75
Appendix D
ACTION PLAN WORKSHEETS
76
Guideline: Low Back Pain Example
Overall Implementation Strategy/Focus:
Key Guideline Element
Identify serious problems
Conservative treatment of
acute LBP patients
Evaluate patients who get
worse
Evaluate patients who do
not get better
Manage chronic LBP or
sciatica
Other leverage point
____________
Gaps in Current Practices
(Planning Step 1)
Action Strategy
(Planning Step 3)
_________________________________________________________________________________________________________
Worksheet 1. IMPLEMENTATION STRATEGY
Guideline: _____________________________________
Identify actions for guideline
introduction and education.
(I&E)
Designate someone to serve as
lead for the action and other
staff to be involved.
Identify the tools
and resources for
the action.
Specify the action
timeline.
Action #I&E.__
Lead:
Other Staff:
Start
Complete
Action #I&E.__
Lead:
Other Staff:
Start
Complete
Action #I&E.__
Lead:
Other Staff:
Start
Complete
Action #I&E.__
Lead:
Other Staff:
Start
Complete
_________________________________________________________________________________________________________
Worksheet 2A. ACTION PLAN FOR GUIDELINE INTRODUCTION AND STAFF EDUCATION
77
78
Worksheet 2B. PLANNING WORKSHEET FOR PRACTICE CHANGE IMPLEMENTATION
Key Guideline Element: ___________________________
Identify actions in the
strategy for this guideline
element.
Designate someone to serve as
lead for the action and other
staff to be involved.
Identify the tools
and resources for
the action.
Specify the action
timeline.
Action #___
Lead:
Other Staff:
Start
Complete
Action #___
Lead:
Other Staff:
Start
Complete
Action #___
Lead:
Other Staff:
Start
Complete
Action #___
Lead:
Other Staff:
Start
Complete
Action #___
Lead:
Other Staff:
Start
Complete
_________________________________________________________________________________________________________
Guideline: _____________________________________________
Guideline: _____________________________________
MONTH OF WORK
Actions
Introduction &
Education
#I&E.__
#I&E.__
#I&E.__
#I&E.__
Practice
Changes
#___
#___
#___
#___
#___
#___
#___
#___
1
2
3
4
5
6
7
8
9
10
11
12
_________________________________________________________________________________________________________
Worksheet 3. GANTT CHART OF TIMELINE FOR GUIDELINE IMPLEMENTATION
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80
Guideline: Low Back Pain Example
Key Guideline Element
Identify serious problems
Conservative treatment of
acute LBP patients
Evaluate patients who get
worse
Evaluate patients who do
not get better
Manage chronic LBP or
sciatica
Other leverage point
_______________
Metric
Data Sources
Monitoring Schedule
_________________________________________________________________________________________________________
Worksheet 4. METRICS AND MONITORING