Appendix A. Action Plan Tool for Project Sustainability

The Purpose of This Tool

This tool is intended to support sustainability efforts for your catheter-associated urinary tract infections (CAUTI) prevention project team. This worksheet will help your team identify its current state, including what’s working and what’s not working, outline future goals for CAUTI prevention, and develop clear next steps and an action plan to reach those CAUTI prevention goals.

Who Should Use This Tool?

Anyone looking for a way to identify and plan their next steps for continued process improvement is encouraged to use this tool.

How To Use This Tool

This tool can be completed individually or in small groups. The tool is divided into three steps that support sustainability planning:

Step 1: Know where you are (Current State)
Step 2: Know where you want to go (Unit Goals)
Step 3: How are you going to get there (Action Planning)

As you complete each step, carefully think about and record all identified barriers and ratings that you assign to each of the statements below. For example, you may want to note any obvious or persistent barriers, as well as any items that you did not consider until now, and think of ways to apply these components to your sustainability action plan. Remember that sustainability is unique to each environment and can vary greatly across facilities or unit teams. At the end of the activity, you are encouraged to share your sustainability action plan with anyone involved in the initiative.

Step 1-a: Know Where You Are (Current State)

Objective: To identify achievements, barriers, and the overall current state of your unit at this phase of the project. This step is crucial to determining appropriate next steps for achieving and sustaining future goals.

Instructions for completion: Read each statement in each section A below and assign a rating from 1 to 5 (1 = Strongly agree and 5 = Strongly disagree), that best depicts your unit. Next, record specific barriers your team has experienced related to each statement. For each section B, record your best practices, lessons learned, or initial reactions to identify what is working. Note that the more you write down, the more you can take to build your action plan for success in Step 3.

Section A: Project Outcome Considerations	Record Rating 1 – Strongly agree 2 – Agree 3 – Neither agree nor disagree 4 – Disagree 5 – Strongly disagree	Barriers or Opportunities for Improvement (What Has Not Been Working)
My unit CAUTI rate is on par with patient safety and quality improvement goals for my facility.
My unit’s data submission rate is at or above 90%.
My unit participates in project events or meetings, such as content calls, coaching calls, and learning sessions, more than 70% of the time.
My unit follows proper insertion guidelines (such as the CDC HICPAC guidelines).¹

¹ Centers for Disease Control and Prevention Healthcare Infection Control Practices Advisory Committee. Guideline for Prevention of Catheter-associated Urinary Tract Infections. 2009. .

Section B: Best Practices, Lessons Learned, Initial Reactions (What’s Working):

Step 1-b: Know Where You Are (Current State)

Section A: Cultural Considerations (Comprehensive Unit-based Safety Program [CUSP])	Record Rating 1 – Strongly agree 2 – Agree 3 – Neither agree nor disagree 4 – Disagree 5 – Strongly disagree	Barriers or Opportunities for Improvement (What Has Not Been Working)
Control and prevention of CAUTI is a priority in my unit.
My unit feels that senior leadership is committed to our success.
The Science of Safety video is a part of my unit’s orientation or training program for all new staff.
Teamwork has improved at my unit since starting this project.
Clinical leadership is committed to my unit’s success.
My unit has an engaged physician champion.

Section B: Best Practices, Lessons Learned, Initial Reactions (What’s Working):

Step 1-c: Know Where You Are (Current State)

Section A: Facility and Operational Considerations	Record Rating 1 – Strongly agree 2 – Agree 3 – Neither agree nor disagree 4 – Disagree 5 – Strongly disagree	Barriers or Opportunities for Improvement (What Has Not Been Working)
My facility has adequate teaching and coaching resources to educate new staff on the project.
My facility has the means to sustain process improvements.
My facility routinely completes an assessment of teamwork and safety culture. (i.e., Hospital Survey on Patient Safety Culture, Safety Attitude Questionnaire)
My facility presents performance data to an executive board regularly.

Section B: Best Practices, Lessons Learned, Initial Reactions (What’s Working):

Step 2: Know Where You Want To Go (Unit Goals)

Objective: Determine future goals for CAUTI prevention at your facility.

Instructions: Read each statement in section A below and assign a rating from 1 to 5 (1 = Strongly agree and 5 = Strongly disagree), that best depicts your unit. Next, record specific barriers your team has experienced related to each statement. Then for section B, record your best practices, lessons learned or initial reactions to identify what is working. Note that the more you write down, the more you can take to build your action plan for success in Step 3.

Section A: Goal Considerations	Record Rating 1 – Strongly agree 2 – Agree 3 – Neither agree nor disagree 4 – Disagree 5 – Strongly disagree	Barriers or Opportunities for Improvement (What Has Not Been Working)
My facility has goals established for CAUTI prevention or reduction.
My unit has goals established for CAUTI prevention or reduction.
My unit is committed to maintaining a culture of safety.
My facility is committed to maintaining an engaged senior leader on CAUTI prevention.
CAUTI is measured on my facility’s strategic dashboard.
My unit collaborates with other teams for CAUTI prevention (e.g., infection prevention, emergency department, etc.)
My facility devotes resources to sustain CAUTI prevention efforts.

Section B: Best Practices, Lessons Learned, Initial Reactions (What’s Working):

Step 3: How Are You Going To Get There (Action Planning)

Objective: Develop actionable next steps after determining your unit’s current state and future goals related to CAUTI prevention.

Instructions:

Review responses to the statements in Steps 1 and 2 above and compare them with the rating assigned to each statement.
On the next page, select the statements you would like to address in your sustainability plan. Consider items with ratings of 4 or 5. Next, insert the barrier(s) you’ve already written above. Also, you might consider listing those topics in which you have achieved great success (ratings of 1 or 2) and identify what best practices might be leveraged in the development of your action plan around areas needing improvement.
Finally, complete the remaining questions in the column headers below to outline your action plan.
An example is provided in the template below.

Hospital Action Plan for Sustainability

Need or Interest	Idea or Activity	Tools To Use	How Will This Happen?	Who Should Make This Happen?	When Will This Happen?	What Other Information Do I Need To Make This Happen?
Example: Implement the Science of Safety Video at all staff orientation.	Example: Share Science of Safety video with human resources (HR) department for inclusion in orientation materials for hospital staff. Include Science of Safety video in unit orientation.	Example: Science of Safety video.	Example: Engage senior executive to meet with HR to share success of CUSP project and explain importance of the Science of Safety Framework to the success of the project. Ask for video to be included in staff orientation materials.	Example: Nurse manager, Senior executive team member, HR director, or orientation coordinator.	Example: By next quarter.	Example: Share video access information.

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A Model for Sustaining and Spreading Safety Interventions