improvement charter template - providence health care · web viewthe project charter serves as a...

Guide to completing yourProject Charter

The Project Charter is your first opportunity to define the scope and identify approach, resources and timeline for your project. Completing this at the outset (as part of the Initiate phase) will pay dividends throughout the life of your project. The Project Charter serves as a guide for the conversations you will need to have with your Project Sponsor, Executive Sponsor and other key stakeholders.

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The process of completing your Project Charter is an important first step in bringing awareness to all of the key stakeholders who will need to be involved or are impacted by the project, and confirm their desire and commitment to participate and support the project.1 The dialogue you have in this process is as important as the Project Charter itself.

For your project, you will need to identify the key individuals who will provide leadership to successfully implement and sustain the change. The responsibilities for all project roles will be described in more detail in Section 4 (“How will we manage and deliver the project?”).

Role Key Considerations

Executive Sponsor

Who is the member of the Senior Leadership Team (SLT) that is most accountable for the project’s overall outcome?

There can only be one Executive Sponsor.

Project Sponsor

Is this person accountable and have demonstrated commitment to the project’s overall outcome?

Is he/she available and committed to be a visible and vocal champion for the project?

Is he/she available to provide support in resolving issues as they arise? This role is always required.

Clinical or Business Lead

Who has the business, operations and/or clinical expertise to lead the development of the solution and how it needs to be implemented?

Who will likely play a key role in the operational sustainment of the change being implemented?

Physician Lead

To what extent are physicians required to be aware of and involved in the project?

Who has the accountability and influence on the physicians that need to be engaged for this project?

Project Manager

Does this person have the required level of experience to manage the project based on its scope and complexity?

Does he/she have the capacity to manage this project?

Be willing to challenge whether you have the appropriate person as your Executive and Project Sponsors. An early indicator of whether this is the case is your Sponsors’ willingness and ability to dedicate time to meet with you to review the Project Charter.

1 Taken from Prosci’s ADKAR (Awareness/Desire/Knowledge/Ability/Reinforcement) model for change. See Appendix A for an overview of this model.

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1. Project Leadership and Timeline


This is the most important question to answer up front. It is critical that all key stakeholders for the project have a shared understanding of why this project is being initiated. To define the Project Purpose, use the following questions in your conversations with your stakeholders – especially your Project Sponsor and Clinical/Business Lead(s):

1. What is the problem we are trying to solve?

2. What is/are the target outcome(s) we are looking to achieve?

3. Why is it needed?

4. What if we don’t do this?

5. What will be the benefits for patients, staff and the organization as a whole?

Consider naming your project based on the project’s purpose or target outcome.

State your Project Purpose with as much specific information as known at this time, applying the SMART approach:

Specific Measurable Attainable Reliable Time bound

In identifying how your project’s benefits support the strategic goals of Providence Health Care or your program, refer to PHC’s 5 strategic directions and 3 foundational strategies from the 2012-15 Providence Plan:

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2. What are we trying to accomplish?

http://phcnews.ca/wp-content/uploads/2012/12/PHC-strategic-directions-2012_2015.pdf


In addition to identifying how your project aligns with the Providence Plan, you may also wish to highlight how it enables/supports specific goals within your program and at a regional, provincial and even national level.

To define the Scope and Boundaries of your project, consider the following:1. What processes or functions will be impacted?2. What sites, departments and programs will be affected?3. What roles or positions will be impacted?

Be explicit on what is out of scope based on your answers to the scope questions on the previous page, particularly for areas where people have been unclear or expressed a desire to include within the scope.

Identify the key assumptions that are being made for this project (e.g. availability of key resources, people, funds), and how you will validate these assumptions. Any assumption that cannot be validated should also be highlighted in Section 4 as Risks/Opportunities.

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The Project Charter has three types of measures:

Type Purpose of this measure Examples

Overall Outcome

Demonstrate that the project’s purpose or target outcome is being achieved (usually from the perspective of the patient, resident or client).In some cases, the purpose may also be related to achieving a financial outcome, such as cost savings.

Reduce incidence of VTE (venous thromboembolism) by X%Reduce the overall department budget by $X

Process Show that the key processes or steps that lead to the overall outcome are being completed

Training for procedure X completed by all staffProcedure X checklist completed 100% of the time

Balancing Ensure that any potential negative impacts (unintended consequences) are avoided. Often, these can be identified from the key risks to the project.

Level of patient satisfactionLevel of staff satisfaction/ engagement

Finding ways to demonstrate that your project has achieved is purpose in a concrete way can be challenging! As a general rule, aim to have no more than 3 to 5 measures (for an extra challenge, see if you can identify the single most important measure for your project).

Here are some tips for addressing some of the most common challenges with measures:

Challenge Tips to address this challenge

“We don’t have the data for the measure.”

Use a proxy measure. Identify other initial indicators or measures such as qualitative feedback from informal surveys or 1:1 interviews to get a sense of whether the change your project is implementing is improving things.As a part of the sustainment plan, identify any new data that needs to be collected and reported on to demonstrate the impact of your project on an ongoing basis.

“The outcome measures are not (fully) within the control of my project.”

The overall outcomes we are looking to achieve are often dependent on a myriad of contributing factors. Driver diagrams can be helpful to show the relationship between the overall target outcome and the change your project is implementing, along with other projects or areas (see Appendix B for an example of a driver diagram).Recognize that there may be a significant lag in the outcome measure demonstrating improvement – therefore consider whether a process measure is more appropriate for determining the end of your project.

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3. How will we know the change is an improvement?


Challenge Tips to address this challenge

“The attention to the key measures will stop once the project ends.”

As a part of your sustainment plan, clearly identify who will be accountable for monitoring and responding to key process and outcome measures in an operational state. Identify ways to associate the measures for the change from your project with PHC’s Balanced Scorecard and/or other existing management processes.

This section identifies:1. The overall approach and guiding principles for the project;2. Who will be on your project team and their expected roles and responsibilities; and 3. The phases of work, major tasks and milestones, and overall timeline for the project.

In describing your overall approach, consider the following: As all projects involve change, there needs to be a communication strategy to

ensure that the messaging is consistent and targeted to each group or individual as appropriate.

How the project will support them in adopting the change; and How the change will be supported and sustained on an ongoing basis – this specific

point will be addressed in Section 5 (“How will we sustain the changes implemented by the project?”).

The Project Team section includes a project organization chart which provides an excellent visual overview of the key roles. You can update the chart included in the template or create one using software such as PowerPoint, Visio or MS Project and import (or copy and paste) it into the Project Charter.

The template provides a minimum list of the essential roles and associated responsibilities. For a more extensive list of potential roles for your project, refer to Appendix C of this guide. It is critical to review this section with the individuals identified for each role to confirm:

their understanding of the role and associated responsibilities; their ability to fulfil these responsibilities; their availability (as identified under the Expected Level of Engagement column).

The Project Timeline provides a visual representation of the major tasks, milestones and timeline, and can be created using PowerPoint, Visio, Smartsheet or MS Project and then imported or paste into the Project Charter document.

In addition, this section includes the identification of the project’s key dates (which should be reflected as the milestones on the timeline), and your project budget.In the risks/opportunities section, be as specific as possible about what the risks and opportunities are. For each risk and opportunity, identify the specific actions you intend to

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4. How will we manage and deliver the project?


take (or require others to take) in order to manage the risk or opportunity. These actions will be included in your Project Workplan in the Planning phase of your project.

The sustainment plan identifies what actions will need to be taken and by whom in order to transition any key support activities from the project team to individuals in their ongoing operational roles. This transition will need to be included as a part of the Project Workplan. If it is not possible to identify who will take ongoing responsibility for sustainment at this stage, then you can identify who will need to be involved in defining the sustainment model, and when this will be done within your project timeline.

Sustainment requires people to have the knowledge and ability, which can be supported through initial training, as well as ongoing reinforcement.2 Example of key things to consider in your sustainment plan include:

Providing opportunities to get feedback from people experiencing the change. Use staff meetings to check in on whether staff feel they have been given the appropriate training and support to implement and sustain the change.

Remove access to processes and equipment that reinforce the previous way of doing things.

This section tracks any major changes to the Project Charter, such as a change in the scope, approach or timeline of the project.

2 Taken from Prosci’s ADKAR (Awareness/Desire/Knowledge/Ability/Reinforcement) model for change. See Appendix A for an overview of this model.

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5. How will we sustain the changes implemented by the project?

6. Project Charter Versions and Updates


Appendix A – Prosci ADKAR Model

The Prosci® ADKAR® Model is an individual model for managing change at the individual level. It is composed of five building blocks that must be addressed before someone can change the way they do something.

ADKAR Element What it means Description

A Awareness of the need for changeDoes the individual know the reasons for changing? They will need to before they can decide to take on the change.

D Desire to participate and support the change

When awareness is built, it’s up to the individual to make the personal decision to change. Are we supporting them while they make their decision?

K Knowledge on how to change Next, the individual must learn the new skills needed to make the change.

A Ability to implement required skills and behaviors

The individual must be able use and apply the new skills learned in the Knowledge phase.

R Reinforcement to sustain the change

Are there systems in place that will keep individuals proficient in the new way of doing things and prevent individuals from reverting back to the old way?

Source: http://www.change-management.com/tutorial-levels-of-cm-mod4.htm

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http://www.change-management.com/tutorial-levels-of-cm-mod4.htm


Appendix B – Driver Diagram Example

Source: “Driver Diagram Tutorial Presentation”http://phcnews.ca/strategic-plan/strategic-directions/quality-safety/

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http://phcnews.ca/strategic-plan/strategic-directions/quality-safety/


Appendix C – Project Roles and Responsibilities

Role ResponsibilityExpected Level of Engagement

Executive Sponsor

Provide overall direction and senior level decisions required by the project, including confirmation and approval of project scope, timeline and budget

Provide support to ensure that the required resources are available Accountable for ensuring the SLT, PHC board committees and external

stakeholders are updated on the overall status of the project as required Address and resolve critical barriers and issues that require executive input

and/or support, particularly those that cross over multiple programs, services and areas

Confirm/approve any changes to project scope, timeline and budget

Monthly meeting to confirm key decisionsAd hoc meetings for senior level input as required

Project Sponsor Champion for the project, ensuring appropriate visibility of the project across the organization and to other organizations as appropriate.

Ensure that the appropriate people and resources within the directly impacted areas are available as required by the project and for sustainment after the project ends

Provide overall direction on the project Provide regular status updates to the Executive Sponsor (frequency to be

agreed up front and adjusted as required) Address issues and barriers that have been escalated by the Project

Manager and engage the Executive Sponsor as required

Every 2 weeks to review project status and address issues

Steering Committee

Provide direct input into key decisions and resolution of critical issues throughout the project

Provide support to the Project Team as requested by the Project Sponsor and Project Manager

Monthly meeting

Project Manager Facilitates the definition and delivery of the project, leading/guiding the project team through the process of executing the project.

Provide direct guidance and support to the Team Leader(s) in the identification and engagement of key stakeholders, resources, approaches and tools required to successfully deliver the project.

Develop project scope, timeline and approach with the Team Leader(s) and confirm approval by Executive and Project Sponsors

Ensure that the required work and engagement of stakeholders is done and tracked on a regular basis throughout the project

Ensure regular project updates are provided to the Project Sponsor and Executive Sponsor

Identify, highlight and facilitate addressing issues, barriers and risks that impact the project

Team Leaders (Operations and Allied)

Provide and ensure that the required content expertise is brought into the project.

Make key design and implementation decisions based on his/her business or clinical subject matter expertise

Provide specific direction on the project approach and deliverables Identify and lead engagement of key stakeholders and resources required

to successfully deliver the project Lead all key meetings with their staff and other key stakeholders throughout

the project, including confirmation of the agenda for meetings and taking on the role of chairperson at the meetings

Lead engagement of key stakeholders to sustain outcomes following the project

Physician Leader

Lead engagement of physicians for the project

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Role ResponsibilityExpected Level of Engagement

Project Advisor (PMO)

Provide overall guidance and support to the Project Manager Provide input and guidance in the development of the project approach,

proposed changes and implementation of changes

Change Management

Conduct an assessment of the readiness of stakeholders for the change Lead the development and delivery of stakeholder engagement and

teambuilding required by the project

Quality and Utilization Improvement Specialist

Establish a system for performance tracking Assist in gathering and analyzing evidence as needed Guide the team in applying QI tools and processes Assist in the development of a communication and education strategy as

needed

Financial Analyst

Develop agreed approach for tracking and reporting financial targets Validate estimated and actual savings

Labour Relations Advisor

Identify implications of proposed changes from a labour relations and collective bargaining agreement perspective

HR Advisor Provide guidance and technical support for HR processes and staff rotation changes

Identify implications of proposed changes from a labour relations and collective bargaining agreement perspective

Staffing Specialist

Develop new rotations required by the project

Communications Lead

Provide guidance on communications strategy to staff and other stakeholders throughout the project

Develop key communication deliverables for staff and patients Ensures the audience has awareness, builds desire, communicates

knowledge and builds expertise and helps reinforce the messages for susteainment.

Professional Practice

Provide guidance and advice on the plan for how to implement the new staffing model as well as communicate, educate and support staff

Support the development of new workflows and processes

Facilitator Provide expert facilitation with groups such as diverse stakeholders, patients/clients, or if external consultation is required.

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