust your timeline if you see the schedule start to slip.
  • Plan to provide routine monthly or quarterly progress updates to your action planning team, leadership, and those affected by the initiative.

Arrow Complete Item 9 in the Action Plan Template.


Communicating Your Action Plan

10. How will you share your action plan and with whom?

Get feedback on the draft action plan, revise as needed, and obtain final approval

Review your action plan to make sure it is complete and accurate. Then review and discuss the draft plan with leadership and other individuals whose support you need for your initiatives. Incorporate their feedback into your plan and present the final plan for official approval.

Share the action plan

Think about effective ways to communicate your action plan to your facility's staff, explaining why it is being implemented, who is involved, what its goals are, what initiatives will be conducted, what the timelines are, and so forth.

Consider using a mix of communication methods, such as meetings, newsletters, email, Web pages, posters, flyers, bulletin boards, and staff representatives in your facility or in each department. Allow time to address staff concerns before you begin your initiatives. You may also want to plan to share interim results with senior leadership and facility staff.

Arrow Complete Item 10 in the Action Plan Template.


i. Hospital: (1.1 MB)
Medical Office: (1.18 MB)
Nursing Home: (575.55 KB)
Community Pharmacy: (506.51 KB)
Ambulatory Surgery Center: (604 KB)

ii. Hospital: (620.44 KB)
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Nursing Home: (642.88 KB)
Community Pharmacy: (437 KB)

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Page last reviewed December 2015
Page originally created December 2015
Internet Citation: Develop Your Action Plan. Content last reviewed December 2015. Agency for Healthcare Research and Quality, Rockville, MD.