DBHDD Enterprise Project Management Project charter Work sheets

Project charter The project charter supports the project by documenting requirements that meet the organization’s needs and expectations and designates what is in scope to minimize confusion. It is used as a beacon to guide the project, and can be used to communicate project details to leadership or others within the organization.

HSQM Strategic Plan FY2017 Project Background Purpose: Improvement of the quality management process at each hospital and as a hospital system Objectives: Increase participation in statewide committees and develop a formal reporting structure from the committees back to the hospitals Evaluate the effectiveness of both the QM&I audits and T&T indicators, and facilitate changes to each as necessary Update Key Performance Indicators to align with new TJC and CMS requirements, and develop/identify other indicators to be used to assess hospital performance Implement a Tracer Methodology process to identify risk points and safety concerns related to hospital patient care and ensure continuous compliance with DBHDD policies and regulating agencies Outcomes/Benefits: More efficient use of Hospital System QM resources and staff Better use of data to evaluate efficacy of treatment provided to individuals Innovative interdisciplinary tracer audit process that identifies strengths of inpatient treatment and opportunities for improvement The ultimate benefit of these activities will provide better treatment for the individuals we serve, as measured by internal and external audits, surveys, and reviews Timeframe: Fiscal Year 2017

Team structure Project Roles Names Responsibility Sponsor Dr. Risby Set project direction and communicate with the business Make decisions on scope / budget/ operating model Steering Committee Greg Hoyt Susan Trueblood Dr. Charles Li Andy Mannich John Robertson Paul Brock Dr. Jamie Short Decision making for the project Monitor project progress and approve project changes Contribute to direction setting Resolve escalated issues and risks Project Lead Evelyn Harris Accountable for the delivery and success of the project Monitor progress, manages scope and ensures solution requirements are met Focus on deliverable and quality management Communicate with steering committee, project manager and project committees Address and/or escalate risks and issues Project Manager Amber Franklin-Lacey (Discipline & Tracer) Theo Beiter (QM&I / T&T) Manage daily operations Track activities against project work plan Manage risks, issues and dependencies Deliver regular reports / updates to Project Lead and Steering Committee Discipline Work Group Yolanda Clay Responsible for the day to day management, execution and delivery Ensure deliverables meet quality criteria Manage risk, issues, and dependencies Identify risks and issues and communicate to Project Manager QM&I and T&T Work Group Justin Norton Brent Eaton KPI Work Group Tracer Work Group Betsy Bradley Beth Jones

Scope and additional considerations In Scope Out of Scope Committee structure, roles, and responsibilities Review of QM&I audits/measures, Triggers & Thresholds, KPIs, and make changes to reports as necessary Quality Management tracer processes Committee Subject matter expertise Policy development process Hospital Clinical and Administrative Operations Additional considerations Item Description Assumptions DBHDD Leadership and RHA support Committee Member Participation Constraints Culture Funding Hospital System QM Staffing Dependencies Development of statewide committee policy Data Management and OIT ability to automate parts of audits CMS and TJC regulations Ongoing support from statewide and hospital leaders to improve QM processes Committee members will provide their best effort to improve the services provided to individuals Historic culture of separate hospitals instead of a single DBHDD Hospital system Funding for TSSs and training Dependency of HSQM on individual hospital staff for statewide projects/availability of hospital staff to participate in statewide projects Currently a draft Plan requires development of new DSS reports and may request additional fields in MyAvatar Any new/changing requirements from CMS and TJC may cause changes in current processes and affect reporting vehicles

Key stakeholders Stakeholders (top 5) Role Individuals The ultimate goal of these changes is to improve the life and care of the individuals we serve. DBHDD Leadership Governing body provides oversight of all DBHDD hospitals as well as Hospital System QM. Hospital Staff Active participation from multiple levels at each hospital is necessary to ensure success of each work group listed in this charter. Data Management and OIT Development of reports needed to improve audit reliability and tracer automation. CMS and TJC These entities develop externally-reported data and require processes to ensure data integrity. These measures and procedures are designed to ensure the highest level of care for the individuals we serve in our hospitals.

High level risks Risks Mitigation Plan Committee inertia – Willingness of Committee Chairs and members to accept recommendation(s) for change from the Work Group designated in this charter, as well as the committee policy Engage Committee Chairs and members reiterate the value and benefit of the committee to Individuals and Staff members we serve Resource and funding barriers Engage RHAs and DBHDD Leadership to reiterate the value and importance of the(se) project(s) Underestimating current processes Only remove current processes when it can be demonstrated there is no current benefit or that existing process is being replaced by more efficient process Possibility of re-design of system(s) that exclude important aspects of operations and/or care for individuals and/or required external reporting processes/data Build in, as part of the workgroup process, assurances that consultation with all stakeholders occurs at regular intervals

Milestones/key deliverables Milestone name (top 5) Target Date Expectations for Committee Chairs and Members 8/15 & 8/31/2016 Recommendations for changes to each QM&I audit and T&T 10/13/2016 Recommendations for changes to KPIs Need dates Team establishment, identify/obtain tracer training materials, & train staff 10/28/2016 Tracer reporting mechanism established 12/30/2016

Success indicators Success Indicators Established, after Committee Policy is approved, Committee structure, roles, and responsibilities of committee chairpersons and members. The success indicator for this Strategic Plan Charter will be the recording, after the aforementioned requirements are met, the training of each individual in each Committee. Completed comprehensive review and revision of QM&I audits/measures, Triggers & Thresholds Report, and KPI Report Establish concrete tracer methodology and complete Tracer Training (90% of Staff)

Links with other initiatives None.