QI Project Charters: Lessons Learned from QI at the Hasbro Children’s Hospital

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• Last Updated on Friday, 23 January 2015 17:17

By: Stacey Aguiar, MPH, CHES and Emily Eisenstein, MPH, Rhode Island Department of Health

Facilitating a QI project in Rhode Island’s largest primary care clinic, which sees the largest number of highest needs (e.g., high percentage of patient population on Medicaid) children in the state, was challenging to say the least, but very rewarding. The clinic, which is staffed by approximately twelve attending physicians and sixty rotating resident physicians cares for approximately 9,000 patients.

One of the most important and useful QI tools used during our project was the QI Project Charter. In order to successfully complete our work, we needed to include physicians on our team; because of their schedules, we were only able to have team meetings once a month, not as frequently as we had hoped. However, even with a limited meeting schedule, the QI Project Charter allowed our team to stay on task and communicate details of the project in a concise way. At the beginning of every team meeting, we used the QI Project Charter to review both our accomplishments as well as our outstanding tasks; the Charter allowed us to make sure that we were meeting our goals and project deliverables. The QI Project Charter also helped each team member remember her individual roles/responsibilities; it ensured that we stayed within the scope of our project. Overall, the QI Project Charter was our “go-to-document” assisting in keeping our team focused, organized and efficient.

Our original aim was to improve the effectiveness and efficiency of the developmental screening process at Hasbro’s Primary Care Clinic. During specific well-child visits, pediatric providers are required to screen children using a standardized questionnaire. Developmental screening is important because if there are any concerns detected from completing the questionnaire, they can be addressed at the earliest point possible by the child’s doctor. As a team, we realized through our Gemba Walk (a structured, direct observation of a process), when we observed the entire well child visit process from start to finish, that the physicians were not getting the questionnaires to review before seeing their patients. We also realized that the questionnaires took too long to complete because caregivers were completing two questionnaires (Ages and Stages: 3 & Ages and Stages: Social Emotional), which were both very long. After some research and multiple Plan-Do-Study-Act (PDSA) cycles, we identified better workflows and came across a shorter questionnaire (Survey of Wellbeing of Young Children), which incorporated not only developmental questions, but also social/emotional and parent concern/family risk questions. The questionnaire is only 2 pages long and takes only an average of 10-15 minutes to complete versus the 30-40 minutes with the previous questionnaires. Not only was the staff satisfied with the changes we made, but the patients were also satisfied as well, which was very rewarding. 

What is a Charter?

A document that organizes all project information into one document.

Components of Charter:

1. Aim: Tells the main focus of the project and why it is important. Our aim took quite a bit of discussion to come up with and changed multiple times, making it a working document.

2. Measures:  Outlines what you are measuring to see if your changes are making an improvement and if your team is reaching the project’s goals. Below are ours as an example:

Measure	Operational Definition	Baseline	Goal
% Screens Received (Type: Process)	Percentage of developmental screens received by provider calculated as; Numerator = Number of developmental screens received by provider before patient has shifted to immunizations. Denominator = total number of screens received by provider.	40%	Increase percent of developmental screens received by provider before patient has shifted to immunizations from 40% to 95%.
% Patient Satisfaction (Type: Process)	Percentage of satisfied parents of patients calculated as; Numerator = Number of surveyed parents of patients who rate their satisfaction with the developmental screening process as an average of between 4 and 5. Denominator = total number of surveyed parents of patients	92%	Improve parents of patient satisfaction with the developmental screening process from 92% to 98%.
% Provider Satisfaction (Type: Process)	Percentage of satisfied providers calculated as; Numerator = Number of surveyed providers who rate their satisfaction with the developmental screening process as an average of between 4 and 5. Denominator = total number of surveyed providers	29%	Improve provider satisfaction with the developmental screening process from 29% to 80%.
Visit time (Type: Balancing)	Track the amount of time it takes for patient to flow through entire child wellness visit from the time of check-in to the time they finish with immunizations.	59 minutes	Decrease or keep same amount of time it takes for patients to flow through visit at Hasbro’s Primary Care Clinic

3. Deliverables: Major products produced during the project. Our project deliverables included provider and customer satisfaction surveys, as well as a storyboard to demonstrate the current and future state of all of the PDSA cycles we completed.

4. Scope: Indicates what the team will and will not do and promotes a common understanding between the quality improvement team and stakeholders/senior leaders. For our team, coming up with what was in and out of scope took a few meetings. It also changed a bit as the project continued. Within our scope, we only focused on the developmental screening process of the visit, instead of worrying about the entire visit.

5. The team participation section communicates the roles and responsibilities for each member of the QI team. It also defines expectations as well and includes a meeting schedule and ground rules. We tried to include members on the team that were part of each step of the process. Since we do not work at Hasbro, we considered ourselves the “fresh eyes” of the team. When creating a team, it is helpful to have someone that is not part of the process because he or she might see things that the people who are part of the process might not see.

6. Stakeholders are defined as those with a vested interest, are affected both positively and negatively by the project, are involved in the process you are improving, and/or might influence the project. In this section of the QI Charter, we listed the stakeholders and also included strategies to communicate and gain their support, which was critical. We chose stakeholders that would be both directly affected by the changes, for example the clinic staff, as well as others who would not be directly affected by the changes, but who would benefit from them like evidence-based community programs.

7. Senior Leadership signoff on the document giving their approval of the project. The signature(s) can also assist with early buy-in.

Why use a Charter?

The Charter allows the team to plan every aspect of the project, including accountability – it is a touchstone throughout your project. It also helps gain early buy-in by defining the purpose of the project and is a great communication tool. In addition, there is a clear agreement between the quality improvement team and senior leadership.