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Quality Improvement Project Charter Copyright © 2018 Institute for Healthcare Improvement. All rights reserved. Article Individuals may photocopy these materials for educational, not-for-profit uses, provided that the contents are not altered in any way and that proper attribution is given to IHI as the source of the content. These materials may not be reproduced for commercial, for-profit use in any form or by any means, or republished under any circumstances, without the written Article permission of the Institute for Healthcare Improvement.

IHI TOOL

IHI TOOL: Quality Improvement Project Charter

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Developing an Improvement Project Charter One of the first steps in setting up an improvement project is to write a project charter: the guiding document that helps a team structure its improvement Article project and develop and communicate a shared vision.

The charter provides a rationale and roadmap for the team’s work that can be used to clarify thinking about what needs to be done and why. It also provides a key communication tool to help inform your team, colleagues, constituents, sponsors, and stakeholders about what the team is doing. The charter helps keep the focus on a specific opportunity or problem and identifies the improvement team members.

The charter begins to answer the three essential questions of the Model for Improvement:

This tool provides a template for developing an improvement project charter and includes an example of a Article completed charter. Your project may require answers to some of these questions and not others, but we encourage teams to think carefully about the effect that each question might have on your project.

The goal is to help the team (including the improvement project sponsor) begin the very important process of thinking through the project, communicating with others, and engaging them in your work.

Developing an improvement project charter is an iterative process. The team should review the charter periodically with the improvement project sponsor, revising the charter as the project evolves and the team learns.

IHI TOOL: Quality Article Improvement Project Charter

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Example: QI Project Charter Team: Team Coordinator: Rachel Creegan, Foster Care Children’s Nurse/Child Protection Advisor; Team Member: Tonya Powell, Child Protection Administrative Assistant; Team Member/Process Owner: Janet Watson, Children and Young People’s Health Network Secretary; Improvement Coach: Edgar Montes, Nurse Consultant Vulnerable Children and Young People and Improvement Advisor

Project: Improving the Health Needs Assessment Process for Article Children

Sponsor: Alisha Green, Head of Children’s Services/Child Health Commissioner

Project Start Date: October 5, 2016

Last Revised: November 12, 2016

What are we trying to accomplish? Problem Health care providers often have concerns about children’s wellbeing when they encounter the health care system, but the process for referring children for a Health Needs Assessment and intervention by Child Protective Services is unreliable, meaning we may be missing some children who need help.

Project Description (defines what) We will seek to improve the Article rate of referral of children for a Health Needs Assessment.

Rationale (defines why) In a spot review of files, only about 75 percent of children who had an initial referral discussion also had a follow-up Health Needs Assessment.

Expected Outcomes and Benefits If successful, this project will improve outcomes for children who we are currently missing with Child Protective Services (CPS); it will improve CPS’s ability to serve children; and it will improve staff morale to have a clear, consistent, and reliable process to act upon their observations about children’s health needs. We hope to have a redesigned process map and a referral form upon completion of the project.

Aim Statement All (100 percent of) children who have an initial Article referral discussion to Child Protective Services will be considered for a Health Needs Assessment; 95 percent of these children will get an assessment, if there is an identified need, by January 2017.

How will we know that a change is an improvement? Outcome Measure(s)

• Percent of Child Protective Services case file audits showing evidence of Health Needs Assessment • Percent of staff who demonstrate understanding about Health Needs Assessment • Staff satisfaction Article with Health Needs Assessment process

Process Measure(s) • Percent of children per week who meet the criteria for Health Needs Assessment • Percent of children per week who have a completed Health Needs Assessment

IHI TOOL: Quality Improvement Project Charter

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Balancing Measure(s)

• Percent and description of unexpected problems leading to failure for child to have Health Needs Assessment

What changes can we make that will result in improvement? Initial Activities Develop operational definitions for measurement and criteria for judgment of necessity for Health Needs Assessment. Develop reliable measures by testing the way we collect data/tools (e.g., number of initial referral discussions, percent of children who have a completed Health Needs Assessment).

Change Ideas • Standardize the Health Needs Assessment process to reduce variation in the system to include the

following: criteria; requesting Health Needs Assessment; recording/documentation; monitoring and evaluation using case file audit

• Develop contingency plans to handle the unexpected problems that arise due to variation (e.g., parent does not consent to Health Needs Assessment, CPS investigation)

• Test new Health Needs Assessment documentation that has been aligned with national guidelines

Key Stakeholders Stakeholders include health care providers, social workers who conduct Health Needs Assessments, and Child Protective Services. We will engage them initially through interviews and process mapping to understand the current state, involve them in tests of change, and hold monthly meetings to share results.

Barriers Health care providers may resist the additional time it takes to make the referral; we will seek to overcome this barrier by making the process as simple as possible.

Boundaries Improvements must not require the hiring of additional staff.

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Template: QI Project Charter Team:

Project:

Sponsor:

Project Start Date:

Last Revised:

What are we trying to accomplish? Problem Describe in 2 to 3 sentences the existing condition you hope to improve (i.e., the gap in quality).

Project Description (defines what) Document your current thinking about the activities of the project (e.g., design a new process, improve an existing product or service, etc.). Note the subsystem, pilot population, and/or demonstration unit where the work will take place. Consider including your long-term vision and short-term project goals.

Rationale (defines why) Explain why the current process or system needs improvement. If possible, include baseline data and other benchmarks.

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Expected Outcomes and Benefits How will this improvement benefit the team, the organization, customers, and/or the community? What is the business impact, such as reduced costs or other financial benefits?

Aim Statement What outcome are you hoping to achieve? Specify how good, for whom, and by when (a specific date).

How will we know that a change is an improvement? When defining your project-level measures, provide operational definitions, which specify unambiguously how to derive each measure, and be sure to define numerators and denominators in measures such as percent or rates.

Outcome Measure(s) List the measure(s) you ultimately want to affect as a result of this project.

Process Measure(s) List the measure(s) that will tell you if the system is performing as planned to affect the outcome measure.

Balancing Measure(s) List the measures that will tell you whether you are introducing problems elsewhere in the system.

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What changes can we make that will result in improvement? Initial Activities Consider starting by exploring the process or system you are trying to improve with tools such as interviews, direct observation, cause and effect diagrams, driver diagrams, and process maps/flowcharts.

Change Ideas What ideas do you have for initial tests of change (Plan-Do-Study-Act cycles)?

Key Stakeholders Whose input and support will this project require? How will you engage these key stakeholders?

Barriers What barriers do you predict to your success? How will you overcome these barriers?

Boundaries List any guidelines for the team, including project constraints, rules or procedures, technology considerations, what is out of scope, etc.

1. Team:
2. Project:
3. Sponsor:
4. Project Start Date:
5. Last Revised:
6. Problem:
7. Project Description:
8. Rationale:
9. Expected Outcomes and Benefits:
10. Aim Statement:
11. Outcomes Measures:
12. Process Measures:
13. Balancing Measures:
14. Initial Activities:
15. Change Ideas:
16. Key Stakeholders:
17. Barriers:
18. Boundaries: