Sample Implementation Planning Template
Sample Implementation Planning Template
Activity
Start
Date
Target
Finish
Date
To be
carried
out by
Status/Comments
• Unit based health care providers:
• nurses
• physicians
• allied health professionals
• personal care assistants
• management
• transporters
Purchasing
Infection Control Professionals
Communications
1.18
Agree on a method for securing support
from key individuals and groups
1.19
Prepare a letter for distribution to senior
managers seeking their support for
program
2.0
Baseline Evaluation
2.1
Complete senior and middle management
perception survey (baseline)
2.2
Complete health care providers
perception survey (baseline)
2.3
Complete unit structure survey (baseline)
2.4
Collect soap and hand rub consumption
data (monthly)
2.5
Complete hand hygiene observations
(baseline)
2.6
Complete health care providers
knowledge survey (baseline)
2.7
Input data
2.8
Analyze data
2.9
Write report
2.10
Schedule health care provider education
and training
Page 2/4
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