Developing Strong
Action Plans
Sue Ann Guildermann
Betsy Jeppesen
Director of Education
Vice President, Program Integrity
Stratis Health
Diane Rydrych
Linda Shell
Assistant Director, Division of Health
Policy, Minnesota Department of Health
Corporate Director, Education
Volunteers of America
Now that you know the root causes and
contributing factors that led to the event
or serious accident, what actions will
you put into place to reduce the chance
of it reoccurring?
Corrective actions often
• Education and training
• Telling staff to “be more careful”
• If we stop at these actions, will we prevent a
Hierarchy of actions
• National Center for Patient Safety’s
“Hierarchy of Actions” classifies corrective
actions as:
– Weaker: actions that depend on staff to remember their
training or remember what is written in the policy
– Intermediate: actions are somewhat dependent on staff
remembering to do the right thing, but they provide tools to
help staff to remember or to promote clear communication
– Strong: actions that do not depend on staff to remember to
do the right thing; the action may not totally eliminate the
vulnerability but provide very strong controls
Dept of Veterans Affairs National Center for Patient Safety,
To be most effective, action plans need
to move to stronger actions than
education or reminders alone
Hierarchy of actions: weaker
Double checks (risk for human error)
Posters or signs on the new requirement
New procedure, policy, memo
Training alone
Additional study/analysis
Dept of Veterans Affairs National Center for Patient Safety,
Hierarchy of actions:
Redundancy—everyone entering room looks for “x”
Eliminate/reduce distractions
Checklists, cognitive aids
Eliminate look-alikes and sound-a-likes
Read back—verbal orders
Software enhancements/modifications
Increase staffing; decrease workload
Enhanced documentation/communication
Dept of Veterans Affairs National Center for Patient Safety,
Hierarchy of actions: stronger
• Physical plant changes—e.g., moving a grab
• Simplify the process—remove unnecessary
steps or steps that no longer make sense
• Standardize equipment or process to reduce
• Conduct usability testing before purchasing
new devices—will it really do what you need?
Hierarchy of actions: stronger
• Engineering controls (forcing functions):
– Edits on electronic medical record that won’t let
you exit until a field is filled
– IV tubing that will not allow you to connect certain
types of piggy backs
• Tangible involvement/action by leadership in
support of resident and staff safety
– Leadership checks in with staff during rounds on
how a new process is going, and follows up if
issues are identified
Action plans
Are action plans:
• Linked directly to the root cause(s) and
contributing factors—will the actions keep
event from happening again?
• Easily understood and can be implemented
—practical and achievable?
• Developed whenever possible with
involvement of those closest to the process?
Action plans
Does the action plan:
• Identify someone who will be responsible for
implementation (not necessarily the one who
will do all the steps, but who will check in with
the team to assure it is accomplished)?
• Have an identified target date for
• Include a measurement plan to determine if
the change is having the intended effect?
Action plans
• Important to communicate plan to leadership
and staff—sharing at staff meetings is not
enough (a weak action)
• Regular interaction with staff carrying out plan
is key to evaluating if it is working and to
make sure the fix sticks
Follow through
• Appreciate and recognize staff efforts
• Listen to staff when they share impact of the
• Share data that shows impact with staff
(residents and families if appropriate)
• Be ready to consider additional analysis or
action if the plan is not having the intended
Sue Ann Guildermann
Director of Education
[email protected]
Betsy Jeppesen
Vice President, Program Integrity
Stratis Health
952-853-8510 or 877-787-2847
[email protected]
Diane Rydrych
Assistant Director
Division of Health Policy
Minnesota Department of Health
[email protected]
Linda Shell
Corporate Director,
Education and Learning
Volunteers of America
[email protected]
Protecting, maintaining, and improving the health of all Minnesotans.
Stratis Health is a nonprofit organization that leads collaboration and
innovation in health care quality and safety, and serves as a trusted
expert in facilitating improvement for people and communities.

Developing Strong Action Plans - Minnesota Department of Health