Module 3: Action Planning for

Safe Hospital

Module 3 Objectives

Module 3 Objectives

At the end of this module, participants will be able to:

1.Utilize decision-making tools in identifying the most appropriate strategy for an identified goal or objective.2.Prepare an action plan for three critical gaps in each of the three “Safe Hospitals” components.3.Present action plan to hospital decision-makers.

Module 3 Expected Outcomes

Module 3 Expected Outcomes

At the end of this module,

An action plan table showing the following:• Three critical gaps in the structural components• Three critical gaps in the non-structural

components• Three critical gaps in the functional

components

Action Plan MatrixGAPS Intervention

(strategy to reach objectives)

Activities(detailed activities to achieve objectives)

Timeline(when will it be done/ accomplished)

Resources Responsible unit /person

Structural

Objectives

Non -structural

Objectives

Functional

Objectives

Module 3 Expected Outcomes

At the end of this module,

An action plan table showing the following:• Recommended interventions (broad strategies)

for each critical gap• Recommended activities for each broad

strategy• Recommended timeline (target deadline) for

each activity

Module 3 Expected Outcomes

At the end of this module,

An action plan table showing the following:• Proposed resources (human, infrastructure,

budget, etc.) for the corrective action of each critical gap

• Proposed responsible persons or units for each critical gap

Action Plan MatrixGAPS Intervention

(strategy to reach objectives)

Activities(detailed activities to achieve objectives)

Timeline(when will it be done/ accomplished)

Resources Responsible unit /person

Structural

Objectives

Non -structural

Objectives

Functional

Objectives

Module 3 Expected Outcomes

At the end of this module,

Presentation of the written action plan mainly for sharing purpose

Agreement to bring back to respective institution for further discussion and possible implementation

Module 3 Sessions

Session Number and Title Time AllotmentSession 1: Action plan: Why and How ~1 hour

Session 2: Formulation of an Action Plan ~3 hours

Session 3: Presentation of an Action Plan ~2 hours

Drafting of Policies for Safe Hospitals

Module 3Links to Module 2

Your HOSPITAL

Identify potential hazards

Do general risk analysisHazards Vulnerabilities Risks

Detailed Assessment of Vulnerabilities(Structural / Non-structural / Functional)

Action Planning

Weaknesses / Gaps

Prioritized Gaps

Modules 2-3: Concept Map of Objectives & Expected Outputs

Module 3: Action Planning for

Safe Hospital

Session 1: Action Plan: Why and

How?

Session 1: Action Plan: Why?

GAPS GOALS

How? What? When?

StrategiesActivities/Tactics

ResourcesTimeframe

How? What? When?

StrategiesActivities/Tactics

ResourcesTimeframe

• Structural• Non-

structural• Functional

Objectives

Action Plan: Why?

Session 1: Action Plan: How?

Writing the plan

Strategic analysis

Objective setting

Problem Identification

Writing the plan

Strategic analysis

Objective setting

Problem identification

Identified gaps

Prioritized gaps to solve - 6

Structural Gaps Non-structural Gaps

Functional Gaps

1. 1. 1.

2. 2. 2.

3. 3. 3.

Identified Gaps to be Prioritized for Action Planning

Problem Identification

Writing the plan

Strategic analysis

Objective setting

Problem identification

Identified gaps

Prioritized gaps to solve - 6

Objectives Setting

GAPS GOALS

How? What? When?

StrategiesActivities/Tactics

ResourcesTimeframe

How? What? When?

StrategiesActivities/Tactics

ResourcesTimeframe

• Structural• Non-

structural• Functional

• Preparedness• Response• Recovery

Objectives

• STRATEGY is an overall approach, based on an understanding of the broader context in which you function, your own strengths and weaknesses, and the problem you are attempting to address.

• STRATEGY involves the “big picture” – the overall plan, how you will achieve safe hospital objectives.

• A strategy gives you a framework within which to work, it clarifies what you are trying to achieve and the approach you intend to use.

• It does not spell out specific activities.

Example:

Objective: 100% electrical power demand of hospital available 24/7

•Life-line upgrading (electricity)

•Increase hospital power generator capacity

• An evaluation tool that helps you to compare and choose among alternative problems or solutions in a rational way

• Helps group or individuals select the best choice

• Quickly profiles every group member’s views about relative strengths and weaknesses of alternatives and graphically see the extent of disagreement

1. Select criteria for evaluating your alternatives.• Spend as much time as necessary because

these criteria are the guiding principles by which you will evaluate alternatives.

2. Write the criteria (e.g. impact, cost of unmet expectations, cost of implementation, wear and tear on staff, and so forth) in the boxes along the top of a matrix chart.

3. Decide on the relative weight of each criterion.

Criteria / Weight

Alternatives 1 = High 10 = Low

1 = High 10 = Low

1 = High 10 = Low

1 = High 10 = Low

Cost (x 2) Acceptability Ease of Implementation

Time Involved Tot Rank

Rating / weight / stotal

Rating / weight / stotal

Rating / weight / stotal

Rating / weight / stotal

List: criteria for rating alternatives

1

2

3

Cost, Acceptability, Ease of implementation, Time involved

4. List the alternative problems or solutions in the left-hand column.

5. Have each person in the group independently rate alternative according to criteria.

6. Have each person total his or her score.

7. Tally the score.

8. Use result to reach a decision.

Criteria / Weight

Alternatives 1 = High 10 = Low

1 = High 10 = Low

1 = High 10 = Low

1 = High 10 = Low

Cost (x 2) Acceptability Ease of Implementation

Time Involved

T

O

T

A

L

R

A

N

K

Rating / weight / subtotal

Rating / weight / subtotal

Rating / weight / subtotal

Rating / weight / subtotal

Strategy 1 1 2 2 5 1 5 3 1 3 3 1 3 13 3

Strategy 2 3 2 6 8 1 8 5 1 5 8 1 8 27 2

Strategy 3 6 2 12 3 1 3 8 1 8 4 1 4 27 2

Strategy 4 10 2 20 3 1 3 10 1 10 4 1 4 37 1

DM Matrix

Writing the plan

Strategic analysis

Objective setting

Problem identification

Identified gaps

Prioritized gaps to solve - 6

Action plan

Strategy decision matrix

Objectives

Action Plan MatrixGAPS Intervention(strategy to reach objectives)

Activities(detailed activities to achieve objectives)

Timeline(when will it be done/ accomplished)

Resources Responsible unit /person

Structural

Objectives

Non -structural

Objectives

Functional

Objectives

GO TO WORKSHOPS and WORKSHEETS

For Sessions 2 and 3Module 3 Session 2:

Formulation of Action Plans

Module 3 Session 3: Presentation of Action Plans

Module 3 Sessions

Session Number and Title Time AllotmentSession 1: Action plan: Why and How ~1 hour

Session 2: Formulation of an Action Plan ~3 hours

Session 3: Presentation of Action Plan ~2 hours

Drafting of Policies for Safe Hospitals

Drafting of Policies for Safe Hospitals

(Ministry of Health)

Policy Statement on Safe Hospital / Safe Health Facility

(from Ministry of Health)

Policy Statement on Safe Hospital / Safe Health Facility

(from Ministry of Health)

The Ministry of Health is committed to developing a national Safe Hospital / Health Facility Initiative or Program which shall strive to ensure that all hospitals / health facilities are safe during disasters and their services remain accessible and functioning, at maximum capacity and in the same facility immediately after a large scale disaster or emergency.

Policy Statement on Safe Hospital / Safe Health Facility

(from Ministry of Health)

In particular, we recognize our responsibility to:

•Create a standing permanent committee or office on Safe Hospital / Health Facility which shall oversee the national Safe Hospital / Health Facility Initiative or Program.•Ensure that all hospitals / health facilities in the country undergo training on Safe Hospital / Health Facility Initiative or Program.

Policy Statement on Safe Hospital / Safe Health Facility

(from Ministry of Health)

In particular, we recognize our responsibility to:

•Ensure that a safe hospital / health facility assessment is regularly done (at least annually) in all hospitals / health facilities.•Ensure that hospital / health facility safety improvements be promptly done upon recognition in all hospitals / health facilities.

Policy Statement on Safe Hospital / Safe Health Facility

(from Ministry of Health)

In particular, we recognize our responsibility to:

•Review the policy statement and the national Safe Hospital / Health Facility Initiative or Program formally every three years.•Subject the national Safe Hospital / Health Facility Initiative or Program to independent audit every three years.

Drafting of a 3-year Action Plan for Safe

Hospitals(Ministry of Health)

3-year Action Plan with Timelines (Safe Hospital / Health Facility Initiative or Program) 

[After training on Safe Hospital / Health Facility Initiative or Program with baseline Safe Hospital / Health Facility

Vulnerability Assessment data and action planning by the hospital / health facility participant - trainee for improvement

of identified gaps]

3-year Action Plan with Timelines (Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Refinement of the baseline Safe Hospital / Health Facility Vulnerability Assessment data, particularly those with UNSURE of Status entries

1 week after training course

Formulation of a 3-year action planning for improvement of identified gaps with prioritization on the critical ones and with an "as soon as possible" timeline

2 weeks after training course

Presentation of 3-year action plan to top management for approval and budget

3 weeks after training course

3-year Action Plan with Timelines (Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Implementation of action plan based on agreed milestones

Tracking of action plan implementation

Quarterly basis

Annual self-assessment using the same Safe Hospital / Health Facility Vulnerability Assessment Tool (done initially)

End of 1st year; 2nd year; and 3rd year after training course

3-year Action Plan with Timelines (Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Presentation of results of tracking of action plan implementation and annual self-assessment on vulnerability to Top Management

End of 1st year; 2nd year; and 3rd year after training course

Submission of annual self-assessment on vulnerability to Ministry of Health

End of 1st year; 2nd year; and 3rd year after training course

Submission to external and field audit by the Ministry of Health or third party

2nd to 3rd year after training course

3-year Action Plan with Timelines (Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Review of the policy statement on the Safe Hospital / Health Facility Initiative or Program

End of 3rd year after training course

Independent audit of the Safe Hospital / Health Facility Initiative or Program

End of 3rd year after training course

Drafting of Policies for Safe Hospitals

(Hospital / Health Facility)

Policy Statement on Safe Hospital / Safe Health Facility

(from Hospitals / Health Facilities)

Policy Statement on Safe Hospital / Safe Health Facility

(from Hospitals / Health Facilities)

(Name of Hospital / Health Facility) is committed to developing a Safe Hospital / Health Facility Initiative or Program which shall strive to ensure that the hospital / health facility is safe during disasters and its services remain accessible and functioning, at maximum capacity and in the same facility immediately after a large scale disaster or emergency.

Policy Statement on Safe Hospital / Safe Health Facility

(from Hospitals / Health Facilities)

In particular, we recognize our responsibility to:

•Create a standing permanent committee on Safe Hospital / Health Facility which shall oversee the Safe Hospital / Health Facility Initiative or Program.•Ensure that all staff undergo training on Safe Hospital / Health Facility Initiative or Program.

Policy Statement on Safe Hospital / Safe Health Facility

(from Hospitals / Health Facilities)

In particular, we recognize our responsibility to: •Ensure that a safe hospital / health facility assessment is regularly done (at least annually).•Ensure that hospital / health facility safety improvements be promptly done upon recognition.

Policy Statement on Safe Hospital / Safe Health Facility

(from Hospitals / Health Facilities)

In particular, we recognize our responsibility to: •Review the policy statement and the Safe Hospital / Health Facility Initiative or Program formally every three years.•Subject the Safe Hospital / Health Facility Initiative or Program to independent audit every three years.

Drafting of a 3-year Action Plan for Safe

Hospitals(Hospital / Health

Facility)

3-year Action Plan with Timelines (National Safe Hospital / Health Facility

Initiative or Program) 

[After training course]

3-year Action Plan with Timelines (National Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Registry of all hospitals / health facilities in the country, stratified by regions, by cities, etc.

2 weeks after training course

Development and publication of the country's Safe Hospital / Health Facility Vulnerability Assessment Tools for different categories of hospitals / health facilities

3 months after training course

3-year Action Plan with Timelines (National Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Training of all hospitals / health facilities on Safe Hospital / Health Facility Initiative or Program with baseline Safe Hospital / Health Facility Vulnerability Assessment data and action planning by the hospital / health facility participant - trainee for improvement of identified gaps within a 3-year period starting from right after the training and assessment session

1 year after training course

3-year Action Plan with Timelines (National Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Tracking of Safe Hospital / Health Facility Status of all hospitals / health facilities which have undergone training

Submission of reports by all concerned hospitals / health facilities

1st, 2nd and 3rd year after training course

Field audit of all concerned hospitals / health facilities

2nd to 3rd year after training course

3-year Action Plan with Timelines (National Safe Hospital / Health Facility Initiative or Program) 

Tasks / Activities Timeline

Review of the policy statement on the national Safe Hospital / Health Facility Initiative or Program

End of 3rd year after training course

Independent audit of the national Safe Hospital / Health Facility Initiative or Program

End of 3rd year after training course

Closing:Module 3

Module 3 Objectives

At the end of this module, participants will be able to:

1.Utilize decision-making tools in identifying the most appropriate strategy for an identified goal or objective.2.Prepare an action plan for three critical gaps in each of the three “Safe Hospitals” components.3.Present action plan to hospital decision-makers.

Module 3 Expected Outcomes

At the end of this module, An action plan table showing the following:

GAPS Intervention(strategy to reach objectives)

Activities(detailed activities to achieve objectives)

Timeline(when will it be done/ accomplished)

Resources Responsible unit /person

Structural

Objectives

Non -structural

Objectives

Functional

Objectives

Module 3 Expected Outcomes

At the end of this module,

Presentation of the written action plan mainly for sharing purpose

Agreement to bring back to respective institution for further discussion and possible implementation

Modules 2-3: Concept Map of Objectives & Expected Outputs

Your HOSPITAL

Identify potential hazards

Do general risk analysisHazards Vulnerabilities Risks

Detailed Assessment of Vulnerabilities(Structural / Non-structural / Functional)

Action Planning

Weaknesses / Gaps

Prioritized Gaps

Drafting of Policies and Action Plan for Safe Hospitals

(Ministry of Health / Hospitals / Health Facilities)

Module 3

Any questions?

Module 3: Action Planning for

Safe Hospital The End