Form 2 Attachment B ICU Action Planning Template

Form Approved
OMB No. 0935-XXXX
Exp. Date XX/XX/20XX

AHRQ Safety Program for Intensive Care Units: Preventing CLABSI and CAUTI

Appendix B. Action Plan

The ICU Team Lead is responsible for completing one Action Plan, and submitting the plan electronically in CDS, within 4 weeks after receiving results from the baseline ICU Assessment. The ICU project team is encouraged to work as a team to review various data sources (e.g. ICU assessment, infection data, or other surveys/assessments), to discuss actions, and complete this plan, to identify gap(s) to be targeted and addressed over the course of this program.

Complete one plan for each gap identified.

1. Identified Gap (describe)

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2. How did you identify the gap you have chosen to address? Select all that apply.

• Unit Data

• ICU Assessment

• Hospital Survey on Patient Safety Culture (HSOPS)

• Safety Attitudes Questionnaire (SAQ)

• Manchester Patient Safety Assessment Framework (MaPSaF)

• Other – Please specify source

3. Reason for Choosing this Gap (For example, is the gap the most obvious barrier? Is this gap something that is likely to be overcome at this time? Is this gap something the unit has overcome before? Be specific):

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4. Desired Aim (Aim Statement, be specific, measurable, time-bound):

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5. What Strength Can be Used (Use the ICU Assessment for guidance or suggest another team strength that can be used):

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6. Take Steps to Strategize for Improvement

   1. How will this happen? [Be specific and include important steps to make the idea/activity happen.]

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2. Who will make this happen? [Be specific for each task.]

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3. How do I know to move to next step and by when? [What does success look like? How will you track your progress?]

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4. What could stand in the way of success and how will I address it?

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5. Tools or Resources to Use [webinars, guides, checklists, TeamSTEPPS, CUSP toolkit, etc. Please be specific, select all that apply]

   1. Option list A: CUSP toolkit tools and resources

   2. Option list B: Program educational offerings

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