National Continuous Improvement Guidance

During the Resolution Phase, organizations can organize and conduct an Action Planning Workshop (APW) to socialize recorded observations and to develop and finalize appropriate recommended actions to be included in an Action Plan. The APW brings together multiple stakeholders to facilitate the development, adoption, and implementation of recommended actions. The workshop includes those entities potentially responsible for implementation of recommended actions. The final product of the APW is an Action Plan that documents all actions that will be taken, who is responsible for ensuring completion, and various other metrics to determine when and how the actions will be completed. The Action Plan is described in additional detail in the next section.

During the action planning process, leadership makes the explicit decision of whether each recommended action will be taken; not all recommended actions will be implemented. If there is not an explicit decision, personnel may assume that all recommended actions will be implemented, which can cause the Action Plan to fail. If possible, organizations should document leadership's decision on whether a recommended action should be implemented and the rationale (e.g., resources, legal or policy barriers).

This decision can be made during the APW, if leadership are available to participate. However, if leadership is not present at the APW, a separate meeting can be held to decide which of the recommended actions from the APW will be implemented. Additionally, if leadership can only attend part of the APW, that time should be used to discuss which recommended actions should be implemented. Other participants can discuss additional details when leadership is not present.

The first step in preparation of an APW is identifying the appropriate personnel who can attend the APW, including potential responsible entities, and sending out a meeting invitation and agenda. When appropriate, organizations may also consider providing external stakeholders the opportunity to provide feedback on recommended actions, either by participating in the APW or providing written feedback. In some cases, the planner or office developing the observations may develop an initial set of recommended actions for other stakeholders to review and redirect as necessary. It is important to identify and work with responsible entities when developing an Action Plan. Responsible entities are programs, agencies, or organizations accountable for completing their assigned recommended actions in a timely manner. For example, the responsible entity for a recommended action based on an observation about rebuilding infrastructure following a flood may be a local public works department.

Defining Responsible Entities

Some observations and recommended actions will require more than one responsible entity to work together to resolve an observation or it may not be clear who the correct responsible entity is. Here are some suggested tips to consider:

The next step in planning an APW is to disseminate an after-action review product or drafted observations to the relevant stakeholders to capture potential recommended actions that are mentioned in the after-action product. It is important that relevant stakeholders have time to review the after-action product and digest the recorded observations to begin brainstorming recommended actions prior to the APW. The responsible entity will use the recommended actions as the foundation of the Action Plan.

After identifying the responsible entities and disseminating the after-action review product, the next step in planning an APW is to identify a lead facilitator, lead notetaker, and any additional support (e.g., co-facilitator or second notetaker).

Creating the Action Plan

An Action Plan is a document used to assign and track the status of recommended actions from observations. The Action Plan can be referenced and updated as necessary to ensure actions are implemented and that relevant points of contact (POC) understand their responsibilities. The plan provides a common understanding of what actions are being taken, who is taking them (e.g., the responsible entity), and when actions are expected to be completed.

The Action Plan will be developed after the APW using the recommended actions identified during the APW. When creating the Action Plan, organizations should identify the Action Plan manager who will be responsible for managing the plan and ensuring accountability by regularly tracking and updating the status of recommended actions. When possible, the Action Plan manager should be a third party not involved in implementing recommended actions that can hold responsible entities accountable.

The Action Plan is a living document. As the responsible entities make progress on recommended actions, the Action Plan manager should track and update these recommended actions in the Action Plan until all recommended actions are complete. In some cases, the Action Plan manager may be tracking open recommended actions from multiple incidents, which can be accomplished using separate Action Plans or using a consolidated approach to track all open recommended actions within a unified tracking system (e.g., spreadsheet or project management software solution). For complex Action Plans, the manager may be an accountable tracking body with multiple people or organizations tracking progress.

The Action Plan manager also works to consolidate and finalize recommended actions from observations into the Action Plan. This task includes ensuring that recommended actions are effective and that responsible entities agree on the final recommended action language and timelines included in the Action Plan.

Table 6 illustrates the key elements of an Action Plan which are:

  1. Observation topic sentence
  2. Recommended action
  3. Responsible entity (both person and position)
  4. Status
  5. Target completion date

However, stakeholders can customize an Action Plan to fit their organizational needs and priorities. For example, it may be useful to categorize recommended actions by: 1) core capabilities, 2) planning, organization, equipment, training, and exercise (POETE) areas, [1] or 3) community lifelines. [2] Additionally, stakeholders may want to prioritize certain recommended actions over others as high or low priority, as identified during the APW. Include all information that will help the Action Plan manager and other stakeholders best track the recommended actions to completion.

Table 6: Action Plan Example

ObservationRecommended Action #Core CapabilityRecommended ActionResponsible EntityPoint of ContactStatusTarget Completion Date
Area for Improvement: Multiple city departments did not have updated Continuity of Operations (COOP) plans at the time of the ice storm incident, which resulted in gaps in the city's ability to provide certain critical city services.1.1PlanningEach city department must develop or update a departmental COOP plan and establish a regular review and maintenance cycle for the plan.Each city department, in coordination with the city's Office of Emergency ManagementContinuity coordinators of each city departmentCompleteAugust 30, 2021
Area for Improvement: Multiple city departments did not have updated Continuity of Operations (COOP) plans at the time of the ice storm incident, which resulted in gaps in the city's ability to provide certain critical city services.1.2PlanningIn alignment with the city's Integrated Preparedness Plan, develop and conduct exercises every other year focused on departmental COOP plans for each departments' personnel.Each city department, in coordination with the city's Office of Emergency ManagementEach department's Continuity Coordinator and the Training and Exercise Officer of the city's Office of Emergency Management (John Smith)In ProgressMarch 31, 2023
Determining the Effect of Recommended Actions on Documents, Policies, and Trainings

Once recommended actions are implemented, they are likely to have effects on other documents, policies, and/or trainings. These effects should be considered when developing recommended actions, and when possible, be identified in the Action Plan.

When possible, the Action Plan should also include success criteria and/or metrics by which to measure each action. A recommended action can be considered implemented successfully if the outcome resembles the desired outcome described in the observation. These success criteria and/or metrics can be used to evaluate whether the recommended action was successfully implemented and had the desired effect on the root cause. Success criteria and/or metrics can be developed for various time intervals (e.g., three months after implementation, six months after implementation, one year after implementation) to ensure that immediate, near-term, and long-term effects are measured. Additionally, success criteria can include the intended effects on various personnel, including staff and leadership, and communities. The assessment of the success criteria is then addressed as part of the fourth phase of the continuous improvement, known as the Evaluation Phase, which is further described in Chapter 2, Section 2.2.4: Evaluation.

Facilitating the Action Planning Workshop

Finally, personnel can schedule and hold the APW. The length of the APW is dependent on how many observations will be addressed, and there may be a need to hold additional APWs if there are many observations. If multiple APWs are necessary, the first meeting will typically be longer as participants become familiar with the process and their responsibilities. Follow-up meetings can be shorter. However, not all recommended actions warrant review by all attendees of an APW. The APW participants may vary depending on priority or number of responsible entities.

At the beginning of the first APW, the APW facilitator should explain the purpose of the meeting to help participants understand the focus of the meeting and their role in the discussions. Additionally, the APW facilitator should share any ground rules to ensure participants understand who has the authority to make decisions and the ranking/voting procedures. The APW facilitator also communicates the level of consensus required to make decisions. This is important because the APW must be a collaborative process and sometimes disagreement over responsibilities may need to be resolved and agreed upon.

APW Priority Matrix

The APW Priority Matrix is designed to consider individual ranking responses and calculate a ranked list of the top priority observations. This can be achieved using a points system, where higher prioritized observations are awarded more points than lower ones. For example, if an observation is ranked as a stakeholder’s top priority, it is given five points. The fifth ranked priority of that same stakeholder; however, only receives one point. Points are combined to calculate the final ranking based upon the cumulative feedback of all stakeholders.

During the APW, the facilitator keeps the discussion focused on the selected topics based on the APW Priority Matrix (defined in the callout box). The primary goal of the APW should be to determine: 1) time of implementation, 2) agreed upon improvement action, 3) owner, 4) milestones, and 5) problems or limitations that may be barriers to the implementation of a recommended action. Throughout the APW, participants should discuss each of these items in relation to a specific recommended action. Throughout the APW, the group will collectively assign recommended actions to appropriate owners, which will also be recorded in the Action Plan.