Sample Implementation Planning Template
Activity
1.0
1.1
1.2
1.3
1.4
1.5
1.6
1.7
1.8
1.9
1.10
1.11
1.12
1.13
1.14
1.15
1.16
1.17
Facility Preparedness
Complete Facility Level Situation
Assessment
Appoint coordinator
Identify key individuals and groups
Establish hand hygiene committee to
oversee implementation
Review the minimum recommended
requirements for implementation
Develop communications plan
Agree on hospital-wide versus phased
unit-based implementation
Complete Product Placement Tool
Select alcohol-based hand rub products
Plan hand care protection program
Establish process for collecting and
analyzing observational data
Identify trainers and observers
Arrange a date and venue to undertake
observer and trainer training
Develop system to collect data on costs
Ensure necessary funds are available for
purchase of alcohol-based hand rub
Complete and obtain sign off on
implementation plan
Assign roles to ensure project task
completion:
• Occupational Health and Safety
• Risk Management
• Quality and Patient Safety
• Housekeeping
• Environmental services/facilities
Start
Date
Target
Finish
Date
To be
carried
out by
Status/Comments
Sample Implementation Planning Template
Activity
Unit based health care providers:
• nurses
• physicians
• allied health professionals
• personal care assistants
• management
• transporters
Purchasing
Infection Control Professionals
Communications
Agree on a method for securing support
from key individuals and groups
Prepare a letter for distribution to senior
managers seeking their support for
program
Baseline Evaluation
Complete senior and middle management
perception survey (baseline)
Complete health care providers
perception survey (baseline)
Complete unit structure survey (baseline)
Collect soap and hand rub consumption
data (monthly)
Complete hand hygiene observations
(baseline)
Complete health care providers
knowledge survey (baseline)
Input data
Analyze data
Write report
Schedule health care provider education
and training
•
1.18
1.19
2.0
2.1
2.2
2.3
2.4
2.5
2.6
2.7
2.8
2.9
2.10
Start
Date
Target
Finish
Date
To be
carried
out by
Status/Comments
Sample Implementation Planning Template
Activity
2.11
3.0
3.1
3.2
3.3
3.4
3.5
3.6
3.7
4.0
4.1
4.2
4.3
4.4
4.5
4.6
4.7
4.8
4.9
4.10
5.0
5.1
Procure and install hand hygiene products
and equipment
Implementation
Launch program and communications
plan
Feed baseline data and analysis back to
health care providers
Distribute posters and promotional
materials
Develop process for distribution of patient
pamphlets
Educate and provide practical training for
health care providers
Install lotion
Hold regular review meetings
Follow up evaluation
Complete senior and middle managers
perception survey (follow-up)
Complete health care providers
perception survey (follow-up)
Complete unit structure survey (follow-up)
Complete hand hygiene observations
(follow-up)
Complete health care providers
knowledge survey (follow-up)
Complete facility Situation Analysis
(follow-up)
Collect MRSA and VRE HAIs
Collect cost information
Input data
Analyze data
Ongoing action plan and review cycle
Review all results
Start
Date
Target
Finish
Date
To be
carried
out by
Status/Comments
Sample Implementation Planning Template
Activity
5.2
5.3
5.4
5.5
5.6
5.7
5.8
Prepare report of the findings
Present findings to senior and middle
management
Present findings to health care providers
Present findings to Board of Directors
Develop an action plan for the next five
years
Implement education of patients/visitors
Provide feedback to Ministry on
implementation process and materials
Start
Date
Target
Finish
Date
To be
carried
out by
Status/Comments