Work

Evaluate Together Assess Needs

Actions &
Public Resources
Health

Healthcare Business

Communit
Government Education
y
Member

Community Philanthropy
Act on Development & Investors
What’s Focus on
Nonprofits
Important What’s
Importan

Communica
te
Choose Effective
Policies &
Programs

TEMPLATE IMPLEMENTATION PLAN

A tool to help your community’s efforts to be focused and effective

Template Implementation Plan v2.0: February 2015 [Link]

Wisconsin Community Health Improvement Plans and Processes (CHIPP) Infrastructure 1
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 Work
Together Assess Needs
Evaluate
Actions &

TEMPLATE
Public Resources
Health

Healthcare Business

IMPLEMENTATION PLAN Government

Communit
y Education

A tool to help your community’s efforts to be focused Members

and effective Act

Ac on
Community
Development
Philanthropy
& Investors
Focus on
What’s Nonprofits
What’s
Important
Important

Communicat
e

Choose Effective
Policies &
Programs
Introduct
ion
When it comes time to take action on a community’s chosen health priorities, sometimes it is a challenge
to move from a broad goal to effective and strategic action. In the “Act on What’s Important” checklist of
the Wisconsin Guidebook on Improving the Health of Local Communities there are several steps outlined to
help ensure effective implementation – be sure to review those steps when using this tool.

This document addresses one specific part of action planning for impact: a well thought-out
implementation plan. An implementation plan can help assure the work gets done. You may have
already created some of the critical parts of this plan: priority areas and broad goals. This template
moves into more specificity, including:
• Specific and measurable objectives
• Strategies that are known to be or have a high likelihood of being effective (i.e.,
• evidence-based) Specific action steps with accountabilities, deadlines and
• resources needed

This template will help your community to create a plan that is focused and evidence-based and that will
help you stay on track. In addition, the tool will help hospitals and health departments to achieve some of
their specific requirements related to community health improvement. Some of the sections of the
template are there to assure those key requirements are included. (See the Attachment 1 for a more

To enhance the effectiveness of your efforts, be sure you are fully engaging the community leaders and
community members concerned with each issue at every stage, including this planning phase. Their
involvement at this stage will help to assure chosen strategies fit the community and will leverage
ongoing support of this work during implementation. (See the “Work Together” checklist in the Wisconsin
Guidebook on Improving the Health of Local Communities for more guidance on engaging partners.)

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How to Use
this Tool
Your community will have already selected top priority areas to address and may have selected broad
goals and some strategies for addressing those priority areas. Many times those elements are included in
a final report to the community on the results of the community health assessment process. Now it is
time to get more specific.
A few things to keep in
mind:
• Consider forming small, focused teams to do this work. Many communities use “implementation
teams” with expertise and interest in the particular priority topics. Engaging those key partners in
this planning process will help in maintaining commitment and involvement over the long haul.
• An implementation plan should describe the logical sequence of events that will result in the
change you desire. It works like a logic model or strategy map, helping you to drill down from a
broad goal to intermediate accomplishments or outcomes and then to very concrete strategies
and action steps. (See Attachment 2 for a description of the link between the Template
Implementation Plan and a logic model. For more information on logic models, see the University
• of Wisconsin Extension resources.)
The most detailed level of your Implementation Plan – the Action Plan – often becomes your
implementations team’s annual work plan. You may wish to cut and paste it into an annual work
plan document and have your teams use that to guide their work.
• When put into use, a work plan should be a dynamic tool. Target dates may need to be
adapted. Actual results may be different than anticipated.
• Use this tool to document your progress. (Note: Some organizations are required to track
and report on their progress in their community health improvement plan. Using this tool
• can achieve that end. See Attachment 1 for more information on those requirements.)
Partner organizations can extract the appropriate sections of this Implementation Plan to insert
into their organization’s reports, strategic plan and/or performance management plan. Doing that
• will help to document their commitment to the collaboration and to track their efforts internally.
While this tool is primarily designed for writing an entire implementation plan for a community
health improvement initiative, it can also be used on a smaller, more specific scale. For example, a
team or volunteer working on strategies to improve healthy nutrition within one particular school

Once your plan is complete, your community will move into actual implementation, when you will use
this document as a foundation for monitoring, evaluating, and communicating progress to community
leaders and community members. For more information on these steps, review the “Act on What’s
Important” and “Evaluate Efforts” checklists in the Wisconsin Guidebook on Improving the Health of

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Helpful
Resources
As you complete this tool for your community, there are several resources that will
be very helpful.

State and National Community • Healthiest Wisconsin 2020

Health Improvement Plans: • Healthy People 2020
• National Prevention Strategy

Sources for Evidence- • The Community Guide

Based Strategies: • What Works for Health

Additional Wisconsin Resources: • Objectives with Focus: A Pick List of Sample Objectives
for Effective Implementation
• Recommended Core Data Set for Community Health
Improvement
• Compendium of Data Sources for Community Health
Improvement Processes

Instructi
ons
Below are both a blank template for you to complete and a sample to help illustrate how it can be used.
Editable versions of the blank template and the sample are available at [Link]
page=customsitetable.
Complete one template for each priority area; add sections for additional goals or objectives as needed.
Adapt this tool as you see fit for your community.

The following brief description of each section will help to guide your work. (Note: Planning terms are
used in many different ways. You may find other definitions of terms such as “objective” or “goal.” The
terms are is
list below used in thisto explain
intended Adapt
howthe terms as needed to fit your
those
document. community.)

Priority Area: Enter here one of the top issues your community selected as a priority to address at
this time.
Goal: Write a broad statement of what you hope to accomplish related to this priority area.

Performance Demonstrate in this section how you will know you are making progress. State
Measures: specifically what you will measure to determine whether changes have occurred.
Select indicators of progress for both the short term (1-2 years) and long term (3-5
years). Specify the data source you will use for those indicators (or your plan to
develop a measurement system if necessary).
Objectives: Describe the specific measurable end-products of your intervention. Objectives should
be SMART: specific, measurable, appropriate, realistic, and time-framed.
(Note: When writing your objectives, consider using the “Objectives with Focus” tool.)

Background: Document the type of strategy you are using. Cite any evidence-base for the
strategy. (See Helpful Resources above.) Cite if the strategy is a policy change
(required for public health accreditation). You may also choose to provide a link to
any program sites as applicable.

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 Activity: Outline the steps you will take to achieve each objective. The activities are the “how”
portion of the action plan. It is best to arrange activities chronologically by start
dates. Place each activity in a separate row and add as many rows as you need to the
template.
Timeline: State the projected start and end date for each activity.

Resourc Include all resources needed for this action step. (Examples: funding, staff time, space
es needs, supplies, technology, equipment, and key partners.)
Require
Lead Identify by name the key person who will initiate the activity, provide direction for the
Person/ work, and monitor progress.
Organizati
Anticipa Describe the direct, tangible and measurable results of the activity. (Examples: a
ted product or document, an agreement or policy, number of participants.)
Result:
Progress Track progress of completion of activities. Also note any unexpected outcomes, both
Notes: positive and negative.

Alignment: Show the alignment between your community’s priority area and both state and
national priorities. Also show the alignment to tribal priorities when applicable. You can
cite the specific objectives listed by state and national health plans (listed above under
Helpful Resources).

This resource was developed with funding from the University of Wisconsin School of Medicine and Public Health
from the Wisconsin Partnership Program. The resource is a result of a collaboration between the Wisconsin
Association of Local Health Departments and Boards, the University of Wisconsin Population Health Institute, and
numerous additional partners. For more information, please go to [Link] or

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Example
Template
Editable versions of the blank template and the example are available at [Link]
page=customsitetable
ABC Community Health Improvement Process
Implementation Plan
Date Date
Created: Reviewed/Updated

PRIORITY AREA: Nutrition & Physical Activity

GOAL:
ABC County will implement policies that support residents in achieving a healthy diet and increased
physical activity.

PERFORMANCE MEASURES
How We Will Know We are Making a Difference

Short Term Indicators Source Frequenc

y
By DATE, decrease the percentage of adults engaging in no physical WI-Behavioral Annual
activity from x% to y%. Risk Factor
Surveillance
System (BRFSS)
By DATE, decrease the percentage of adults eating less than five servings WI-BRFSS Annual
of fruits and vegetables daily from x% to y%.

By DATE, increase the percentage of WIC infants ever breastfed from x% WI-Dept. of Annual
to y%. Health
Services,
Pediatric
Nutrition
Surveillance
Long Term Indicators Source Frequenc
y
By DATE, decrease the percentage of overweight adults from x% to y%. WI-BRFSS Annual

By DATE, decrease the percentage of obese adults from x% to y%. County Annual
Health
Rankings

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 OBJECTIVE #1:
By DATE, increase the number of ABC County municipalities that are working towards adopting
local complete street policies from # to #.

BACKGROUND ON STRATEGY
Source: Complete Streets Program [Link]
Evidence Base: “Urban design and land use policies” recommended by The Guide to Community
Preventive Services Policy Change (Y/N): Yes

ACTION PLAN

Anticipated
Target Resourc Lead Progre
Activity Product or
Date es Person/ ss
Result
Require Organizati Notes
Attend training on WI’s 12/31/15 d
Staff on
Amy Adams, Increased
complete street legislation and time ABC Health knowledge
assess expected impact on ABC Travel Department Written
County by discussing with resources
Highway Dept. Assessment of
impact
Finish photovoice project, 4/30/16 Staff time Amy Adams and Photo display/
targeting the communities of X, Volunteer Physical Activity presentation
Y, and Z. time Travel Team Volunteers for each
Cameras community

Find at least 1 street/road in 4/30/16 Staff time Amy Adams Graphic

each community and presentation
graphically design a complete of desired
street. design for
each
community’s
selected
Conduct walkability/ 5/31/16 Staff time Amy Adams and Completed
bikeability checklists in Volunteer Physical Activity assessment
those communities. time Travel Team Volunteers for each
community
Create a presentation for city 8/30/16 Staff time Susie Smith, PowerPoint
councils about the new state ABC Health presentation
law, using photovoice and Officer Terri and packet of
complete street pictures. Thomas, ABC materials
Hospital
Present to city councils and 10/31/16 Staff time Susie Presentation
invite to go on a walk audit. Smith Terri and walk audit
Thomas completed

Follow up with city council 11/30/16 Staff time Susie Smith Discussed
chair after meeting next steps

Announce approved policy to 12/31/16 Staff time Terri Thomas Press

the community release
collaboratively with the city Press
council (if approved) coverage

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 OBJECTIVE #2:
By DATE, increase the number of schools participating in a comprehensive Farm to School Program from
# to #.
BACKGROUND ON STRATEGY
Source: [Link]
Evidence Base: Farm to School programs indicated to be effective based on “expert opinion” in “What
Works for Health” Policy Change (Y/N): Yes

ACTION PLAN

Anticipa
Target Resourc Lead Progre
Activity ted
Date es Person/ ss
Product
Require Organizati Notes
or
d on

OBJECTIVE #3:
By DATE, increase the number of early care and education providers who have adopted the Ten
Steps to Breastfeeding- Friendly Child Care Centers from # to #.

BACKGROUND ON STRATEGY
Source: 10 Steps Resource Kit
Evidence Base: Breastfeeding promotion programs indicated to be “scientifically supported” in
“What Works for Health’” Policy Change (Y/N): Yes

ACTION PLAN

Anticipat
Target Resources Lead Progre
Activity ed
Date Required Person/ ss
Product
Organizati Notes
or
on

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ALIGNMENT WITH STATE/NATIONAL PRIORITIES

Obj # Healthiest Wisconsin Healthy People 2020 National Prevention

2020 Strategy
1 Design communities to Increase legislative policies Encourage community
encourage activity for the built environment that design and development
enhance access to and that support physical
availability of physical activity activity
opportunities (Physical
Activity-15)
2 Make healthy foods Increase access to healthy
available for all and affordable foods in
Increase access to communities
healthy foods and support
breastfeeding
3 Increase access to healthy Increase the proportion of Support policies and
foods and support infants who are breastfed programs that promote
breastfeeding (Maternal, Infant and Child breastfeeding
Health-21)

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Blank
Template
Editable versions of the blank template and the example are available at [Link]
page=customsitetable..
[Name of Community] Health Improvement Process
Implementation Plan
Date Date
Created: Reviewed/Updated
PRIORITY AREA:

GOAL:

PERFORMANCE MEASURES
How We Will Know We are Making a Difference

Short Term Indicators Source Frequenc

y

Long Term Indicators Source Frequenc

y

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 OBJECTIVE #1:

BACKGROUND ON STRATEGY
Source:
Evidence
Base:
Policy Change (Y/N):
ACTION PLAN

Anticipa
Target Resources Lead Progre
Activity ted
Date Required Person/ ss
Product
Organizati Notes
or
on

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 OBJECTIVE #2:

BACKGROUND ON STRATEGY
Source:
Evidence
Base:
Policy Change (Y/N):

ACTION PLAN

Anticipa
Target Resourc Lead Progre
Activity ted
Date es Person/ ss
Product
Require Organizati Notes
or
d on

OBJECTIVE #3:

BACKGROUND ON STRATEGY
Source:
Evidence
Base:
Policy Change (Y/N):
ACTION PLAN

Anticipat
Target Resources Lead Progre
Activity ed
Date Required Person/ ss
Product
Organizati Notes
or
on

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ALIGNMENT WITH STATE/NATIONAL PRIORITIES

Obj # Healthiest Wisconsin Healthy People 2020 National Prevention

2020 Strategy

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Attachmen
t 1:
Hospital and Public Health Department Requirements Related to
Implementation Planning

Not-for-profit hospitals have particular requirements related to community health

improvement. In terms of an Implementation Strategy, those requirements include:
• Adopt a written Implementation Strategy to address the community health needs identified
• during the assessment.
Describe
• Thehow the hospital
actions will address
the hospital thetake
intends to needs including:
to address the needs (or indicates if the hospital
does not intend to address the need and explains why they will not be addressing the
• health need).
• The anticipated impact of these actions.
• The programs and resources the hospital plans to commit to address the health needs.
Any planned collaboration between the hospital and other facilities or organizations in
• If the hospital does not intend to address the need, describe why they will not be
• addressing the health need.
Execute the implementation strategy.
Additionally, the hospital’s CHNA must include an evaluation of the impact of any actions that were
taken to address the significant health needs since the previous assessment.

[Note: While the IRS requirements for non-profit hospitals were reviewed and expertise was consulted,
using this template does not guarantee compliance with IRS requirements. Hospitals should consult
with their community benefit (or other appropriate) staff in order to determine whether or not a local
plan meets the IRS requirements.]
Public health departments seeking national accreditation need to meet the specific requirements for
an implementation plan outlined in Public Health Accreditation Board (PHAB) Standard 5.2.2L and 5.2.3L.
• Community
Those requirements include:
health priorities, measurable objectives, improvement strategies and performance
measures with measurable and time-framed targets.
• Strategies should be evidence-based or promising practices (using sources such as the
National Prevention Strategy, Guide to Community Preventive Services, and Healthy
People 2020).
• Strategies should consider the social determinants of health, causes of higher risks and worse
• health outcomes in special populations, and health inequities.
Policy changes needed to accomplish health objectives.
• • Policy changes should address the causes of health inequities, including social and
• economic factors. Individuals and organizations who have accepted responsibility for
• implementing strategies.
• Measurable health outcomes or indicators to monitor progress.
Alignment between the community health plan and the state and national priorities (and tribal

[Note: While state and national experts familiar with the PHAB Standards reviewed and gave input on
this tool, using this template does not guarantee PHAB compliance. Only PHAB site reviewers during
the accreditation review process can determine whether or not a local plan meets the PHAB
requirements.]

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All public health departments in Wisconsin are required under state statute and
administrative rulepolicymakers
• Involve key to: and the general public in determining and developing a community health
improvement plan that includes actions to implement the services and functions specified under s.
• 250.03(1)(L). [251.05 (3)(c)]
Develop and deliver services to reduce the incidence or prevalence of the chronic diseases or
injuries that are the leading causes of disability and premature death in the jurisdiction of the local
health department, the chronic diseases or injuries for which resources are available to the local
health department from the department or the chronic diseases or injuries identified through a
community needs assessment under s. 251.04(6)(a), Stats., as priority public health problems, or by
the regular and systematic collection of information on the health of the community as required
• under
s. 251.05(3)(a), Stats. [DHS 140.04(1)(c)]
Provide an annual report on the activities of the local health department for the preceding

Sourc
es
1 Affordable Care Act (ACA) – Title IX/Section 9007 [Link]
. 111publ148/pdf/PLAW- [Link]
2 IRS Notice 2011-52 (7/25/11) [Link]
. IRS Proposed Rule April 2013 [Link]
3 IRS Final Rule December 2014
. [Link] Public Health
4 Accreditation Board (PHAB) [Link]
. Wisconsin State Statutes & Administrative Rules
5 [Link]

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Attachmen
t 2:
Link Between Template Implementation Plan
and Logic Model
The template implementation plan provided here is intended to follow a typical logic model by providing
a structure to move from a broad goal to intermediate accomplishments or outcomes and then to very
concrete strategies and action steps.
Because different models/tools use different language, this crosswalk is provided to illustrate the link

Template Implementation Plan Logic Model

Category
Category Long
Goal
Term Outcome
………………………………………………………
………….. Medium-Term
Long Term Indicators Outcomes Medium-
………………………………………..
Term Outcomes
Short Term
Short-Term
Indicators……………………………………….

Source:
[Link]

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Acknowledge
ments
This template draws heavily on the work of the Healthy Wisconsin Leadership Institute’s Action Plan
Template. The Healthy Wisconsin Leadership Institute is a continuing education and training resource
supported jointly by the University of Wisconsin School of Medicine and Public Health and the Medical
College of Wisconsin.
The sample implementation plan borrows from actual examples created by Polk County Health
Department (WI) and Oneida County Health Department (WI).

Consultation on this tool was provided by members of the CHIPP Infrastructure Improvement Project
Operations Group and Lauren Shirey, Senior Program Manager, Assessment and Planning for
Accreditation Preparation, National Association of County and City Health Officials (NACCHO).

This resource was developed with funding from the University of Wisconsin School of Medicine and Public Health
from the Wisconsin Partnership Program. The resource is a result of a collaboration between the Wisconsin
Association of Local Health Departments and Boards, the University of Wisconsin Population Health Institute, and
numerous additional partners. For more information, please go to [Link] or

Template Implementation Plan v2.0: February 2015 [Link]

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