Project Charter
After reviewing the detailed assignment instructions in the course for each of the Project Charter components, use this template to complete your project charter, replacing the instructional text in the cells with the required information.
PLEASE NOTE. THIS PROJECT:
- Cannot be implemented and measured until after you have IRB approval from Capella and your site if indicated. The gap analysis for the Project Charter is a retrospective data analysis. So, you cannot make your whole project a retrospective data analysis, as it is just a small part of planning the project.
- Sections need to be written in a narrative with grammatically correct sentences, unless indicated in the specific section.
Part 1 |
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| Project Charter Information | |||||||||||||||
| Project Name | Create a title for your Project Charter. Make the title specific and distinct from other projects so the reader knows the goal and wants to learn more! | ||||||||||||||
| Project Site | Name you approved project site and department within the site. | ||||||||||||||
| Contact at site | Name with credentials:
Organizational Email: Phone Number: |
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| Preceptor | Name with credentials:
Email: Phone Number: |
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| Executive Sponsor | Identify this person by role and title (no names) and briefly describe why this person was selected (rationale for the selection). | ||||||||||||||
| Gap Analysis | Post-operative pneumonia is on a slow but steady rise at the acute care center. Pneumonia contributes to an increased length of stay by 7-9 days, cost, morbidity, and mortality (Livie et al., 2020). Post-pneumonia rates have increased from January 2020 by 1.3% compared to the National Surgical Quality Improvement Program (NSQIP) expected rate of 1.1% (Caparelli et al., 2019). As of the end of 2021, the rate remains at 7.3%, and most of the data will come from abdominal and thoracic surgeries. NSQIP is designed to improve surgical care using risk-adjusted clinical data (Caparelli, 2019). Developing post-operative respiratory complications determines longer hospital stays, morbidity, mortality, and increased healthcare costs. The incidence of post-operative respiratory complications varies from 1% to 23% (Livie et al., 2020). | ||||||||||||||
| Evidence to Support the Need | Pneumonia is a common and severe condition that adversely affects patients’ health and well-being (Halpern, 2017). The situation makes it challenging for patients to breathe. The complications raise questions about gaps within the care system that expose individuals to post-operative pneumonia. In this case, patients are vulnerable to life-threatening symptoms that jeopardize recovery and increase the risk of premature death (Livie, 2020). With over 50,000 Americans dying from pneumonia yearly, it is crucial to design bundles that help the care team identify and intercept errors. Timely interventions protect patients from widespread complications in different parts of the body. Comprehensive treatment in a comfortable environment provides opportunities to identify vulnerable patients and patient-centered measures available to enhance the quality and safety of patient care (Caparelli et al., 2019). | ||||||||||||||
| PICOT | For staff caring for post-operative patients, how will implementation of the ICOUGH bundle and early ambulation affect post-operative pneumonia rates compared to the current practice in 8- 10 weeks? | ||||||||||||||
| Project Aim | The aim is to implement the ICOUGH bundle and early ambulation to prevent post-operative pneumonia. The goal is to avoid the increased length of stay by 7-9 days, increased cost, morbidity, and mortality associated with post-operative pneumonia. Focusing on the health issue is essential based on the need for evidence-based and patient-centered interventions that help create a caring and comfortable environment for everyone. In this case, White Plains can maintain safe and quality patient care based on a timely response to risks within the clinical setting. Notably, reducing post-operative rates to below 1% makes the facility responsive to standards established by the National Surgical Quality Improvement Program (NSQIP). The move strengthens patients’ trust and confidence in the ability of the care team to deliver optimal post-operative care.
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Part II |
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| Stakeholders | |||||||||||||||
| Stakeholder | Identify the key stakeholders for your project. Think of key stakeholders (internal and external). This might include patients/clients, families, community leaders and organizations, health agencies, systems within the organization etc. List between 3-4 potential stakeholder members | ||||||||||||||
| Initials or fictitious name | Title, Role or Affiliation. | Connection to the project. | Potential impact (how affected). | Contribution to the project. | Barriers or anticipated challenges if any | ||||||||||
| Nursing team | Staff Nurse | Surgical ward nurses | The nursing team understands the need for evidence-based interventions to prevent post-operative pneumonia. | The team will embrace training and education on the ICOUGH bundle and early ambulations necessary to establish and maintain quality and safe post-operative practices. | More time taken explaining ICOUGH bundles and individual and collective responsibilities necessary to improve care outcomes. | ||||||||||
| Patients | Recipient of surgical services | Beneficiaries of practices initiated within the surgical unit | Patients are the victims of post-operative pneumonia. Their input and feedback enhance awareness about gaps and improvements necessary to reduce post-operative pneumonia. | Patients share details of vulnerabilities in the surgical unit and interventions necessary to enhance the quality and safety of patient care throughout surgical care. | The functional decline may limit patients from sharing accurate and complete views about issues likely to expose them to post-operative pneumonia. | ||||||||||
| The project team | Responsible for designing and implementing the ICOUGH bundle and early ambulation | Oversee interventions tailored towards enhancing the quality and safety of patient care. | The team will ensure that the ICOUGH bundle and early ambulation strategies match the facility’s strategic priorities. | Share different ideas and perspectives on gaps in the surgical unit and interventions appropriate to reduce the risk of post-operative pneumonia. | Different hierarchies within the team may interfere with decision-making at different points of the project. | ||||||||||
| Team Leader | W.C is the project leader. The leader will guide team members through the stages of problem identification, designing ICOUGH bundles and early ambulation practices, and training to understand the knowledge and skills appropriate for preventing post-operative pneumonia. As the project leader, I will use practical experience to emphasize the need to consistently use ICOUGH bundles and early ambulation to avoid post-operative pneumonia. I aim to leverage qualities and traits such as intent listening, problem-solving, and interdisciplinary collaboration to encourage team-based functions for addressing the issue. The transformational leadership style is ideal for encouraging individuals to embrace team behaviors and attitudes (Harsono et al., 2021). The approach allows the leader to inspire individuals to understand a common goal and the need for a shared vision toward eliminating post-operative pneumonia.
The rationale for selecting the transformational style is the need for individual and collective motivation toward eliminating post-operative pneumonia. The leader creates a conducive environment where everyone shares their suggestions and participates in decisions to optimize outcomes (Specchia et al., 2021). A second leadership approach is a situational style appropriate for guiding the project team to understand individual and collective responsibilities toward producing the intended results. In this case, the leader will initiate incentives for celebrating short-term accomplishments associated with implementing the ICOUGH bundle and early ambulation (Restivo et al., 2022). The rationale for selecting the situational style is to guide project team members in their daily activities. The approach enhances the diagnosis of a problem, flexibility in implementing the change, and partnership with members to produce the best performance.
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| Team Members | Identify 4-6 team members (initials or fictitious name), department or affiliation and credentials or qualifications. Think about how a diverse set of individuals (demographics, disciplines, experiences, knowledge) will add to the team!
Describe each team member’s title, department or affiliation, qualifications/credentials and the rationale for inclusion and how the person contributes to the project’s success. |
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| Title | Department or Affiliation | Credentials or Qualifications | Rationale for selection/Contribution to the project | ||||||||||||
| M.B | Assistant VP of Quality | Nursing | DNP, NEA- BC | The assistant VP of quality analyzes data and initiates evidence-based strategies for improving patient outcomes. The member works with quality data and has significant achievements in guiding the nursing team to maintain the highest patient satisfaction scores. | |||||||||||
| S.S | Assistant Director of Surgical Quality | Nursing | MSN, BSN, RN, CPHQ, CNOR | The director champions optimization of surgical procedures to reduce the risk of post-operative pneumonia. The member fulfills oversight roles necessary for capturing staff and patient input and initiating improvements across the surgical unit. | |||||||||||
| W.C | DNP learner | Nurse in the surgical unit | RN | The DNP learner is the project leader responsible for guiding members through the various phases of the project. Serving as a nurse in a surgical ward makes the member familiar with events including risks associated with post-operative pneumonia. Familiarity with the components of ICOUGH and early ambulation makes the member appropriate for guiding others to enhance quality and safety of patient care. | |||||||||||
| P.Q | Medical Surgical Clinical Nurse specialist | Quality excellence programs | RN, MSN | The specialist assesses the current scenario and coordinates efforts with nurses to improve quality and safety aspects. Experience in addressing infections within the surgical unit makes P.Q a key inclusion in this project. | |||||||||||
| Communication Plan | |||||||||||||||
| Develop a communication plan for each person associated with the Project Charter, e.g., Executive Sponsor, Stakeholders, Team Leader, Team members. | |||||||||||||||
| Team Member/Stakeholder. | Purpose of communication (Inform, share, engage, solicit information?). | Frequency and timing of communication. (How often, specific stages of project?) | Method of communication (consider audience, method, culture, language, inclusion). | Who is responsible for the communication to this member? (Why is it important who delivers the message?) | Potential challenges/ barriers or assets with communication (barriers, language, culture, different disciplines, best practices (cite the literature 1-2 sources as needed). | ||||||||||
| Executive sponsor | Seek feedback on progress and adjustments necessary to achieve the intended results. | Weekly meetings to discuss the progress | Face-to-face conversations, e-mails | The project leader provides reports and responds to questions about the progress. | The executive sponsor has a busy schedule that could delay feedback to the project leader. | ||||||||||
| Team leader | Respond to questions and suggestions made throughout the project | Weekly reports and meetings | Face-to-face conversations, emails | The executive seeks feedback on progress and relevant adjustments | Busy schedule handling team members and coordinating activities throughout the project | ||||||||||
| Project team members | Share details of alignment of the project with strategic priorities and improvements necessary to optimize outcomes. | Weekly sessions on progress and necessary adjustments | Face-to-face discussions | The team leader seeks feedback from team members to understand progress and improvements necessary to achieve the desired results. | Engaging senior and experienced members could be challenging for the leader due to hierarchical barriers. | ||||||||||
| Stakeholders | Share progress regularly explaining milestones and alignment with strategic priorities | Monthly progress reports and weekly e-mails | Reports sent to e-mails | The project team communicates to stakeholders communicating the progress and changes made at different stages of the project. | Stakeholders may avoid providing feedback necessary to strengthen the quality of deliverables. | ||||||||||
Intervention and Measurement |
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| Planned Intervention | · ICOUGH compliance: Emphasize the need for consistent staff compliance with ICOUGH practices. The emphasis is on increased awareness about post-operative pneumonia and staff contribution to risks that expose patients to adverse care outcomes (Seton et al., 2022). For instance, the care team adheres to calls to elevate the head of bed between 30-45 degrees to help patients with their breathing.
· Coughing exercises necessary to make healthcare professionals and patients aware of self-care activities that help prevent post-operative pneumonia. Patients learn about practices such as getting out of bed at least three times every day and proper oral hygiene appropriate for preventing post-operative pneumonia (Mahama et al., 2020). · ICOUGH education to promote interdisciplinary care practices necessary for preventing infections. The care team identifies multiple tactics for reducing post-operative pneumonia such as incentive spirometry, accurate and complete documentation, progress activity to ambulate, and self-care activities (Livie et al., 2020). |
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Improvement Model / Framework |
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| The National Surgical Quality Improvement Program (NSQIP), used to report surgical outcomes, that can be used for performance improvement within a hospital system (Caparelli, 2019). The reasons for selecting the model includes, national validation and the outcome-based nature. The framework is ideal for measuring and improving the quality of surgical care. NSQIP also assesses a facility’s surgical outcomes and guides the care team to initiate targeted quality improvement initiatives such as the ICOUGH bundle meant to enhance quality of care while reducing post-operative complications and costs. | |||||||||||||||
Proposed Outcomes |
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| Metric (What is being measured to determine success): | Outcome Measure (What is the desired outcome in measurable terms): | Process Measure (Are you doing the right things to get to the outcome? Are the steps in the process leading to the planned outcome?): | Balancing Measure (Are the changes being made causing problems in other areas?): | ||||||||||||
| ICOUGH compliance | N/A | Increased rate of compliance with measures associated with ICOUGH bundle | N/A | ||||||||||||
| Post-operative pneumonia cases | Reduced rate of post-operative pneumonia cases by 60% | N/A | N/A | ||||||||||||
| Early ambulation | Increased rates of early ambulation in the surgical unit by 60% | N/A | N/A | ||||||||||||
Part III |
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| Data Collection & Management | |||||||||||||||
| Develop a plan for the collection, management, and stewardship of the data you will collect for your Project Charter. | |||||||||||||||
| Compliance with ICOUGH bundle
Compliance with early ambulation procedures
Post-operative pneumonia cases |
The project leader
The project leader
The project leader, VP of quality, and the assistant director of surgical quality |
Date collected on the fifth week after the implementation
Data collected collected on the fifth week after initiating the implementation process.
Data collected from the third to the fifth week of the implementation process |
Data stored in computers within the surgical care unit
Data stored in the EHRs for effective coordination of early ambulation protocols
EHRs used to stored data for easy assessment of progress and improvements needed to prevent post-operative pneumonia cases. |
Log-in credentials required to access the information. The project leader in charge of monitoring access and approving access requests.
Access privileges to the project team to prevent illegitimate access to sensitive details.
Access privileges to project team members and executive sponsors |
Successful outcomes depend on the care team’s efforts to understand patients’ needs within the surgical care unit. Evidence on past post-operative pneumonia cases and implications necessary to identify improvements and resources necessary to achieve the desired outcomes.
Data on miscommunication and other mishaps important to determine effectiveness of early ambulation procedures.
Data on patients’ demographic details necessary to determine the connection between post-operative pneumonia and patients’ age or functional capacity |
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| Data Anaylsis | |||||||||||||||
| The project is a quality improvement initiative meant to reduce post-operative pneumonia cases. Descriptive statistics is the preferred analysis method, to enable the team make informed conclusions from summaries about rates of compliance with ICOUGH bundle. The descriptive evidence including summary tables and graphs describe the findings on the rate of compliance to identify deviations and improvements necessary to achieve the desired results. | |||||||||||||||
| SWOT Analysis and Business for Project | |||||||||||||||
| Think about how this project benefits the target population, the organization, and those served. Complete the SWOT Analysis. | |||||||||||||||
| Strengths | |||||||||||||||
| · The project team has adequate knowledge and experience in addressing quality and safety issues within the clinical environment.
· White Plains’ leaders understand the importance of safety improvement initiatives and are likely to support the project by allocating adequate resources throughout the implementation phase. · The facility has adequate technical and human resources necessary to achieve the best outcomes from safety and quality improvement projects. · Compliance with ICOUGH bundle is key to enhancing White Plains’ reputation and credibility. |
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| Weaknesses | |||||||||||||||
| · The project team may ignore human-related aspects such as communication barriers and burnout associated with declining quality and safety standards.
· The nursing team may not respond positively to the quality improvement process due to additional responsibilities allocated in the absence of new motivational incentives. · There is a risk of incomplete ICOUGH compliance evidence, which limits the team from making informed conclusions about the relevance of the project. |
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| Opportunities | |||||||||||||||
| · Increased compliance with ICOUGH bundle make the care team responsive to calls for consistent efforts to improve and sustain the highest safety and quality standards.
· White Plains will have a sustainable solution for monitoring safety issues and protecting patients from the risk of post-operative pneumonia. · Patients feels motivated to share opinions and experiences on safety standards and improvements necessary to optimize care outcomes. |
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| Threats | |||||||||||||||
| · Increased patient confidence and trust in the brand exposes White Plains to a larger customer traffic, which means additional human, technical, and administrative resources to maximize patient experiences.
· More funds needed for training and acquiring additional staff for successful implementation of ICOUGH bundle. · Inadequate motivational incentives for the care team may compromise commitment to embracing new changes. |
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References
Caparelli, M. L., Shikhman, A., Jalal, A., Oppelt, S., Ogg, C., & Allamaneni, S. (2019). Prevention of post-operative pneumonia in non-cardiac surgical patients: A prospective study using the National Surgical Quality Improvement Program database. The American Surgeon, 85(1), 8-14. https://pubmed.ncbi.nlm.nih.gov/30760338/
Halpern, L.W. (2017). Early ambulation is crucial for improving patient health. American Journal of Nursing, 117(6), 15. https://pubmed.ncbi.nlm.nih.gov/28541976/
Harsono, A.D., Indrawati, R., & Jus’at, I. (2021). Situational leadership style supports the performance of doctors in the military based hospital. European Journal of Business and Management Research, 6(2), 118-126. https://www.ejbmr.org/index.php/ejbmr/article/download/780/447/2745
Livie, V., Livie, J., & Hilton-Christie, S. (2020). Improving the use of the ‘COUGH’ bundle in surgical high dependency unit, Ninewells Hospital, Dundee. BMJ Open Quality, 9(2), 1-6. https://bmjopenquality.bmj.com/content/bmjqir/9/2/e000851.full.pdf
Mahama, G., Silva, A., Vigneswaran, L., Davis, D., Thomas, L., Barretto, B., Weller, S., Gajasan, J., & Jackson, T. (2020). A bundled approach to care: Reducing the incidence of post-operative pneumonia in patients undergoing hepatectomy and Whipple procedures. Canadian Journal of Surgery, 64(1), 9-13. https://www.researchgate.net/publication/348742139_A_bundled_approach_to_care_reducing_the_incidence_of_postoperative_pneumonia_in_patients_undergoing_hepatectomy_and_Whipple_procedures
Restivo, V., Minutolo, G., Battaglini, A., Carli, A., Capraro, M., Gatea, M., Odone, A., Trucch, C., Vitale, F., & Casuccio, A. (2022). Leadership effectiveness in healthcare settings: A systematic review and meta-analysis of cross-sectional and before–after studies. International Journal of Environmental Research and Public Health, 19, 1-13. https://www.mdpi.com/1660-4601/19/17/10995/pdf
Seton, J. M., Hovan, H. M., Bogie, K. M., Murray, M. M., Wasil, B., Banks, P. G., Burant, C. J., Miller, C., & Vogt, M. (2022). Interactive evidence-based pressure injury education program for hospice nursing: A quality improvement approach. Journal of Wound, Ostomy, and Continence Nursing, 49(5), 428-435. https://europepmc.org/article/med/36108226
Specchia, M.L.; Cozzolino, M.R.; Carini, E.; Di Pilla, A.; Galletti, C.; Ricciardi, W.; Damiani, G. (2021). Leadership styles and nurses’ job satisfaction. Results of a systematic review. International Journal of Environmental Research and Public Health, 18(1552), 1-10. https://doi.org/10.3390/ ijerph18041552