Quality Improvement Zone

An action plan records what needs to happen, who is responsible, when it should be completed and how progress will be monitored.

An action plan provides a shared overview of the work and helps teams coordinate activities, maintain momentum and follow through on decisions. It should be treated as a living document and updated as the team learns more about the system and what is needed.

An action plan usually includes:

• the action to be completed
• a named owner for each action
• the target completion date
• the current status
• any support or resources required
• relevant dependencies, risks or barriers
• progress updates or evidence of completion

Improvement projects often involve several people completing different activities. An action plan makes responsibilities and timescales visible, helping the team coordinate its work and monitor progress.

An action plan can help you:

• translate agreed priorities into practical next steps
• clarify ownership and accountability
• coordinate activities across the team
• identify dependencies and resource requirements
• make delays, risks and barriers visible
• maintain momentum between meetings
• communicate progress to stakeholders
• adapt planned activities as learning emerges

Completing actions is not, by itself, evidence that improvement has occurred. The action plan should be used alongside project measures to understand whether the work is contributing to the intended outcomes.

1. Review the improvement aim and priorities

Start by reviewing what the project is trying to achieve and the priorities agreed by the team. This helps ensure the action plan remains focused on work that is relevant to the improvement aim.

Actions may come from:

• project meetings
• driver diagrams
• process mapping
• stakeholder engagement
• PDSA learning
• implementation planning 

2. Identify the actions required

Break each priority down into specific and manageable actions. Describe what needs to happen clearly enough that everyone understands what is expected.

Avoid vague entries such as:

• improve communication
• provide training
• develop the process

Instead, describe the activity more precisely:

• agree and circulate a weekly project update format
• develop and test a training session with one team
• map the referral process with frontline staff and service users

3. Assign an owner

Assign one named owner to each action. This does not mean that the person must complete the action alone, but that they are responsible for ensuring it progresses and providing updates.

Where several people will contribute, these can also be recorded in the plan.

4. Agree a realistic completion date

Set a clear and achievable completion date for each action. Consider competing priorities, available capacity and any other work that must happen first.

Larger actions may need to be divided into smaller steps with separate deadlines.

5. Identify support and dependencies

Consider what is needed to complete each action successfully.

This may include:

• time and staff capacity
• information or data
• equipment or technology
• funding
• approval or leadership support
• input from stakeholders
• completion of another action

Recording these requirements can help the team identify potential delays and address barriers early.

6. Review progress regularly

Review the action plan during project meetings. Update the status of each action using clear categories, such as:

• Not started
• In progress
• Complete
• Delayed or at risk
• No longer required

If colours are used to show status, include text labels so the plan does not rely on colour alone.

For actions that are delayed or at risk, agree what support or further action is needed.

7. Update the plan as learning emerges

Improvement work does not always follow a fixed path. New actions may emerge from data, feedback and PDSA testing, while some planned actions may no longer be needed.

Update the plan when:

• priorities change
• new learning becomes available
• risks or barriers emerge
• responsibilities change
• an action is no longer relevant
• further actions are required

This keeps the plan relevant and prevents it from becoming a static list of outdated tasks.

• Keep actions specific, practical and manageable.
• Assign one named owner to every action.
• Use realistic deadlines that reflect available capacity.
• Record decisions and actions during meetings rather than afterwards.
• Make the plan accessible to everyone responsible for delivering it.
• Review progress regularly and address delays early.
• Remove or revise actions that are no longer relevant.
• Use project measures to understand whether completed actions are contributing to improvement.