Part 2:Draw on the context you developed concerning the gap, need, or opportunity for improvement to
choose the team members you will need to address your quality improvement project, a leader to guide
your project, an executive sponsor, project stakeholders, and a plan for communicating to various
groups and stakeholders.
Introduction
In this assessment, you will identify your team, the relevant stakeholders, and an executive sponsor. You
will also decide who will lead the quality improvement team. The team leader is the “driver” of the
project and is typically someone with the power and support to implement a change. The leader not
only needs to be aware of the clinical, process, or administrative implications and potential
consequences of the proposed change, but also be proficient in leadership skills, strategies, and
emotional intelligence, with the ability to lead and connect with diverse team members and
stakeholders. Does your team leader model effective leadership consistent with change management?
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course
competencies through the following assessment scoring guide criteria:
•
•
•
Competency 1: Evaluate the application of leadership styles to a practice or process change
within a health care or public health delivery system.
•
Identify and justify the selection of executive or organizational sponsors.
•
Justify the selection of a team leader whose leadership style and attributes are most
appropriate to the needs of the project.
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
Justify the selection of team members appropriate to the needs of the project.
•
Justify the selection of key stakeholders for the project.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
•
Develop a communication plan for the executive sponsor, stakeholders, and team
members that explains the purpose, methods, and potential assets and challenges.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
Overview
•
Address most components of the assessment prompt appropriately, using the
assessment description to structure text.
•
Apply APA style and formatting to scholarly writing.
For this second course assessment, you will continue to build upon the Project Charter you began. Draw
on the context you developed concerning the gap, need, or opportunity for improvement to complete
Part 2
Your Project Charter will be a foundational plan, so you will not actually implement the project, collect
or analyze data, et cetera. You may use fictitious information as needed; however, you also need to
obtain data from scholarly literature (cited using the most recent edition of APA style) to support your
Project Charter. Try to make it as realistic as you can!
Instructions
Now that you have identified the “gap” or opportunity for change, completed the SMART objectives,
and developed the AIM statement, it is time to identify an executive sponsor, the team members you
will need to address your quality improvement project, a leader to guide your project, stakeholders
impacted by the project, and a plan for communicating to various groups. The team should
have adequate representation from the respective systems and stakeholders, including end users or
those served. As you create your team, consider the importance of leadership style(s) and issues related
to diversity, equity, and inclusion in making your selections.
Part 2:
1. Executive or Organizational Project Sponsor: Select a project executive sponsor and explain why
you choose this person. The project sponsor holds an authority position in the organization and
ensures the project aligns with the organizational mission and strategy. This person is the liaison
with executive leadership/management. This person is not involved in the day-to-day work of
the team but should be aware of the team’s progress. This person takes responsibility for the
success (or failure) of the project at the organizational level. You may identify the executive
sponsor by title or role. When selecting the executive or organizational sponsor, consider the
following to explain why you selected this person:
•
Identify this person by role and title. Provide a fictional name or use initials (please do
not use a person’s real name or other identifying information).
•
Explain why you selected this person, including factors such as:
▪
Executive level accountability for success or failure.
▪
Access to support and resources.
▪
The ability to address resistance and challenges.
▪
Creates conditions for success.
2. Select the Team: Identify 4–6 team members for the Project Charter. Think about who is familiar
with the different parts of the systems. The team should consist of the people who are involved
with the practice change and carrying out the effort. Some people may have expertise in several
areas. Think about the people who are most important to the project, then complete the
following:
o
o
o
Describe each team member’s title, department, or affiliation.
▪
Think about who is familiar with the different parts of the systems.
▪
As you consider team members, prioritize them in terms of “must have.”
Explain how the person contributes to the project’s success/rationale for inclusion.
▪
The team should consist of the people who are involved with the practice
change and carrying out the effort.
▪
Some people may have expertise in several areas.
Explain how the person will add to the team and/or project’s success.
▪
Consider how a diverse set of individuals (demographics, disciplines,
experiences, knowledge) will add to the team and/or project’s success.
3. Select Your Team Leader: After reviewing the Applying Leadership Styles interactive media
activity, consider the leadership styles and organizational roles most appropriate to drive your
project. Then describe a real or fictitious leader who reflects this style and their primary role in
the organization. Include the following to demonstrate why this leader is best suited to drive
your project:
o
Identify the team leader by initials or a fictitious name and primary role within the
organization.
o
Describe two leadership styles appropriate to the project that the leader might utilize.
o
▪
Present 1–2 sources (published within the last five years) to support your
discussion of these leadership styles. Include APA-style citations.
▪
Explain why these two leadership approaches are important to your project’s
success.
▪
Provide examples of how the leader might apply these leadership approaches in
practice.
Describe useful qualities this leader might leverage for success.
▪
Consider emotional intelligence and communication/collaboration attributes.
▪
Consider proficiency with practices related to diversity, equity, and inclusion.
4. Key Stakeholders: Identify 3–4 key stakeholders for the project. Stakeholders have a vested
interest in the planned change and represent a wide variety of people and organizations, e.g.,
patients/clients, family members, policymakers, advocacy groups, providers, community
resources, health promotion organizations, nonprofit groups, et cetera. Use fictional names or
initials when identifying stakeholders, and include the following when identifying key
stakeholders for your Project Charter:
o
Who is the targeted population?
o
What is the stakeholder’s connection to the project?
o
How is the stakeholder affected or impacted by the project?
o
What is the stakeholder’s contribution to the project?
5. Communication Plan: Develop a communication plan for the executive sponsor, stakeholders,
and team members. Consider the “audience,” and different needs according to culture,
language, and other factors. Include information related to the following:
o
The purpose of the communication.
o
The methods of communication employed (e.g., who is the audience, type of
communication needed for team members versus stakeholders, sponsor, etc.).
o
Potential challenges and assets:
o
▪
Cultural competency.
▪
Implicit bias.
▪
Different levels of knowledge, experience, disciplines, and roles.
▪
Representation.
▪
Diversity and inclusion.
Cite literature to support best practices related to communication and collaboration
within diverse teams (1–2 sources, published within the last five years, using the APA
format).
Additional Requirements
Your assessment should meet the following requirements:
•
Written Communication: Write clearly, accurately, and professionally, incorporating sources
appropriately.
•
Length of Paper: Complete all fields of the Project Charter Template Part 2 (approximately 2–4
pages when complete).
•
Resources: Include sources where appropriate within the template; each part of the Project
Charter must include its own reference page formatted according to the most recent APA style.
•
Font and Font Size: APA format (7th edition) permits Times Roman (12-point), Arial (11-point),
and Calibri (11-point).
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following
course competencies and scoring guide criteria:
•
Competency 1: Evaluate the application of leadership styles to a practice or process change
within a health care or public health delivery system.
•
•
•
Identify and justify the selection of executive or organizational sponsors.
•
Justify the selection of a team leader whose leadership style and attributes are most
appropriate to the needs of the project.
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
Justify the selection of team members appropriate to the needs of the project.
•
Justify the selection of key stakeholders for the project.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
•
Develop a communication plan for the executive sponsor, stakeholders, and team
members that explains the purpose, methods, and potential assets and challenges.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
•
Address most components of the assessment prompt appropriately, using the
assessment description to structure text.
•
Apply APA style and formatting to scholarly writing.
Project Charter Part 2 Scoring Guide
CRITERIA
Identify and
justify the
selection of
executive or
organizational
sponsors.
NONPERFORMANC
E
Does not
identify
executive or
organizational
sponsors.
BASIC
PROFICIENT
Identifies
executive or
organizational
sponsors but
does not
justify their
selection.
Identifies and
justifies the
selection of
executive or
organizational
sponsors.
DISTINGUISHE
D
Analyzes the
selection and
justification of
executive or
organizational
sponsors in
terms of
addressing the
organizational
culture,
including
challenges and
conditions for
success.
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISHE
D
Justify the
selection of
team members
appropriate to
the needs of
the project.
Does not
describe the
team members
appropriate to
the needs of
the project.
Describes but
does not
justify the
selection of
team members
appropriate to
the needs of
the project.
Justifies the
selection of
team members
appropriate to
the needs of
the project.
Justifies the
selection of
team members
appropriate to
the needs of the
project and
explains how a
diverse team
(demographics,
disciplines,
experiences,
knowledge)
could benefit
the project.
Justify the
selection of a
team leader
whose
leadership
style and
attributes are
most
appropriate to
the needs of
the project.
Does not
describe the
selection of a
team leader
whose
leadership
style and
attributes are
most
appropriate to
the needs of
the project.
Describes but
does not
justify the
selection of a
team leader
whose
leadership
style and
attributes are
most
appropriate to
the needs of
the project.
Justifies the
selection of a
team leader
whose
leadership
style and
attributes are
most
appropriate to
the needs of
the project.
Justifies the
selection of a
team leader
whose
leadership style
and attributes
are most
appropriate to
the needs of the
project and
demonstrates
how these
might be
applied in
practice with
examples and
supporting
evidence.
Justify the
selection of
key
stakeholders
for the project.
Does not
identify key
stakeholders.
Identifies key
stakeholders
for the project
but
justification
for their
Justifies the
selection of
key
stakeholders
for the project.
Analyzes the
selection and
justification of
key
stakeholders for
the project,
demonstrating
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
selection is
not clear.
DISTINGUISHE
D
the importance
of
representation.
Develop a
communicatio
n plan for the
executive
sponsor,
stakeholders,
and team
members that
explains the
purpose,
methods, and
potential
assets and
challenges.
Does not
develop a
communicatio
n plan for the
executive
sponsor,
stakeholders,
and team
members.
Develops a
communicatio
n plan for the
executive
sponsor,
stakeholders,
and team
members but
does not
explain the
purpose,
methods, or
potential
assets and
challenges.
Develops a
communicatio
n plan for the
executive
sponsor,
stakeholders,
and team
members that
explains the
purpose,
methods, and
potential
assets and
challenges.
Develops a
communication
plan for the
executive
sponsor,
stakeholders,
and team
members that
explains the
purpose,
methods, and
potential assets
and challenges
with supporting
evidence.
Address most
components of
the assessment
prompt
appropriately,
using the
assessment
description to
structure text.
Does not
address the
assessment
prompt.
Writing lacks
a clear
purpose or
message that
inhibits
effective
communicatio
n with the
intended
audience.
Addresses
most
components of
the assessment
prompt
appropriately,
using the
assessment
description to
structure text.
Addresses all
components of
the assessment
prompt
appropriately
and uses the
prompt to guide
organization.
Additionally,
shares
information
relevant to all
assessment
components at
a level that
communicates
clear meaning.
CRITERIA
Apply APA
style and
formatting to
scholarly
writing.
NONPERFORMANC
E
Does not apply
APA style and
formatting to
scholarly
writing.
BASIC
PROFICIENT
Applies APA
style and
formatting to
scholarly
writing
incorrectly
and/or
inconsistently,
detracting
noticeably
from good
scholarship.
Applies APA
style and
formatting to
scholarly
writing.
DISTINGUISHE
D
Applies APA
style and
formatting to
scholarly
writing.
Exhibits strict
and nearly
flawless
adherence to
stylistic
conventions,
document
structure, and
source
attributions.
What You Need to Know Before Adopting Servant Leadership
Smith, David F, PhD. The Journal of Medical Practice Management : MPM; Tampa Vol. 36, Iss. 6,
(May/Jun 2021): 312-314.
Change Leadership: The Role of Emotional Intelligence
Developing primary care teams prepared to improve quality: a mixed-methods evaluation and lessons
learned from implementing a microsystems approach
Diversity, Inclusive Leadership, and Health Outcomes
Part 3:
Develop an intervention; devise how you will measure if the “change” had the desired effect; establish
how you will collect, manage, protect the data as well as its use and interpretation; consider leadership
in the context of ethics, diversity, equity, and inclusion; and discuss the potential benefits as a result of
this work.
Introduction
In this assessment, you will define the intervention, measurement, and how you will manage and
protect the data. Now is also the time to take a step back and consider ethical leadership within the
context of quality improvement. How might the Quadruple Aim/Quintuple Aim be used to frame quality
improvement efforts with a focus on the patient/client experience (quality and satisfaction), the health
of populations, reducing per capita costs, the well-being of the health care workforce, and health
equity? In this assessment, you will have an opportunity to consider ethical principles and leadership
and complete a SWOT analysis to assess how your quality improvement project affects the target
population, the organization, and those served.
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course
competencies through the following assessment scoring guide criteria:
•
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
•
•
Explain organizational or systemic strengths, weaknesses, opportunities, and threats
(SWOT) relative to the identified project aim.
Competency 3: Develop a project charter that addresses a potential gap, problem, or
opportunity within a health care system.
•
Describe the planned intervention specific to the identified gap.
•
Explain how the intervention will be evaluated including outcome, process, and
balancing measures.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
•
Develop a data collection and management plan that explains how information is
collected, managed, and protected.
•
Describe how ethical leadership practices might be addressed in this project, including
ethical leadership principles.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
•
Address most components of the assessment prompt appropriately, using the
assessment description to structure text.
•
Apply APA style and formatting to scholarly writing.
Your Project Charter will be a foundational plan, so you will not actually implement the project, collect
or analyze data, et cetera. You may use fictitious information as needed; however, you also need to
obtain data from scholarly literature (cited using the most recent edition of APA style) to support your
Project Charter. Try to make it as realistic as you can!
Instructions
You have identified the gap, set measurable objectives, gathered the team, designated leadership, and
developed a plan for communication and collaboration. Now you are ready to develop the intervention
and decide how you will measure if the “change” had the desired effect, and consider how you will
collect, manage, and protect the data as well as its use and interpretation. Think about your Project
Charter in the context of ethics, diversity, equity, and inclusion, and the potential benefits that may
result from this work
Part 3:
1. Intervention & Measurement: Now that you have your team members and a plan, it is time to
consider the intervention for the “change” and how you will measure the impact.
•
o
Describe the planned intervention.
▪
What will you do that is different from the current condition or state? This is the
“change strategy” that will address the identified gap.
▪
Who will be involved with implementing the change?
▪
Process for implementation including when, where, and how. The planned
intervention should address the specific gap you identified in Part 1.
▪
The information provided should allow someone to replicate the planned
intervention so be sure to include specific steps/information.
Develop Outcome, Process, and Balancing Measures.
▪
Outcome: What is the desired outcome in measurable terms.
▪
Compare to the SMART objective you developed that is stated in
measurable terms.
▪
o
o
State the desired outcome after the intervention has been
implemented. This should be stated in very specific and measurable
terms with time parameters.
Process: State 1–2 process measures that address:
▪
Are you doing the right things to achieve the outcome?
▪
Are the steps in the process leading to the planned outcome?
▪
These should be specific and in measurable terms.
Counter/Balancing: As you are not implementing the project, develop
counter/balancing measures that might be anticipated if the planned
intervention is implemented:
▪
Consider the potential for the changes being made causing problems in
other areas that may not be anticipated.
2. Develop a data collection and management plan: Use the template provided to input your data
collection and management plan. This plan should explain how information is collected,
managed, and protected. Include the following:
o
Describe the data that will be collected.
o
Describe who will collect the data. Explain their role and why this person(s) is selected.
o
Describe when the data will be collected. Provide a beginning and ending time frame.
o
Describe how the data will be stored/protected. Consider security, de-identification,
confidentiality, and anonymity.
o
o
Diversity, Equity, and Inclusion: How will the data be interpreted? Do you have
any concerns about how bias might affect data collection, interpretation or
application?
Provide 1–2 citations/references as needed to support your conclusions (cited using the
most recent edition of APA style).
3. Ethical Considerations/Diversity, Equity, Inclusion: As a leader in the field, evaluate how you
might address the following within the context of the Quadruple/Quintuple Aim:
o
Who may benefit from the project?
o
Who may be harmed by the project?
o
Who is included and who is excluded? Consider vulnerable populations
o
How does this align with ethical leadership?
o
How might you leverage power as a leader toward equity?
o
Will you utilize different leadership styles or approaches?
o
o
What specialized skills or best practices might be utilized?
o
How will the well-being of those taking part in the project be addressed?
Include 1–2 citations/references published within the last five years, using the APA
format..
4. Complete a SWOT Analysis:
o
Strengths: Project strengths: What are the assets of the organization that will help it
achieve a successful outcome, e.g., knowledge, support, resources, funding, etc.? Some
examples might include things your organization does well, qualities that make you
different from others, internal resources and assets (loyalty, retention, et cetera).
o
Weaknesses: Potential obstacles or challenges—limitations that may affect success.
What are the potential barriers that might interfere with success? In the past, what
factors were aligned with lack of success and obstacles to change. Some examples might
include lack of resources, lack of personnel, organizational commitment, et cetera.
o
Opportunities: Opportunities to facilitate project success—factors that might be utilized
to increase the likelihood of success. Some examples might include accessing external
resources, opportunities for training and education to meet the needs, needs
assessment for underserved groups, et cetera.
o
Threats: Potential threats to the project—factors and events that may disrupt goal
attainment. Some examples might include increased competition, changes in
regulations or policies, changes in populations, attitudes, et cetera.
Additional Requirements
•
Written Communication: Write clearly, accurately, and professionally, incorporating sources
appropriately.
•
Length of Paper: Complete all fields of the Project Charter Template Part 3 (approximately 2–4
pages when complete).
•
Resources: Include sources where appropriate within the template; each part of the Project
Charter must include its own reference page formatted according to the most recent APA style.
•
Font and Font Size: APA format (7th edition) permits Times Roman (12-point), Arial (11-point),
and Calibri (11-point).
•
Academic Honesty: Submit a draft of your assessment to SafeAssign and make any necessary
changes before you submit it to your instructor for grading.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following
course competencies and scoring guide criteria:
•
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
•
•
•
Explain organizational or systemic strengths, weaknesses, opportunities, and threats
(SWOT) relative to the identified project aim.
Competency 3: Develop a project charter that addresses a potential gap, problem, or
opportunity within a health care system.
•
Describe the planned intervention specific to the identified gap.
•
Explain how the intervention will be evaluated including outcome, process, and
balancing measures.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
Develop a data collection and management plan that explains how information is
collected, managed, and protected.
•
Describe how ethical leadership practices might be addressed in this project, including
ethical leadership principles.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
•
Address most components of the assessment prompt appropriately, using the
assessment description to structure text.
•
Apply APA style and formatting to scholarly writing.
Project Charter Part 3 Scoring Guide
CRITERIA
Describe the
planned
intervention
specific to the
identified
gap.
NONPERFORMANC
E
Does not
identify the
planned
intervention.
BASIC
PROFICIENT
DISTINGUISHED
Identifies the
planned
intervention
but it is not
specific to the
identified gap.
Describes the
planned
intervention
specific to the
identified
gap.
Analyzes the planned
intervention specific
to the identified gap
with a complete
process for
implementation.
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISHED
Explain how
the
intervention
will be
evaluated
including
outcome,
process, and
balancing
measures.
Does not
identify a
means to
evaluate the
intervention
(outcome,
process, and
balancing
measures).
Identifies a
means to
evaluate the
intervention
that includes
incomplete
information
(outcome,
process, and
balancing
measures).
Explains how
the
intervention
will be
evaluated
including
outcome,
process, and
balancing
measures.
Explains how the
intervention will be
evaluated (outcome,
process, and
balancing measures)
including an analysis
of the evaluation
process.
Develop a
data
collection and
management
plan that
explains how
information is
collected,
managed,
and
protected.
Does not
develop a data
collection and
management
plan.
Develops a
data collection
and
management
plan but how
information is
collected,
managed,
and/or
protected is
not included
Develops a
data
collection and
management
plan that
explains how
information is
collected,
managed,
and
protected.
Develops a data
collection and
management plan
that explains how
information is
collected, managed,
and protected, and
addresses its
relevance to
population health.
Describe how
ethical
leadership
practices
might be
Does not
identify
ethical
leadership
practices that
might be
Identifies
ethical
leadership
practices that
might be
addressed in
this project.
Describes
how ethical
leadership
practices
might be
addressed in
this project
Describes how
ethical leadership
practices might be
addressed in this
project, including
ethical leadership
principles, and links
CRITERIA
NONPERFORMANC
E
addressed in
this project,
including
ethical
leadership
principles.
addressed in
this project.
Explain
organizationa
l or systemic
strengths,
weaknesses,
opportunities,
and threats
(SWOT)
relative to the
identified
project aim.
Does not
analyze
organizational
or systemic
strengths,
weaknesses,
opportunities,
and threats
(SWOT)
relative to the
identified
project aim.
Address most
components
of the
assessment
prompt
appropriately,
using the
assessment
description to
Does not
address the
assessment
prompt.
BASIC
PROFICIENT
DISTINGUISHED
including
ethical
leadership
principles.
this with the
Quadruple/Quintupl
e Aim with
supporting evidence.
Identifies
organizational
or systemic
strengths,
weaknesses,
opportunities,
and threats
(SWOT)
relative to the
identified
project aim.
Explains
organizationa
l or systemic
strengths,
weaknesses,
opportunities
, and threats
(SWOT)
relative to the
identified
project aim.
Analyzes
organizational or
systemic strengths,
weaknesses,
opportunities, and
threats (SWOT)
relative to the
identified project
aim.
Writing lacks a
clear purpose
or message
that inhibits
effective
communicatio
n with the
intended
audience.
Addresses
most
components
of the
assessment
prompt
appropriately,
using the
assessment
description to
structure
text.
Addresses all
components of the
assessment prompt
appropriately and
uses the prompt to
guide organization.
Additionally, shares
information relevant
to all assessment
components at a
level that
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
communicates clear
meaning.
structure
text.
Apply APA
style and
formatting to
scholarly
writing.
DISTINGUISHED
Does not
apply APA
style and
formatting to
scholarly
writing.
Applies APA
style and
formatting to
scholarly
writing
incorrectly
and/or
inconsistently,
detracting
noticeably
from good
scholarship.
Applies APA
style and
formatting to
scholarly
writing.
Applies APA style
and formatting to
scholarly writing.
Exhibits strict and
nearly flawless
adherence to stylistic
conventions,
document structure,
and source
attributions.
QI tips: Developing a successful measurement strategy
Types of health care quality measures
Developing program goals and measurable objectives
Patient safety from the perspective of quality management frameworks: a review
Part 4:
Create a poster that showcases your work as you reflect on what you learned while developing the
Project Charter in the previous three assessments.
Introduction
You have developed a project charter for your quality improvement project. Now is the time to
“showcase” your work. In this assessment, you will submit your poster to disseminate your results in a
professional manner. Now is a good time to think about how you will sustain these improvements in
terms of organizational commitment and leadership. Heinrich (2021) states: “Instead of getting to the
end and asking, ‘Now that we’ve made some great improvements, what can we do to continue them?’
you need to think about that aspect from the very beginning” (para 2). Active involvement of leadership,
organizational support and commitment, and an understanding that “team” matters are aligned with
quality improvement success.
Reference
Heinrich, P. (2021). Setting the stage for sustainability in quality improvement projects. National
Institute for Children’s Health Quality. https://www.nichq.org/insight/setting-stage-sustainabilityquality-improvement-projects
Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the following
course competencies and scoring guide criteria:
•
Competency 1: Evaluate the application of leadership styles to practice or process change within
a health care or public health delivery system.
•
•
•
•
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
Present a problem statement that focuses on a specific area.
•
Present an AIM statement that includes the goals the project is intended to accomplish
and who will benefit, with a time frame.
•
Present the planned intervention, including initial steps to get started, the proposed
intervention, and the process for implementation.
Competency 3: Develop a project charter that addresses a potential gap, problem, or
opportunity within a health care system.
•
Provide a Gap Analysis that presents an existing change opportunity and the desired
state after improvement.
•
Describe 2–3 next steps that could be taken once the charter project is completed to
initiate the project and anticipated outcomes.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
•
Identify team members, stakeholders, sponsors, and a team leader appropriate to the
needs of the project.
Describe the purpose and use of the data collection plan.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
•
Overview
Create a poster that is professional and engaging in design and addresses the required
components.
Presenting information to an audience is a common skill that is needed for leaders who work in health
care today. At some time in your career, you might attend a conference in person or virtually to share
information about a project. Many health care conferences now include virtual poster presentation
sessions.
The purpose of this assessment is to give you practice presenting the project charter that you have
designed in a poster format. You will include the gap analysis, the problem statement, the AIM
statement, the planned intervention, the project team, the data management plan, next steps if you
were going to implement this project, and lessons learned during this process.
Prepare
For an example of the completed assessment, access and review the Project Charter Poster Exemplar
[PPTX] and/or the Project Charter Poster Exemplar [PDF] resource.
Scenario
You are a health care leader who has just finished your first Project Charter. Imagine that you have been
invited to present your project in the form of a poster to your organization or at a professional
conference. Prepare your poster to succinctly describe the different parts of your project in text,
pictures, and graphs or statistics.
How might the results of the project be communicated to sponsors, stakeholders, and team members?
Think about how the project will benefit the target population, the organization, and those served. How
does this project demonstrate leadership in terms of a process change for those served, the
organization, and/or the profession?
Instructions
Using the Project Charter Poster Template [PPTX] and/or the Project Charter Poster Template [PDF],
complete the following to create a poster that acts as a visual presentation of your Project Charter:
1. Apply your creativity while using charts, graphs, and visual images to tell your story for the
change improvement you have created and the value to those served. The Project Charter
Poster Template will help organize your information, but feel free to change the colors,
rearrange sections, and otherwise use it to meet the requirements for the assessment.
2. Include a title at the top of the poster.
3. Include a Gap Analysis that identifies the gap (difference between the current state and desired
state in measurable terms), how the gap was identified, and why improvement is needed
(importance/relevance).
4. Include the problem statement (1–2 sentences) that focuses on one specific area that can be
realistically solved and identify the effect on the population.
5. Include the AIM Statement including the SMART Objectives, who will benefit, what will be done,
where the change will occur, the timeline, and the impact on the population/process.
6. Planned Intervention: Include the proposed intervention, who will be involved in
implementation, the process for the implementation, e.g., when, where, and how, and the
potential effects on the population/process
7. Project Team: List the team members, stakeholders, executive sponsor, and team leader, and
their roles and contribution to the project (why they were selected).
8. Data Management Plan: Describe the data management plan including what data will be
collected, who will collect the data, when it will be collected, the storage and protection of the
data, and its interpretation and utilization (think about diversity, inclusion, and use of data).
9. Next Steps/Lessons Learned: What do you anticipate as the next 2–3 steps if you were actually
going to implement this change? What is your anticipated outcome of the planned intervention?
How will you know if it is successful? What lessons did you learn via this process?
Additional Requirements
Your assessment should meet the following requirements:
•
Written Communication: Use short but complete sentences that are clear, comprehensible, and
free of jargon for each paragraph or bullet point.
•
Length of Presentation: Complete all fields of the Project Charter Poster Template succinctly but
thoroughly.
•
Tone: Ensure your presentation is relevant to and easily understood by everyone in the
audience. Remember, you could be speaking to people in all levels of the organization.
•
Font and Font Size: Use fonts and sizes appropriate for a presentation.
Competencies Measured
By successfully completing this assessment, you will demonstrate your proficiency in the following
course competencies and scoring guide criteria:
•
Competency 1: Evaluate the application of leadership styles to practice or process change within
a health care or public health delivery system.
•
•
Identify team members, stakeholders, sponsors, and a team leader appropriate to the
needs of the project.
Competency 2: Analyze a health care issue from a leadership perspective, applying quality
improvement principles and evidence-based standards.
•
Present a problem statement that focuses on a specific area.
•
Present an AIM statement that includes the goals the project is intended to accomplish
and who will benefit, with a time frame.
•
Present the planned intervention, including initial steps to get started, the proposed
intervention, and the process for implementation.
•
•
Competency 3: Develop a project charter that addresses a potential gap, problem, or
opportunity within a health care system.
•
Provide a Gap Analysis that presents an existing change opportunity and the desired
state after improvement.
•
Describe 2–3 next steps that could be taken once the charter project is completed to
initiate the project and anticipated outcomes.
Competency 4: Develop a data management plan, including a plan for ethical stewardship for
data use and communication.
•
•
Describe the purpose and use of the data collection plan.
Competency 5: Communicate in a manner that is scholarly, interprofessional, and respectful of
the diversity, dignity, and integrity of others.
•
Create a poster that is professional and engaging in design and addresses the required
components.
Project Charter Part 4: Poster Presentation Scoring
Guide
CRITERIA
NONPERFORMANC
E
BASIC
PROFICIENT
DISTINGUISHED
Provide a Gap
Analysis that
presents an
existing change
opportunity
and the desired
state after
improvement.
Does not
provide a Gap
Analysis that
identifies an
existing
change
opportunity.
Provides a
Gap Analysis
that identifies
an existing
change
opportunity.
Provides a Gap
Analysis that
presents an
existing change
opportunity
and the desired
state after
improvement.
Provides a Gap
Analysis that
presents an
existing change
opportunity and
the desired state
after
improvement,
how the gap was
identified, and its
relevance to
health care.
Present a
problem
statement that
Does not
present a
problem
statement.
Presents a
problem
statement
that does not
Presents a
problem
statement that
Presents a
problem
statement that
focuses on a
specific area and
CRITERIA
NONPERFORMANC
E
focuses on a
specific area.
BASIC
PROFICIENT
DISTINGUISHED
focus on a
specific area.
focuses on a
specific area.
identifies the
effect on the
population/proces
s.
Present an AIM
statement that
includes the
goals the
project is
intended to
accomplish and
who will
benefit, with a
time frame.
Does not
present an
AIM
statement
that includes
the goals the
project is
intended to
accomplish.
Presents an
AIM
statement
that includes
the goals the
project is
intended to
accomplish.
Presents an
AIM statement
that includes
the goals the
project is
intended to
accomplish and
who will
benefit, with a
time frame.
Presents an AIM
statement that
includes the goals
the project is
intended to
accomplish, who
will benefit, a time
frame, and the
anticipated impact
on the population,
system, or
organization
served.
Identify team
members,
stakeholders,
sponsor, and a
team leader
appropriate to
the needs of
the project.
Does not
identify team
members,
stakeholders,
and a team
leader
appropriate
to the needs
of the
project.
Identifies
some but not
the complete
list of team
members,
stakeholders,
and a team
leader
appropriate to
the needs of
the project.
Identifies team
members,
stakeholders,
sponsor, and a
team leader
appropriate to
the needs of
the project.
Identifies team
members,
stakeholders,
sponsor, and a
team leader
appropriate to the
needs of the
project that
considers
representation.
Present the
planned
intervention,
including initial
Does not
present the
planned
intervention.
Presents the
planned
intervention
but the
connection to
Presents the
planned
intervention,
including initial
steps to get
Presents the
planned
intervention,
including initial
steps to get
CRITERIA
NONPERFORMANC
E
steps to get
started, the
proposed
intervention,
and the process
for
implementatio
n.
BASIC
PROFICIENT
DISTINGUISHED
the project is
unclear.
started, the
proposed
intervention,
and the process
for
implementatio
n.
process started,
who will be
involved in the
process for
implementation,
and its potential
effects on the
population/proces
s.
Describe the
purpose and
use of the data
collection plan.
Does not
identify the
purpose and
use of the
data
collection
plan
Identifies but
does not
describe the
purpose and
use of the
data collection
plan.
Describes the
purpose and
use of the data
collection plan.
Describes the
purpose and use
of the data
collection plan and
discusses ethical
stewardship for
data use including
the interpretation
and utilization of
the data.
Describe 2–3
next steps that
could be taken
once the
charter project
is completed to
initiate the
project and
anticipated
outcomes.
Does not
identify next
steps.
Identifies next
steps that
could be taken
once the
charter
project is
complete to
initiate the
project.
Describes 2–3
next steps that
could be taken
once the
charter project
is completed to
initiate the
project and
anticipated
outcomes.
Describes 2–3 next
steps that could be
taken once the
charter project is
completed to
initiate the
project,
anticipated
outcomes, and
includes lessons
learned.
CRITERIA
Create a poster
that is
professional
and engaging in
design and
addresses the
required
components.
NONPERFORMANC
E
Does not
create a
poster that is
professional,
engaging, nor
addresses the
required
component.
BASIC
PROFICIENT
DISTINGUISHED
The poster
lacks a
professional
and engaging
design, clear
purpose or
includes
content that
inhibits
effective
communicatio
n with the
intended
audience.
Creates a
poster that is
professional
and engaging in
design and
addresses the
required
components.
The poster is
professional and
engaging in design,
appropriately
addresses the
required
components.
Additionally,
shares clearly
presented
information
relevant to all
assessment
components.
Enter Your Poster Title Here
Author Name
Gap Analysis
• Identify the gap (difference between the
current state and desired state
• How was the gap identified?
• Why is improvement needed? Why is this
important/meaningful?
Problem Statement
Include your problem statement (1-2 sentences).
• Focus on one specific are that can be realistically
solved
• Identify the effect on the population or process
Planned Intervention
• Proposed intervention.
• Who will be involved in implementation
• Process for implementation including when,
where, and how.
• Potential effects on population/process
Project Team
List team members, stakeholders, sponsor,
including the team leader and their
roles/contribution to the project (Why they
were selected)
Data Management Plan
AIM Statement
Include your AIM Statement for your Project
Charter.
• The specific goals you intend to accomplish
(SMART objective)
• Who will benefit
• What will be done
• Where the change will occur
• Timeline
• Impact on the population/process
Describe the data management plan including:
• What data will be collected.
• Who will collect the data
• When it will be collected
• Storage and protection of the data collected
• Interpretation of the data and its utilization
Next Steps/Lessons Learned
•
•
•
.
What
do you anticipate as the next 2-3 steps if
you were going to implement this change?
What is your anticipated outcome of the planned
intervention? How will you know if it is
successful?
What lessons did you learn via this process?
Be creative in designing your poster. Use
graphics, pictures, charts, colors, etc. and
create a professional and engaging poster that
showcases your work.
Changing the Culture of Care
Gap Analysis
Monthly declines in patient/clinic visits from opening to present time:
• Gap: Desired state of 700 visits versus the current state of 400 visits;
Gap = 300 visits
• Contributing factors by survey: Cultural competency of staff and
feeling unwelcomed were identified
• The Center can serve as a source of health promotion, prevention, and
education, and a point of access to care for this underserved
community
Number of patient/client visits recorded at
Hillside Community Health Center
700
600
500
400
300
200
100
0
650
• Training and education of the clinic staff related to culturally
competence and patient/client centered care initiated within 14 days of
the project start
• All staff will complete the trainings within three months. New staff will
undergo the training as part of orientation/on boarding.
• After completing the trainings, the staff will be
administered a cultural awareness assessment with an expected score of
90% or higher. If the score does not meet the set threshold of 90%, the
training will be extended, and the assessment repeated within 30 days
• Supervised by the certified Diversity Educator or representative
• If the planned intervention is successful, an “in house” person will be
trained, certified, and designated to deliver the training on a regular
basis
580
430
390
Project Team
370
350
Title
August
Data Management Plan
Planned Intervention
September
October
November December
Year 1
January
Year 2
Problem Statement
The decline in patient/client volume since inception is
attributed to issues related to cultural competency and feeling
unwelcomed at the clinic based on survey responses. This has
impacted residents’ utilization of health-care services,
resulting in suboptimal health promotion, prevention, and
treatment activities
Aim Statement
Cultural responsiveness is an ongoing focus for the Health
Center. As the center strives to serve more meaningfully in the
underserved and culturally diverse neighborhood, an immediate
and important aim for the center is to see an improvement in
the number of patient/client visits per month.
The aim of the project is to achieve the expected average
patient/client visits per month to the center (700) by December
by implementing relevant and effective training for the staff
related to cultural competency and patient/client centered care.
Role
Internal and
External
StakeholdersCommunity
Acts as a liaison between team members, sponsor, and the
Stakeholders Leaders, Residents
community to provide relevant input and feedback.
of the community,
Administrators/Boa
rd of Directors,
Clinic Staff
Executive
Clinic director
sponsor
Provides contacts necessary for community engagement,
approves the project, sanctions budgets for the project
Oversees patient/client and community engagement,
Team leader Clinic administrator focuses on staff development aimed at providing
quality health care
Clinic health care
providers
Ensure correct diagnosis and accurate care based
on patients’/clients’ clinical histories and unique social
and cultural needs
Team
Educate medical staff on aspects of care for
members Diversity Educator patients/clients with unique social and cultural needs,
collect and analyze data for the project
Community
Engagement
Specialist
Oversees the Diversity Advisory Committee and
coordinates community outreach; acts as a bridge
between the team and community
▪ The number of patient visits, including missed
appointments or lack of follow up
appointments will be collected each month and
analyzed by the designated auditor.
o Data collection begins Day 1 of the
project and will be collected via EHRs
▪ To maintain the security of the data collected,
o Data will be de-identified but will retain
demographic information for analysis
o Data will be password protected, stored
on the cloud, and follow HIPAA
regulations
o Access to the data will be limited to
authorized personnel only.
o Patterns and trends will be identified to
assist in meeting the community’s needs
and increasing patient/client visits
Next Steps/Lessons Learned
Next Steps
Based on the post-training scores and community
survey responses, the Diversity Educator will
improve training modules and develop outreach
programs and hiring policies.
Lessons learned/Potential consequences of change
▪ Staff resistance toward policy changes and
diversity and inclusion training programs has the
potential to act as a barrier to implementing
project interventions.
▪ If successful, the process could be formalized for
new and current clinic personnel on an ongoing
basis
▪ Attrition due to policy changes could be seen as
an opportunity to implement improved hiring
policies that ensure better representation of
diverse communities as well as the staff’s
alignment with the organizational vision.
▪ Implementation of culturally competent care
could optimize outcomes, enhance relationships,
and increase job satisfaction and retention
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