1. DBHDD Enterprise Project Management
Project charter Work sheets

2. 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.

3. 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

4. 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

5. 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

6. 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.

7. 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

8. 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

9. 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)

10. Links with other initiatives
None.