This document provides a template for hospitals to develop an action plan to address gaps identified in their facilities. The plan involves: 1) Listing prioritized structural, non-structural and functional gaps. 2) Setting objectives and goals for addressing each gap. 3) Identifying strategy alternatives for each gap. 4) Using a decision matrix to select strategies, considering criteria like cost and feasibility. 5) Creating an action plan matrix laying out activities, timelines, resources and responsibilities for implementing the selected strategies.

1. Worksheets
ACTION PLANNING FOR SAFE HOSPITALS

2. Worksheets
ACTION PLANNING FOR SAFE HOSPITALS
Instructions:
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size.
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Make a presentation that is ready for submission to your
organization’s leaders.

3. ACTION PLANNING FOR SAFE HOSPITALS
Name of Hospital / Health Facility:
Name of Assessor Team Leader:
Date of Self-assessment:
Email Address of Assessor Team Leader:
Pls. accomplish – required!
May place picture of façade of your hospital / health facility.

4. ACTION PLANNING FOR SAFE HOSPITALS
1. LIST OF PRIORITIZED GAPS FOR ACTION PLANNING
STRUCTURAL Gaps NON-STRUCTURAL
Gaps
FUNCTIONAL Gaps
1. 1. 1.
2. 2. 2.
3. 3. 3.
*Must have at least 3 for each element of Safe Hospital listed in the table.

5. ACTION PLANNING FOR SAFE HOSPITALS
2. OBJECTIVE AND GOAL SETTING FOR EACH GAP
STRUCTURAL Gaps Objectives Goals
1.
2.
3.

6. ACTION PLANNING FOR SAFE HOSPITALS
2. OBJECTIVE AND GOAL SETTING FOR EACH GAP
NON-STRUCTURAL
Gaps
Objectives Goals
1.
2.
3.

7. ACTION PLANNING FOR SAFE HOSPITALS
2. OBJECTIVE AND GOAL SETTING FOR EACH GAP
FUNCTIONAL Gaps Objectives Goals
1.
2.
3.

8. ACTION PLANNING FOR SAFE HOSPITALS
3. STRATEGY ALTERNATIVES
STRUCTURAL Gaps Objectives STRATEGY ALTERNATIVES
(at least 2)
1. 1.
2.
3.
2. 1.
2.
3.
3. 1.
2.
3.

9. ACTION PLANNING FOR SAFE HOSPITALS
3. STRATEGY ALTERNATIVES
NON-STRUCTURAL Gaps Objectives STRATEGY ALTERNATIVES
(at least 2)
1. 1.
2.
3.
2. 1.
2.
3.
3. 1.
2.
3.

10. ACTION PLANNING FOR SAFE HOSPITALS
3. STRATEGY ALTERNATIVES
FUNCTIONAL Gaps Objectives STRATEGY ALTERNATIVES
(at least 2)
1. 1.
2.
3.
2. 1.
2.
3.
3. 1.
2.
3.

11. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
STRUCTURAL GAP 1:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

12. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
Criteria Keys
Keys Criteria
1
2
3
4
5
For STRUCTURAL GAPS

13. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
STRUCTURAL GAP 2:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

14. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
STRUCTURAL GAP 3:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

15. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
Criteria Keys
Keys Criteria
1
2
3
4
5
For NON-STRUCTURAL GAPS

16. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 1:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

17. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 2:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

18. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 3:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

19. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
Criteria Keys
Keys Criteria
1
2
3
4
5
For FUNCTIONAL GAPS

20. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
FUNCTIONAL GAP 1:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

21. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
FUNCTIONAL GAP 2:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

22. ACTION PLANNING FOR SAFE HOSPITALS
4. DECISION-MATRIX IN SELECTING STRATEGIES FOR GAPS
FUNCTIONAL GAP 3:
Objectives:
STRATEGY
ALTERNATIVES
(at least 2)
Criteria [at least 3 with relative weights
1. lowest; 3 - highest)] – see Key
Number of persons giving scores: ___
Total
Score
(Sum)
Rank
1 2 3 4 5
1.
2.
3.

23. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
STRUCTURAL GAP
1:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

24. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
STRUCTURAL GAP
2:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

25. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
STRUCTURAL GAP
3:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

26. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 1:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

27. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 2:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

28. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
NON-STRUCTURAL
GAP 3:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

29. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
FUNCTIONAL GAP
1:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

30. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
FUNCTIONAL GAP
2:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

31. ACTION PLANNING FOR SAFE HOSPITALS
5. ACTION-PLAN MATRIX FOR SELECTED STRATEGIES FOR GAPS
FUNCTIONAL GAP
3:
Objectives:
A STRATEGY
SELECTED:
(indicate below)
Activities to
achieve strategy
and objectives
(at least 2)
Timeline
(target
deadlines)
Resources
(human,
infrastructure,
budget, etc.)
Responsibl
e unit and
/ or person
1.
2.
3.

32. Worksheets
ACTION PLANNING FOR SAFE HOSPITALS
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