Action Plan Monitoring Format

Year 2013
Month the action plan/QI project designed ___________________
Objective _____________________________________________________________________________
Intervention_________________________________________________________________-

indicator/ Base phase 1 (month1) phase 2 (month 2) phase 3 (month 3)

intervention line Targe Performanc status Reaso Targ Perfor status Re Targe Performan status Reaso
/activity t e n et mance aso t ce n
n
SBA 12% 18% 13% Delaye Interve 23% 30%
d ntion
not
properl
y
imple
mente
d
Maternal 3 9 4 Delaye Task 9 9
conference d shift/w
ork
overla
od
 Year 2013
Month the action plan/QI project designed December

indicator/ Bas Month:___________ Month:_____________ Month: ________

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on
 Year 2013
Month the action plan/QI project designed January

indicator/ Bas phase 1 phase 2 phase 3

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on
 Year 2013
Month the action plan/QI project designed February

indicator/ Bas phase 1 phase 2 phase 3

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on

Pneumon
ia
 Year 2013
Month the action plan/QI project designed March

indicator/ Bas phase 1 phase 2 phase 3

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on
ANC-4

SBA

PNC

Pneumon
ia
All
forms of
TB
Data
Quality
Diarrhea
 Year 2013
Month the action plan/QI project designed April

indicator/ Bas phase 1 phase 2 phase 3

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on
SBA

ANC-1

Data
Quality
HIV-
testing
 Year 2013
Month the action plan/QI project designed May

indicator/ Bas phase 1 phase 2 phase 3

interventi e Targe Performance status Reaso Targ Perfor status Re Targe Performan status Reaso
on/ line t n et mance as t ce n
activity on