National Training for Safe Hospitals - Sri Lanka - Module 3 - 14Sept22-25

Module 3:
Action Planning for
Safe Hospital

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:
• Three critical gaps in the structural components
• Three critical gaps in the non-structural
components
• Three critical gaps in the functional
components

Action Plan Matrix
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

• Recommended interventions (broad strategies)
for each critical gap
• Recommended activities for each broad
strategy
• Recommended timeline (target deadline) for
each activity

• Proposed resources (human, infrastructure,
budget, etc.) for the corrective action of each
critical gap
• Proposed responsible persons or units for each
critical gap

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 Allotment
Session 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

Modules 2-3: Concept Map of Objectives & Expected Outputs
Your HOSPITAL
Identify potential hazards
Do general risk analysis
Hazards Vulnerabilities Risks
Detailed Assessment of Vulnerabilities
(Structural / Non-structural / Functional)
Action Planning
Weaknesses / Gaps
Prioritized Gaps

Session 1:
Action Plan: Why and
How?

Action Plan: Why?
GAPS GOALS
How? What?
When?
Strategies
Activities/Tactics
How? What?
When?
Strategies
Activities/Tactics
Resources
Timeframe
Resources
Timeframe
• Structural
• Non-structural
• Functional
Objectives

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

Problem Identification
Identified Gaps to be Prioritized for Action Planning
Structural Gaps Non-structural
Gaps
Functional Gaps
1. 1. 1.
2. 2. 2.
3. 3. 3.

GAPS GOALS
How? What?
When?
Strategies
Activities/Tactics
How? What?
When?
Strategies
Activities/Tactics
Resources
Timeframe
Resources
Timeframe
• 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
•Increase hospital power generator capacity
•Life-line upgrading (electricity)

National Training for Safe Hospitals - Sri Lanka - Module 3 - 14Sept22-25

• 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.
1. 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.
2. Decide on the relative weight of each
criterion.

Cost, Acceptability, Ease of implementation, Time involved
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

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.

DM Matrix
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
TAL
R
A
NK
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

Writing
the plan
Strategic
analysis
Objective
setting
Problem
identification
Identified
gaps
Prioritized
gaps to solve
- 6
Action
plan
Strategy
decision
matrix
Objectives

GAPS InterventionAction Plan Matrix
(strategy to
reach
objectives)
Activities
(detailed
activities to
achieve
objectives)
Timeline
(when will it be
done/
accomplished)
unit /person
Structural
Objectives
Non
-structural
Objectives
Functional
Objectives

GO TO
WORKSHOPS and WORKSHEETS
For Sessions 2 and 3
Module 3 Session 2:
Formulation of Action Plans
Module 3 Session 3:
Presentation of Action Plans

Module 3 Sessions
Session Number and Title Time Allotment
Session 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
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.

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.

•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.

•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]

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

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

Presentation of results of
tracking of action plan
implementation and annual
self-assessment on
vulnerability to Top
Management
Submission of annual self-assessment
on vulnerability to
Ministry of Health
Submission to external and
field audit by the Ministry of
Health or third party
2nd to 3rd year after training
course

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
course

Drafting of Policies for
Safe Hospitals
(Hospital / Health
Facility)

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.

•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.

•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.

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

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

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

Review of the policy statement
on the national Safe Hospital /
Program
course
Independent audit of
the national Safe Hospital /
Program
course

GAPS Intervention
(strategy to
reach
objectives)
Activities
(detailed
activities to
achieve
objectives)
Timeline
(when will it
be done/
accomplished)
unit /person
Structural
Objectives
Non
-structural
Objectives
Functional
Objectives

Drafting of Policies and Action
Plan for Safe Hospitals
(Ministry of Health / Hospitals /
Health Facilities)

Module 3:
Action Planning for
Safe Hospital
The End

National Training for Safe Hospitals - Sri Lanka - Module 3 - 14Sept22-25

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National Training for Safe Hospitals - Sri Lanka - Module 3 - 14Sept22-25