Date Decided (dd-mm-yyyy)	Person Responsible:	Deadline for Action (dd/mm/yyyy)	Status Update:
[Click on field and type to insert text]	[Click on field and type to insert text]	[Click on field and type to insert text]	[Click on field and type to insert text]

Question	Your Answer
Which quality statement is this action plan for?	[Click on field and type to insert text]
Does this statement apply to your organization? (yes/no)	[Click on field and type to insert text]
What are we doing now?	[Click on field and type to insert text]
What are the gaps between current practice and the quality statement?	[Click on field and type to insert text]
What is the behavioural practice that needs to change?	[Click on field and type to insert text]
Whose behaviour needs to change?	[Click on field and type to insert text]
What are the barriers/facilitators to change?	[Click on field and type to insert text]
Has the statement been prioritized for quality improvement? If so, how? (e.g. QIP)	[Click on field and type to insert text]
What intervention/s can address the barrier and/or enhance the facilitators?	[Click on field and type to insert text]