1 Doctoral Project Charter Proposal Checklist Instruct

1
Doctoral Project Charter Proposal Checklist
Instructions: Faculty and Secondary Reviewers will use this
checklist to review the charter for your doctoral project. Items
checked indicate
the criterion was met. Items NOT checked are either missing or
incomplete.
Review the Feedback and incorporate the feedback when
revising the Project Charter Proposal. Failure to incorporate
feedback may result in
deferral of the proposal. Prior to submitting to IRB, please
provide a copy the approved Project Charter and Checklist to
the 9902 faculty for
signature
.
Learner Name: EMPID
Primary Faculty: Secondary Reviewer
Date: Iteration: 1 Decision: Approved
NURS9902 Faculty Attestation: I have reviewed the Project
Charter for the above named learner and can attest the charter
was
approved by two separate reviewers and has not been modified.

(9902 Faculty Name)
Part 1
General Project Information: Clearly describes the people who
will be involved in and affected by a project. Description
includes multiple specifics and details that further characterize
participants and narrow the focus
Project Name
2
Named the project.
Acronym to identify the project.
Feedback:
Iteration 1
Iteration 2
Iteration 3
Executive Sponsors
List key supporters using initials.
Describes why they were chosen (such as fiscal or political
support, useful skills such as marketing ability).

Feedback:
Iteration 1
Iteration 2
Iteration 3
Departmental Sponsors
List departmental sponsors.
Identifies sponsors departmental roles and why they were
chosen to support this project.
Feedback:
Iteration 1
Iteration 2
Iteration 3
3
Project Aim
Describes the project’s overarching aim.
Include the goals you intend to accomplish impact on systems
Feedback:

Iteration 1
Iteration 2
Iteration 3
Project Focus
Describes the specific intervention that will be used to achieve
the project aim
Intervention is evidence based and appropriate evidence is
provided and cited appropriately
Intervention meets the scope and rigor for a doctoral level
project
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Team
Project
Manager
Describes the relevant skills and experience that qualify the
person to lead the initiative.
Describes the project managers primary organizational role
Describes the project managers unique contributions to the
project

4
Feedback:
Iteration 1
Iteration 2
Iteration 3
Team
Members
Describes each team member’s primary role in the organization
as well as skills or qualifications that could
contribute to the project’s success.
Feedback:
Iteration 1
Iteration 2
Iteration 3
Stakeholders
Lists titles, categories, or initials of those who will be affected
by project outcomes
Describse the impact on each individual or group.
Identifies impact on patients and consumers, customer
satisfaction, safety, and quality outcomes
Synthesizes scholarly, authoritative evidence. Synthesis
includes multiple, relevant, and current evidence from peer

reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Part 2
Project Overview: Clearly describes an overview of all aspects
of a project plan. Description includes multiple specifics; is
detailed,
yet concise; and all elements of the plan work together to create
a coherent whole.
Project Description
5
Includes concise descriptions of who, what, when, where, and
how long.
Describes the problem, how it was diagnosed, and how its
solution aligns to strategic priorities.
Includes a timeline and required resources for the project: staff
time, administrative resources, activity sites, and so on.
Includes a budget estimate if applicable

reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Evidence to Support Need
Provides empirical and contextual evidence to support the gap,
need, or improvement and includes organizational data,
Includes primary and secondary data sources, regulatory
requirements, clinical practice guidelines, and benchmarking
data.
Data and sources are supported by citations and/or personal
communications to ensure academic merit and integrity
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Purpose/Business Case

6
Describes the business or clinical need the project addresses
Describes the change or improvement and how will it impact
consumers, staff, and health care system as a whole
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
SMART Objectives (Specific, Measurable, Attainable, Relevant,
Time-Bound)
Provides a concise list of objectives using the SMART model.
Feedback:
Iteration 1
Iteration 2
Iteration 3
Deliverables
Lists the specific high-level products or processes that will be
created, such as training materials, policies, or process
improvements.

reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Scope
Specifies what the project will and will not address.
Includes all relevant people and processes and addresses
alignment to strategic organizational goals.
Includes a brief discussion of the project’s limitations.
reviewed sources
7
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Milestones
Describes specific deliverables for each project phase.

Identifies interim milestones including timeframes in terms of
number of days, weeks, or months. Identify those responsible
for each
deliverable.
Project length meets the requirements for doctoral work (DNP
projects must be between 8-10 weeks to allow for enough
data collection and to accumulate the necessary number of
practicum hours).
Feedback:
Feedback:
Iteration 1
Iteration 2
Iteration 3
Part 3
SWOT Analysis: Clearly describes the strengths, weaknesses,
opportunities, and threats related to a project plan. Description
identifies knowledge gaps, unknowns, missing information,
unanswered questions, or areas of uncertainty
Strengths
Identifies project strengths could include things like executive
support or financial resources.Write them here.
Weaknesses

Identifies here at least three potential obstacles to a successful
project outcome.
Opportunities
8
Identifies current opportunities to facilitate project success
Threats
Identifies at least three current or future threats to the project’s
success
Feedback:
Iteration 1
Iteration 2
Iteration 3
Known Major Risks
Ranks the SWOT weaknesses and threats listed and identifies at
least one high risk and discuss how it might be mitigated
Feedback:
Iteration 1
Iteration 2

Iteration 3
Ethical Considerations: Clearly describes the ethical
considerations, constraints, external dependencies, and
communication
strategy of a project plan. Description includes multiple
specifics, examples, and references to relevant, current
scholarly and/or
authoritative sources
9
Describes any potential for human rights violations.
The project does not involve vulnerable populations.
Addresses data security factors and includes a description of
how data will be accessed and stored, including team members
who will
have access to personal health data and how it will be
safeguarded
The project, as described, is NOT Research
Synthesizes scholarly, authoritative evidence. Synthesi s
reviewed sources
Feedback:
Iteration 1
Iteration 2

Iteration 3
Constraints
Identifies any constraints that may limit the project potential (
i.e. personnel, funding, scheduling, or other options, such as a
predetermined budget, limited staff, or deadlines)
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
External Dependencies
Describes external dependencies such as personnel, funding,
communication channels, or community resources, describe
them here.
If there are no external dependencies, describes internal
support.
Feedback:
Iteration 1
Iteration 2
Iteration 3

10
Communication Strategy
Indicates here how the project manager will communicate to
sponsors, project team, and stakeholders.
Describes the means and frequency of communication, including
meetings, processes, and tools such as charts, wikis, and
dashboards.
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Proposed Outcomes: Clearly describes the outcome measures
related to a project plan. Plans for each proposed outcome
measure are linked to authoritative evidence.
Describes what is specifically being measured to determine
project success
Operationally defines all outcome, process, counter, or proxy
measures that will be used to evaluate the success of the project
reviewed sources

Feedback:
Iteration 1
Iteration 2
Iteration 3
Data Collection Plan: Clearly describes the data collection
procedures related to a project plan. Description includes
multiple
scholarly and/or authoritative sources.
11
Describes the type of data that will be collect and analytical
methods to determine project success
Describes how and when data will be collected per the project
milestones described.
Identifies twho will collect, analyze the data and where the data
will be stored
Addresses the integrity of the data collection process (will it be
done by team members or staff)
Explains the integrity of the data sources.
If using a survey tool, the survey is described in detail
including validity and relability testing and permissions.
Describes the plan to handle missing data and how data will be
securely stored
Feedback:

Iteration 1
Iteration 2
Iteration 3
Data Collection Tool
Optional: The data collection tool is included as an Appendix in
the Project Charter Proposal Document
DO NOT submit the excel sheet to the assignment / assessment
in NURS/NURSFPX9100. The sheet will be reviewed by your
faculty
in NURA/NURSFPX9902.
Scolarly Writing and Academic Integrity
Scholarly Evidence and Support: Synthesizes scholarly,
authoritative evidence where indicated within the project
charter. Synthesis
includes multiple, relevant, and current evidence supporting all
parts of the project charter.
Feedback:
Iteration 1
Iteration 2
Iteration 3
12

Writes clearly and coherently using communication style and
vocabulary appropriate for scholarly work (no grammar, usage,
or
mechanical errors).
Feedback:
Iteration 1
Iteration 2
Iteration 3
Correctly references and cites scholarly and/or authoritative
sources in APA 7th ed.
Feedback:
Iteration 1
Iteration 2
Iteration 3
General Summary Feedback:
Iteration 1
Primary Faculty Name
Iteration 2
Iteration 3

1
Supporting Young Children’s Learning at Home
Families and Literacy:
Families affect language and literacy learning in a variety of
ways – before enrollment in early
education programs and after formal education begins. When
families act, react, and interact
with their babies during feeding, diapering, and play activities ,
they are influencing literacy
development. Responding to a baby’s needs, actions, and
expressions with conversation and
other exchanges provides opportunities for children to hear a
wide variety of sounds. As
language develops, families continue to support literacy through
conversations; reading
together; providing books and other materials; teaching about
signs and symbols in the
community; taking trips to libraries, museums, and bookstores,
and labeling items in the child’s
environment.
Family literacy is an important component of school success,

and it has been reported that
children in low-income families are read to as little as 25 hours
prior to entering first grade while
their peers from middle- income families have been read to for
more than 1,250 hours. It has
been advised that interactive literacy programs be put in place
that train parents in being their
child’s primary teacher and becoming full partners in their
education.
Families can encourage and support language development
through games. With very young
children, peek-a-boo and pat-a-cake can be played. Formal and
informal word play such as “I
Spy” with preschoolers and kindergartners, and board games
with elementary-aged children, all
enhance language development. Play enriches children’s
vocabulary, helping them develop
language skills by using contextual clues, and children are
given valuable experiencing
practicing literacy while playing.
While engaging in everyday activities, families support
language development. Families can
discuss television shows, asking questions about what children
think is happening, having
conversations about program content, and expanding
understanding on what is being presented
in the show. Family members can encourage children to look at
traffic signs and license plates,
spell and say town names, read numbers on exit and speed limit
signs, and have conversations
about landmarks while driving in the car. Car time is also a
great opportunity to sing songs and
play word and memory games.

Early childhood educators can help families understand
language and literacy development in a
number of ways. They can send home newsletters for parents
that contain ideas on how to
encourage literacy development at home, host school programs
for parents related to language
development, and provide other resources, such as DVDs, web
sites about language and
literacy strategies. It’s important that teachers reach out to the
families in their program and help
guide them towards language and literacy activities they can use
at home to help their children
achieve academic success.
2
Families and Science:
Sharing information with families about how to support
scientific learning at home can be done
through newsletters, workshops, e-mail, or displays at school.
To help families develop and
support scientific learning in their young child, the following
major points should be conveyed:
magnets, cars on ramps,
water play).
talk and work with other

people.
just a science word learner).
n is
related to their own
experiences (e.g., food, plants, wheels, care of animals).
and questions and then
respond to and expand on children’s interests.
When teachers help families learn how to support science
learning at home, it is important to
provide them with information about how science learning
occurs at school. When families
understand how the two environments work together, they can
better support scientific
explorations at home.
Families and Mathematics:
It is also important to help family members understand how
young children gain mathematical
concepts and skills. Activities such as family math nights and
take-home activities are great
resources to support families. Math packs can be developed to
send home that include math
games, manipulative materials such as Legos, blocks, and
shapes, graph paper, and other
instruments to support mathematics and literacy skills.
Families and Social Studies:

As previously discussed, creating effective family partnerships
in any subject area needs
understanding and appreciation of families’ diverse histories,
cultures, and traditions. Building
home social studies activities around these differences
encourages family involvement. Children
can draw maps of their house or neighborhood (geography);
make charts about what they
“need” or “want” (beginning economics); and make a timeline
or collage with photos of family
and friends (family history/historical understanding).
Families and Health, Safety, Nutrition, and Movement:
Early childhood programs can provide information to parents
and families regarding the health
and safety of their children. Most families have routine doctor
and dentist visits and practice
safety while crossing the street, riding in a car, or riding a bike.
Some practices are not
universal, however, so sometimes families need additional
information about basic health and
safety.
Families and schools often find they must act in partnership for
children’s mental health needs.
For children to succeed, they must not only be physically
healthy, but psychologically healthy,
as well. Teachers and programs need to help families understand
that psychological health is
3

founded on positive relationships with caregivers but may also
have a biological or neurological
basis. When early childhood professionals help families
understand these needs, children are
more likely to get the services needed to support their emotional
health.
Social and Emotional Foundations of Children’s Learning:
Social and emotional development supports relationship-
building, competence, and success in
life. Family members influence children’s confidence,
enthusiasm for learning, self-control, and
cooperation. Sharing information on this developmental domain
increases family understanding
about effective ways to interact and build positive relationships
with their children, which is
essential for academic success.
Teachers can make suggestions, such as the following, to help
parents support their child’s
social and emotional literacy:
conversation as you read to them.
-emotional
development, such as sharing and
making friends.
Suggestions provided for teachers to involve families include:

that support children’s social
and emotional development, including recommended books and
shared activities.
-home literacy kitsfor families and
children to share.
storytelling, and age-appropriate
dramatics that focus on social and emotional skills.
young children to support
both literacy and social and emotional development.
Teachers, families, and other community members can be
involved in activities that support
children’s learning without resorting to rote drill or
memorization. Early childhood educators can
teach families about the thought processes of young children to
better enable them to relate to
their children’s ideas and conceptual frameworks. When
teachers, families, and community
members build partnerships to support children’s learning at
home and at school, greater
success is bound to happen!

1
Doctoral Project Charter Proposal Checklist
Instructions: Faculty and Secondary Reviewers will use this
checklist to review the charter for your doctoral project. Items
checked indicate
the criterion was met. Items NOT checked are either missing or
incomplete.
Review the Feedback and incorporate the feedback when
revising the Project Charter Proposal. Failure to incorporate
feedback may result in
deferral of the proposal. Prior to submitting to IRB, please
provide a copy the approved Project Charter and Checklist to
the 9902 faculty for
signature
.
Learner Name: EMPID
Primary Faculty: Secondary Reviewer
Date: Iteration: 1 Decision: Approved
NURS9902 Faculty Attestation: I have reviewed the Project
Charter for the above named learner and can attest the charter
was
approved by two separate reviewers and has not been modified.
(9902 Faculty Name)
Part 1
General Project Information: Clearly describes the people who

will be involved in and affected by a project. Description
includes multiple specifics and details that further characterize
participants and narrow the focus
Project Name
2
Named the project.
Acronym to identify the project.
Feedback:
Iteration 1
Iteration 2
Iteration 3
Executive Sponsors
List key supporters using initials.
Describes why they were chosen (such as fiscal or political
support, useful skills such as marketing ability).
Feedback:
Iteration 1

Iteration 2
Iteration 3
Departmental Sponsors
List departmental sponsors.
Identifies sponsors departmental roles and why they were
chosen to support this project.
Feedback:
Iteration 1
Iteration 2
Iteration 3
3
Project Aim
Describes the project’s overarching aim.
Include the goals you intend to accomplish impact on systems
Feedback:
Iteration 1
Iteration 2

Iteration 3
Project Focus
Describes the specific intervention that will be used to achieve
the project aim
Intervention is evidence based and appropriate evidence is
provided and cited appropriately
Intervention meets the scope and rigor for a doctoral level
project
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Team
Project
Manager
Describes the relevant skills and experience that qualify the
person to lead the initiative.
Describes the project managers primary organizational role
Describes the project managers unique contributions to the
project
4

Feedback:
Iteration 1
Iteration 2
Iteration 3
Team
Members
Describes each team member’s primary role in the organization
as well as skills or qualifications that could
Feedback:
Iteration 1
Iteration 2
Iteration 3
Stakeholders
Lists titles, categories, or initials of those who will be affected
by project outcomes
Describse the impact on each individual or group.
Identifies impact on patients and consumers, customer
satisfaction, safety, and quality outcomes
reviewed sources
Feedback:

Iteration 1
Iteration 2
Iteration 3
Part 2
Project Overview: Clearly describes an overview of all aspects
of a project plan. Description includes multiple specifics; is
detailed,
yet concise; and all elements of the plan work together to create
a coherent whole.
Project Description
5
Includes concise descriptions of who, what, when, where, and
how long.
Describes the problem, how it was diagnosed, and how its
solution aligns to strategic priorities.
Includes a timeline and required resources for the project: staff
time, administrative resources, activity sites, and so on.
Includes a budget estimate if applicable
reviewed sources
Feedback:
Iteration 1

Iteration 2
Iteration 3
Provides empirical and contextual evidence to support the gap,
need, or improvement and includes organizational data,
Includes primary and secondary data sources, regulatory
requirements, clinical practice guidelines, and benchmarking
data.
Data and sources are supported by citations and/or personal
communications to ensure academic merit and integrity
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
6
Describes the business or clinical need the project addresses
Describes the change or improvement and how will it impact
consumers, staff, and health care system as a whole

reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Time-Bound)
Provides a concise list of objectives using the SMART model.
Feedback:
Iteration 1
Iteration 2
Iteration 3
Deliverables
Lists the specific high-level products or processes that will be
improvements.
reviewed sources
Feedback:
Iteration 1

Iteration 2
Iteration 3
Project Scope
Specifies what the project will and will not address.
Includes all relevant people and processes and addresses
alignment to strategic organizational goals.
Includes a brief discussion of the project’s limitations.
reviewed sources
7
Feedback:
Iteration 1
Iteration 2
Iteration 3
Project Milestones
Describes specific deliverables for each project phase.
Identifies interim milestones including timeframes in terms of
number of days, weeks, or months. Identify those responsible
for each
deliverable.

Project length meets the requirements for doctoral work (DNP
projects must be between 8-10 weeks to allow for enough
data collection and to accumulate the necessary number of
practicum hours).
Feedback:
Feedback:
Iteration 1
Iteration 2
Iteration 3
Part 3
SWOT Analysis: Clearly describes the strengths, weaknesses,
opportunities, and threats related to a project plan. Description
identifies knowledge gaps, unknowns, missing information,
unanswered questions, or areas of uncertainty
Strengths
Identifies project strengths could include things like executive
support or financial resources.Write them here.
Weaknesses
Identifies here at least three potential obstacles to a successful
project outcome.
Opportunities

8
Identifies current opportunities to facilitate project success
Threats
Identifies at least three current or future threats to the project’s
success
Feedback:
Iteration 1
Iteration 2
Iteration 3
Known Major Risks
Ranks the SWOT weaknesses and threats listed and identifies at
least one high risk and discuss how it might be mitigated
Feedback:
Iteration 1
Iteration 2
Iteration 3
Ethical Considerations: Clearly describes the ethical
considerations, constraints, external dependencies, and

communication
strategy of a project plan. Description includes multiple
scholarly and/or
authoritative sources
9
Describes any potential for human rights violations.
The project does not involve vulnerable populations.
Addresses data security factors and includes a description of
how data will be accessed and stored, including team members
who will
have access to personal health data and how it will be
safeguarded
The project, as described, is NOT Research
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Constraints
Identifies any constraints that may limit the project potential (

i.e. personnel, funding, scheduling, or other options, such as a
predetermined budget, limited staff, or deadlines)
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Describes external dependencies such as personnel, funding,
communication channels, or community resources, describe
them here.
If there are no external dependencies, describes internal
support.
Feedback:
Iteration 1
Iteration 2
Iteration 3
10

Indicates here how the project manager will communicate to
sponsors, project team, and stakeholders.
Describes the means and frequency of communication, including
meetings, processes, and tools such as charts, wikis, and
dashboards.
reviewed sources
Feedback:
Iteration 1
Iteration 2
Iteration 3
Proposed Outcomes: Clearly describes the outcome measures
related to a project plan. Plans for each proposed outcome
measure are linked to authoritative evidence.
Describes what is specifically being measured to determine
project success
Operationally defines all outcome, process, counter, or proxy
measures that will be used to evaluate the success of the project
reviewed sources
Feedback:
Iteration 1

Iteration 2
Iteration 3
Data Collection Plan: Clearly describes the data collection
procedures related to a project plan. Description includes
multiple
scholarly and/or authoritative sources.
11
Describes the type of data that will be collect and analytical
methods to determine project success
Describes how and when data will be collected per the project
milestones described.
Identifies twho will collect, analyze the data and where the data
will be stored
Addresses the integrity of the data collection process (will it be
done by team members or staff)
Explains the integrity of the data sources.
If using a survey tool, the survey is described in detail
including validity and relability testing and permissions.
Describes the plan to handle missing data and how data will be
securely stored
Feedback:
Iteration 1
Iteration 2
Iteration 3

Optional: The data collection tool is included as an Appendix in
the Project Charter Proposal Document
DO NOT submit the excel sheet to the assignment / assessment
in NURS/NURSFPX9100. The sheet will be reviewed by your
faculty
in NURA/NURSFPX9902.
Scolarly Writing and Academic Integrity
Scholarly Evidence and Support: Synthesizes scholarly,
authoritative evidence where indicated within the project
charter. Synthesis
includes multiple, relevant, and current evidence supporting all
parts of the project charter.
Feedback:
Iteration 1
Iteration 2
Iteration 3
12
Writes clearly and coherently using communication style and
vocabulary appropriate for scholarly work (no grammar, usage,
or
mechanical errors).

Feedback:
Iteration 1
Iteration 2
Iteration 3
Correctly references and cites scholarly and/or authoritative
sources in APA 7th ed.
Feedback:
Iteration 1
Iteration 2
Iteration 3
General Summary Feedback:
Iteration 1
Iteration 2
Iteration 3
Doctoral Project Charter

Use this template to develop the charter for your doctoral
project, replacing the instructional text in the cells with the
required information. Consider making a copy of this template
should you require a second look at the instructions.
Part 1General Project Information
Project Name
Name your project here. Be creative. Use a clever, memorable
acronym to identify the project. This will help gain stakeholder
buy-in.
Executive Sponsors
List key supporters using initials here. Briefly describe why
they were chosen (such as fiscal or political support, useful
skills such as marketing ability).
Department Sponsors
List departmental sponsors by initials here. Identify their
departmental roles and why they were chosen to support this
project.
Project Aim
Describe the project’s overarching aim here. Include the goals
you intend to accomplish by the end of the project and their
impact on systems (such as “decrease the number of patients
presenting to the ED without treatment”).
Focus
In this space, describe the specific intervention strategy that
will be used to achieve the project aim. (For the example above,
the project focus might be to use LEAN methodology to
improve hospital throughput.)Project Team
Title
Department
Credentials
Role
Project Manager

Include a brief description here of the relevant skills and
experience that qualify this person to lead the initiative. What is
his or her primary organizational role? What other useful
qualities might this person leverage as a contributor to this
project?
Team Members
Describe here each team member’s primary role in the
organization as well as skills or qualifications that could

Stakeholders
Stakeholder
List here titles, categories, or initials of those who will be
affected by project outcomes and describe the impact on each
individual or group. Remember to include patients and
consumers, describing customer satisfaction, safety, and quality
outcomes.

Part 2
Project Overview
Project Description
Include here concise descriptions of who, what, when, where,
and how long. Include a budget estimate if applicable. Describe
the problem, how it was diagnosed, and how its solution aligns
to strategic priorities. Include a timeline and required resources
for the project: staff time, administrative resources, activity
sites, and so on.
Provide here empirical and contextual evidence to support the
gap, need, or improvement. Consider primary and secondary
data sources, regulatory requirements, clinical practice
guidelines, and benchmarking data. Be sure to include proper
citations and descriptions of integrity and reliability of any data
you provide.
Describe the business or clinical need this project addresses
here. What will the change or improvement accomplish and how
will it impact consumers, staff, and health care system as a
whole?
Time-Bound)
Provide a concise list of objectives using the SMART model
here.
Deliverables
List here the specific high-level products or processes to be
improvements.
Project Scope
Specify clearly here what the project will and will not address.
Include all relevant people and processes; this is an opportunity
to address alignment to strategic organizational goals. Be sure
to include a brief discussion of the project’s limitations.
Project Milestones
Describe specific deliverables for each project phase here. For

the development and planning stage, team member recruitment
from each involved department might be a deliverable, for
example. If using PDCA, interim milestones may correspond to
completion of different PDCA cycles. Indicate timeframes in
terms of number of days, weeks, or months. Identify those
responsible for each deliverable.
Part 3
SWOT Analysis
Strengths
Project strengths could include things like executive support or
financial resources.Write them here.
Weaknesses
Identify here at least three potential obstacles to a successful
project outcome.
Opportunities
Note here current opportunities to facilitate project success,
such as leveraging existing EMP to implement a clinical
decision support system.
Threats
Identify at least three current or future threats to the project’s
success here. Examples include increased competition or high
staff turnover in the affected department or service line.
Known Major Risks
Rank the SWOT weaknesses and threats listed above here.
Identify at least one high risk and discuss how it might be
mitigated.
Risk Level (Low, Medium, High)
Risk

Ethical Considerations
Taking into account PHI, HIPAA, human subject considerations,
equitable care, and IRB oversight, describe here any potential
for human rights violations. Note any vulnerable populations
involved and plans for equitable subject treatment. Describe
data security factors: how data will be accessed and stored,
including team members who will have access to personal
health data and how it will be safeguarded (such as “Only [X]
people will access the EMR”).
Constraints
List here any limits to personnel, funding, scheduling, or other
options, such as a predetermined budget, limited staff, or
deadline.
If the project’s success may depend on external relationships or
resources such as personnel, funding, communication channels,
or community resources, describe them here. If there are no
external dependencies, describe internal support.
Indicate here how the project manager will communicate to
sponsors, project team, and stakeholders. Describe the means
and frequency of communication, including meetings,
processes, and tools such as charts, wikis, and dashboards.
Proposed Outcomes
Metric

Outcome Measure
Process Measure
Countermeasure (optional)
What is being measured to determine project success
Answers specifically final outcome (“So what?”), such as [X]
percent patient satisfaction rate increase
Measures supporting final outcome such as compliance, time
motion, competency
Measures to ensure that there are no negative consequences in
other areas

Data Collection Plan
Describe in detail here the data you will collect and analyze to
determine project success, including how and when it will be
collected per the project milestones described above. Identify
those who will collect, analyze, and store the data and address
the integrity of the process (will it be done by team members or
staff). Explain the integrity of the data sources: will data be
collected from the EMR, online survey, or an internally created
tool? Describe your plan to handle missing data and where you
will securely store the data.
Develop a data collection tool for future use in Excel using
appropriate headers for columns and rows. DO NOT submit the
Excel sheet to the assignment / assessment in NURS/NURS-
FPX9100. Be sure to keep your Excel sheet as a reference and a
possible resource for a future NURS course where it may be
reviewed by faculty.
Sheet 1: The data collection tool should include at least one
filtering application and one analytical function (sum, mean,
calculation).
Sheet 2: Add dummy data to show the operation above.
Sheet 3: Based on the dummy data, create a graphic
representation (such as histogram, line graph, bar graph, or pie
chart) to show how the data can be displayed and
communicated.

1
2
Doctoral Project Charter
Use this template to develop the charter for your doctoral
project, replacing the instructional text in the cells with the
required information. Consider making a copy of this template
should you require a second look at the instructions.
Part 1General Project Information
Project Name
Name your project here. Be creative. Use a clever, memorable
acronym to identify the project. This will help gain stakeholder
buy-in.
Executive Sponsors
List key supporters using initials here. Briefly describe why
they were chosen (such as fiscal or political support, useful
skills such as marketing ability).
Department Sponsors
List departmental sponsors by initials here. Identify their
departmental roles and why they were chosen to support this
project.
Project Aim
Describe the project’s overarching aim here. Include the goals
you intend to accomplish by the end of the project and their
impact on systems (such as “decrease the number of patients
presenting to the ED without treatment”).
Focus
In this space, describe the specific intervention strategy that
will be used to achieve the project aim. (For the example above,
the project focus might be to use LEAN methodology to
improve hospital throughput.)Project Team

Title
Department
Credentials
Role
Project Manager
Include a brief description here of the relevant skills and
experience that qualify this person to lead the initiative. What is
his or her primary organizational role? What other useful
qualities might this person leverage as a contributor to this
project?
Team Members
Describe here each team member’s primary role in the
organization as well as skills or qualifications that could

Part 2
Project Overview
Project Description
Include here concise descriptions of who, what, when, where,
and how long. Include a budget estimate if applicable. Describe
the problem, how it was diagnosed, and how its solution aligns
to strategic priorities. Include a timeline and required resources
for the project: staff time, administrative resources, activity
sites, and so on.
Provide here empirical and contextual evidence to support the
gap, need, or improvement. Consider primary and secondary
data sources, regulatory requirements, clinical practice
guidelines, and benchmarking data. Be sure to include proper
citations and descriptions of integrity and reliability of any data
you provide.
Describe the business or clinical need this project addresses
here. What will the change or improvement accomplish and how
will it impact consumers, staff, and health care system as a
whole?
Time-Bound)
Provide a concise list of objectives using the SMART model
here.
Deliverables
List here the specific high-level products or processes to be
improvements.

Project Scope
Specify clearly here what the project will and will not address.
Include all relevant people and processes; this is an opportunity
to address alignment to strategic organizational goals. Be sure
to include a brief discussion of the project’s limitations.
Project Milestones
Describe specific deliverables for each project phase here. For
the development and planning stage, team member recruitment
from each involved department might be a deliverable, for
example. If using PDCA, interim milestones may correspond to
completion of different PDCA cycles. Indicate timeframes in
terms of number of days, weeks, or months. Identify those
responsible for each deliverable.
Part 3
SWOT Analysis
Strengths
Project strengths could include things like executive support or
financial resources.Write them here.
Weaknesses
Identify here at least three potential obstacles to a successful
project outcome.
Opportunities
Note here current opportunities to facilitate project success,
such as leveraging existing EMP to implement a clinical
decision support system.
Threats
Identify at least three current or future threats to the project’s
success here. Examples include increased competition or high
staff turnover in the affected department or service line.
Known Major Risks
Rank the SWOT weaknesses and threats listed above here.
Identify at least one high risk and discuss how it might be
mitigated.
Risk Level (Low, Medium, High)
Risk

Taking into account PHI, HIPAA, human subject considerations,
equitable care, and IRB oversight, describe here any potential
for human rights violations. Note any vulnerable populations
involved and plans for equitable subject treatment. Describe
data security factors: how data will be accessed and stored,
including team members who will have access to personal
health data and how it will be safeguarded (such as “Only [X]
people will access the EMR”).
Constraints
List here any limits to personnel, funding, scheduling, or other
options, such as a predetermined budget, limited staff, or
deadline.
If the project’s success may depend on external relationships or
resources such as personnel, funding, communication channels,
or community resources, describe them here. If there are no
external dependencies, describe internal support.

Indicate here how the project manager will communicate to
sponsors, project team, and stakeholders. Describe the means
and frequency of communication, including meetings,
processes, and tools such as charts, wikis, and dashboards.
Proposed Outcomes
Metric
Outcome Measure
Process Measure
Countermeasure (optional)
What is being measured to determine project success
Answers specifically final outcome (“So what?”), such as [X]
percent patient satisfaction rate increase
Measures supporting final outcome such as compliance, time
motion, competency
Measures to ensure that there are no negative consequences in
other areas

Describe in detail here the data you will collect and analyze to
determine project success, including how and when it wil l be
collected per the project milestones described above. Identify
those who will collect, analyze, and store the data and address
the integrity of the process (will it be done by team members or
staff). Explain the integrity of the data sources: will data be
collected from the EMR, online survey, or an internally created
tool? Describe your plan to handle missing data and where you
will securely store the data.
Develop a data collection tool for future use in Excel using
appropriate headers for columns and rows. DO NOT submit the
Excel sheet to the assignment / assessment in NURS/NURS-
FPX9100. Be sure to keep your Excel sheet as a reference and a
possible resource for a future NURS course where it may be
reviewed by faculty.
Sheet 1: The data collection tool should include at least one

filtering application and one analytical function (sum, mean,
calculation).
Sheet 2: Add dummy data to show the operation above.
Sheet 3: Based on the dummy data, create a graphic
representation (such as histogram, line graph, bar graph, or pie
chart) to show how the data can be displayed and
communicated.
1
2
1
Copyright ©2020 Capella University. Copy and distribution of
this document are prohibited.1
Project Charter – Secondary Review
Learner’s Name

Capella University
NURS-FPX9100: Project Charter – Secondary Review
Instructor Name
January 1, 2020
2
this document are prohibited.
Project Charter – Secondary Review
Part 1
General Project Information
Project Name
MSUDBN: Medical Surgical Unit Discharge Before Noon
Executive Sponsors
The Director of Nursing was chosen both for political support
and for her knowledge of Joint
Commission requirements.
The Chief of Surgery will provide political support.

The Administrative Director of the Medical Surgical Unit
(MSU) was chosen for political support for
provider and practitioner buy-in.
3
Department Sponsors
The attending surgeon manages the medical care of patients
within the MSU. The attending surgeon was
chosen for their knowledge of daily MSU processes, policy, and
procedures.
The nurse practitioner (NP) supervisor oversees scheduling and
general NP management within the
MSU. This person ensures that proper care protocols are
followed and has a direct influence on NP
patient care management.
The clinical director of the MSU manages direct care staff in
the MSU. This person will be instrumental
in advocating staff buy-in.
The chair of the quality and patient safety committee is a staff
nurse who conducts monthly

interdisciplinary quality improvement and patient safety
(QI/PS) meetings at the organizational level.
4
Project Aim
Late-afternoon hospital discharges cause admission bottlenecks
which negatively affect the flow
of patients who need hospital admission. Delays in discharge
are widespread in health care and have
been linked to increased length of stay, lower patient
satisfaction scores, and adverse outcomes (Kaye, et
al., 2017). Therefore, hospitals are taking a renewed look at
early discharge as a way to reduce
admission delays and achieve optimal patient flow.
The aim of the project is to improve patient flow through the
MSU of AZ Hospital by
eliminating discharge bottlenecks in the unit. This w ill comply
with the Joint Commission 2009
Leadership operations Standard LD.04.03.11, which rationalizes

that “managing the flow of patients
throughout their care is essential to prevent overcrowding”
(Schyve, 2009, p. 31).
5
Focus
MSUDBN will use Six Sigma methodology DMAIC (Define,
Measure, Analyze, Improve,
Control) process of improvement to increase the number of
discharges by noon in the MSU of AZ
Hospital. A completed Emergency Department (ED) throughput
analysis report and supporting literature
will be used to define the need for more discharges by noon in
the MSU. The patient’s journey through
the MSU will be analyzed to determine points at which patients
are required to wait. The root cause for
delays will be determined with the help of a fishbone exercise
and will be worked on by all MSU staff
members. The project manager will conduct focus groups and
simultaneous PDSA (Plan, Do, Study,
Act) cycles to generate appropriate interventions to improve the

efficiency of the discharge process and
arrive at a standardized discharge process.
Solution
s will be implemented, measured, and refined.
Sustainability will be maintained through the implementation of
standard operating procedures,
guidelines, and statistical process control (SPC).
The patient discharge process is complex, requiring different
groups including physicians,
nurses, ancillary service staff, patients, and their families to
coordinate. Complex processes tend to be
high in variability. The Six Sigma methodology focuses on
reducing defects and variations. Six Sigma
uses a “structured approach to uncover the root cause of a
problem using the Define, Measure, Analyze,

Improve and Control (DMAIC) method by: defining the
problem; measuring the defect; analyzing the
causes; improving the process by removing major causes; and
controlling the process to ensure defects
do not recur” (El-Eid et al., 2015, p. 2). The Six Sigma
methodology was chosen for this project because
6
the goal is to eliminate variation in the discharge process of the
MSU. Standardizing the process by
establishing set criteria for patient discharges by noon will
decrease variation in the process among the
staff and providers thereby decreasing ED holds and improving
patient satisfaction with the discharge

process.
The PDSA cycle is an iterative model for improving a process
involving four steps. In the first
step, the who, what, when, and where of the plan is developed
in which predicted outcomes are outlined
and tasks are assigned. The plan is implemented in the do phase.
The data and results of the
implementation are analyzed in the study phase. In the act
phase, the plan is either adopted, adapted, or
abandoned based on the outcome from the study phase. If the
plan is not adopted, changes are made to
the plan based on learnings from the previous PDSA cycle and a
new PDSA cycle is initiated. This
process is repeated till a plan is adopted (Christoff, 2018).
Project Team
Title Department Credentials Role

Project
Manager Charge Nurse MSU MSN
The team leader of this initiative will be responsible for the
initial analysis, design, implementation, and test as per the
guidelines and schedule stated in the schedule of work.
7
Team
Members
Attending
Surgeon

MSU MD
The attending surgeon is an expert in the care of
preoperative and postoperative patients, in addition to
surgeries. The attending surgeon will provide medical
oversight of any policy or protocol changes that impact the
patient discharge process in the MSU. The attending surgeon
will also champion the initiative among physician
colleauges.
Clinical
Director
MSU RN, BSN
The clinical director will oversee the work of the MSU staff
in a managerial capacity and care processes. The MSU

clinical director will be inovled in policy revisions that
impact nursing directly and will be involved in
disseminating information to the staff.
8
Staff Nurse
Project
Champions
MSU RN
The MSU staff nurse provides direct patient care. In
addition, the bedside nurse is the main advocate for the MSU

patients and their family. The MSU nurse will foster change
at the bedside during shift report and medical rounds. They
will serve as role models and assist in staff education and
policy revisions. Staff nurse champions will also be in
charge of weekly compliance audits and data collection.
Respiratory
Therapy
MSU RRT
The respiratory therapist provides support for critical
respiratory needs. The respiratory therapist will provide
inputs in policy change decisions and serve as a champion
for the respiratory care staff that rotates through the unit.
Stakeholders

Stakeholder
Benefits
Patients
The patients benefit from decreased wait time. An established
discharge process will keep them
informed about their discharge readiness in advance, which will
allow them to arrange
transportation or complete discharge or billing paperwork in
advance.
9
Emergency Department
The ED benefits from reduced ED holds due to increased bed
availability in the MSU.

MSU Staff
The MSU staff benefits from fewer discharge bottlenecks
enabled by the new standardized
discharge process.
Part 2
Project Overview
Project Description
10
The ED of AZ hospital performed an analysis of ED throughput
between April and June 2019. The results of the analysis
showed increase in the number of ED holds, which led to
increased wait times for patients. The results also showed an

increase in the
number of patients leaving the ED without being seen by a
provider. The call to action was for all inpatient units to
implement process
improvements to increase the number of available beds. The
MSU at AZ hospital intends to answer that call with the process
improvements proposed in this Project Charter.
A charge nurse of the MSU will act as the team leader for the
MSUDBN. The charge nurse is an employee of the organization
and works full time in the MSU. The team leader will obtain
approval for the project from the clinical director of the MSU.
The team
leader of this initiative will be responsible for the initial
analysis, design, implementation and test according to the
guidelines and
schedule stated in the schedule of work (Table 2). The fishbone
model will be placed in the staff breakroom for convenient
access and

all MSU staff will be encouraged to participate in the fishbone
exercise. Focus groups will be conducted by team members to
discuss
findings from the fishbone exercise and will, over the course of
the following week, perform rapid PDSA cycles to finalize a
standardized discharge process.
Baseline data will be collected to determine the current
percentage of patients discharged by noon in the MSU, length of
stay
(LOS) data in the MSU, percentage of the patients leaving
without being seen in the ED, ED holds and wait time data.
With staff input
from the fishbone analysis the team will identify potential
solutions to increase patient discharges by noon in the MSU.
The new
standardized discharge process will be established and
communicated to the staff during the week of 9/29/2019.
Implementation of the

new criteria along with twice daily huddles will start on
10/1/2019. On 10/13/2019 an interim data report of MSU
discharges before
11
noon will be communicated to the staff through postings in the
workroom. Final data analysis and results will be completed the
week of
10/20/2019.
Project expenses are expected to be minimal and will include
lamination of two 8x11 cards displaying the new standardized
discharge process ($5.00), material for fishbone poster ($15.00),
and staff celebratory thank you lunch at the end of the project
($75.00).

The project budget is $100.00. All project work is anticipated to
occur during regular staff work time hours.
Table 2. Schedule of Work
SCHEDULE OF WORK
DATES HOURS DMAIC ACTIVITY DELIVERABLE
8/22 – 8/30
10
D

The team leader will obtain approval for
the project from the clinical director of
the MSU.
Conduct presentation for MSU staff to
highlight ED throughput analysis report
and its call to action for other inpatient
departments to improve discharge process
efficiency.
Determine feasibility of data collection
plan including a pilot data collection
Project charter

9/2 – 9/7
6
M
Pilot data collection tool
Begin collecting pre-implementation data
Baseline data
summary

12
9/8 – 9/14
8
A

Disseminate the results of baseline data
collection
Post fishbone diagram for staff input
Standardized
discharge
process to
increase the
number of
discharges by
noon in the MSU
9/15 – 9/21

6
Conduct focus groups to review fishbone
diagram results. Focus groups will
determine root cause of delayed
discharges or discharge bottlenecks in the
MSU.
Rapid PDSA cycles will determine what
policies need to be changed or improved
to develop a standardized discharge
process. Plan for twice daily huddles to
discuss the effects of and further refine
PDSA cycles

9/22/ – 9/28 4
I
Finalize new standardized discharge
process
Finalize statistical process control tools to
ensure post-implementation sustainability
Laminate new

standardized
discharge
process cards
9/29 – 10/5 6
E-mail communication of plan for twice
daily huddles to review adherence to the
new standardized discharge process
Begin twice-daily review huddles
13

10/6 – 10/12 6 Implementation week one
Data collection and interim analysis
Histogram and
Line graphs
week one
10/13/ – 10/19 4
Implementation week two
Data collection
Begin final presentation write up
Histogram and

Line graphs
week two
10/21 – 10/23 6
Implementation week three, data
collection and final data analysis
Histogram and
Line graphs
week three
10/25 6
C
Present summary to staff with
recommendations

Summary
Histogram and
line graph and
post
implementation
baseline
summary data
14

Patient arrivals in the ED increases over the course of the day
resulting in the increase in the number of patients admitted to
inpatient units such as the MSU. Delays in discharging patients
from inpatient units results in patients being held in the ED.
Focusing
on discharges before noon in inpatient units has been
demonstrated to improve ED flow by lessening the number of
ED holds prior to
the time that the ED is busiest (McKenna, et al., 2019).
Studies conducted on the subject of discharges before noon
have demonstrated a clear positive effect on hospital throughput
metrics. Durvasula et al. (2015) employed quantitative methods
to gauge if an interdisciplinary approach to discharge planning
could
increase the percentage of discharges occurring before 11:00
a.m. The intervention consisted moving discharge process steps
to the
night before the discharge and giving the discharge order before

9:00 a.m. on the morning of the discharge. Prior to the
intervention, the
rate of discharges before 11:00 a.m. was 8% and increased to
11% after implementation of the new discharge process. The
study
demonstrated that a multidisciplinary approach to discharge is a
low cost, safe, and effective way to increase discharges before
11:00
a.m. and improve hospital throughput.
Chaiyachati and Chia (2016) measured the effects of targeted
discharge interventions on a hospital’s overall patient flow
using a
quantitative research study. The intervention involved daily
morning discharge rounds to identify who could possibly be
discharged the
next day. Discharge preparation began immediately after
identification for discharge the next day. The proportion of
discharges before

11:00 a.m. was measured and compared to hospital departure
times. The baseline determined from a retrospective review of
data 1
month prior to the study was compared to the new baseline
determined from the data 3 months after implementation. The
conclusion
demonstrated that targeted interventions could significantly
improve early discharges.
15
Health care organizations have been driven to adopt strategies
aimed at reducing patient length of stay since the introduction
of
the prospective payment system by Medicare in 1983 which
made changes to the way hospitals were reimbursed.
Reimbursements were

changed from a per-diem basis to a flat payment based on the
diagnosis. Reducing the length of stay was a cost effective way
for the
hospitals to remain competitive (McKenna, et al., 2019). The
completion of this project will ensure that AZ Hospital complies
with the
Joint Commission 2009 Leadership Standard LD.04.03.11 which
rationalizes that “managing the flow of patients throughout their
care
is essential to prevent overcrowding” (Schyve, 2009, p. 31).
The MSU is in a level three tertiary care hospital. The unit
consists of 40 beds serving approximately 7,700 patients a year.
The
unit is staffed by a team of hospitalists who cover 12 hour
shifts. The team includes nurses, respiratory therapists, case
managers,

nursing assistants, and housekeeping. The hospital serves an
urban community.
The primary beneficiaries from the MSUDBN project will be
patients. They will benefit from shorter wait times after the
discharge order is given in the MSU. The increased bed
availability will also benefit patients upstream in the ED,
resulting in shorter
admission times and fewer patients leaving the ED without
being seen by a provider. The staff in the MSU will benefit
from a
standardized discharge process. AZ Hospital will benefit from
the increase in revenues afforded by improved hospital
throughput.
Time-Bound)
16

Objective 1: By week three, the project team will develop and
implement a new standardized discharge process targeted at
increasing
the percentage of discharges by noon in the MSU.
Objective 2: By week six, there will be 80% staff compliance
with the new standardized discharge process with each patient
handoff.
Objective 3: By the end of 12 weeks there will be a 20%
increase in the discharges before noon in the MSU.
Deliverables
Deliverables included the results of a baseline analysis of
discharge before noon percentage in the MSU, fishbone
diagram,
bimonthly progress reports to the Chief of Surgery, the
administrative director of the MSU, and MSU staff. Interim

progress reports and
a summary of the final data will also be presented to
stakeholders. The final results will also be presented to the
multidisciplinary QI/PS
committee that meets quarterly. The final deliverable for the
MSUDBN project will be a new standardized discharge process
that will
increase the percentage of discharges before noon in the MSU.
Project Scope
17
The MSUDBN project was created to improve bed availability
in the MSU by increasing the percentage of discharges before

noon, which in turn will help reduce ED holds during high
patient volumes. The project’s affect will be minimal during
times of low
patient volumes. The project is intended to contribute to
internal process quality improvement. The project scope will
not be expanded
beyond the MSU environment as this patient population consists
of those coming in through the ED as well as the OR, and other
inpatient units. The project is not intended to be generalizable
to other MSU’s. For this reason, the project is not intended to
be
published in peer-reviewed literature or disseminated outside
the organization.
Project Milestones
18

Key Occurrences for Week of:
8/22-8/30
• Project approval
• Complete ED throughput analysis report presentation for MSU
staff on 8/25
• Develop project charter
• Develop and test a data collection tool
9/2-/9/7
• Pilot test data collection tool
• Begin collecting pre implementation and current state data on
discharges before noon of all patients in MSU
9/8-9/14

• Baseline data analysis
• Fishbone exercise for staff
• Staff e-mail communication
9/15-9/21
• Focus groups on day and night shifts
• Perform rapid PDSA cycles to address root causes of
discharge delays in the MSU
• Staff e-mail communication
9/22 – 10/5
19

• Finalize new standardized discharge process
• Communicat plan to staff via e-mail for twice daily huddles,
review on a.m. and p.m. rounds.
• Post laminated discharge process in unit
• Begin implementation on 10/1/19
• First data collection on 10/4/19
10/6 – 10/20
• Interim report posted in work room
• E-mail reminder to NP’s to review new standardized discharge
process
• Continue data collection
• Complete final data analysis
• Present summary to staff via e-mail and power point on
departmental website

• Submit report to Chief of surgery and Administrator Director
of the MSU
Part 3
SWOT Analysis
Strengths
20
• The proposed project will significantly reduce the wait time
for patients in the hospital ensuring that none of the patients are
forced to leave without obtaining the required treatment.
• The project ensures a significant increase in the overall
revenue generated by the hospital.
• The budget for the proposed project is minimal and the project

is scheduled during normal work hours of the staff and does not
require them to put in additional work hours.
Weaknesses
• The proposed project and its processes are not universal and
cannot be applied as is to another hospital. The processes would
require substantial changes as per the differing variables
presented in another organization.
Opportunities
• After the initial implementation of the project, SPC can be
utilized to closely monitor and control the post-implementation
variations in the protocols in the proposed project charter. The
data obtained through statistical process control should be
frequently monitored and any variation can be rectified
immediately using rapid PDSA cycles.
Threats

• Poor analyzation of the data obtained from SPC can hinder the
progress of the project.
• Lack of communication between the staff members can hamper
the flow of processes and lead to failure of the project.
• The successful implementation of the project can happen only
if there are high patient volumes during the project duration.
21
Known Major Risks
Risk Level (High, Medium, Low) Risk
Lack of Communication
High
Mitgation strategy. Lack of communication among the staff

members can have drastic effects
on the project. Miscommunication can cause misunderstanding
between staff members and the
roles they play in the project. Project champions such as staff
nurses responsible for data
collection and process implementation have an additional
responsibility, which is to identify
any instances of miscommunication among team members and
resolve it before it can affect the
project.
Improper Analyzation of Data
Medium
Mitagation strategy. Data can be poorly analyzed because of
varying levels of expertise and
differing perspectives of individuals. In order to combat this
issue, we can form focus groups

that can meet twice a month to discuss the results of the
analysis as well as reach a consensus
on the implementation of a process depending on the data.
22
The MSUDBN project will focus on improving the discharge
process of patients in the MSU by increasing the percentage of
patients discharged before noon. This will be accomplished by
making improvements to the existing discharge process and as
such,
there are no foreseeable ethical violations for patients due to the
improvements. The project charter will be submitted to the
Internal

Review Board of AZ hospital to determine if its oversight is
needed.
Constraints
Patient Volumes
The MSUDBN project aims to increase the availability of beds
in the MSU by prioritizing discharges before noon. This in turn
will reduce the percentage of ED holds and the percentage of
patients leaving the ED without being seen during times of high
patient
volumes. However, the effectiveness of the project will be
minimal duing times of low patient volumes. To ensure
adequate patient
volumes, the implementation period for this project was set
between the months of August and November, which have
historically been
high volume months at AZ hospital.

MSUDBN is an internal project within AZ hospital and will be
conducted only within the MSU. The project does not have
external dependencies. The success of the project will depend
on MSU staff buy-in and sustained efforts by them to develop,
implement
and sustain the new standardized discharge process.
23
The presentation of the ED throughput analysis report will
demonstrate to the MSU staff a clear need to improve the
discharge
process in the MSU. The presentation of the analysis will also

help paint a picture of what the future of the discharge process
could look
like after the improvement is realized. The fishbone diagram
will elicit multidisciplinary input, which will both involve and
empower
the stakeholders to identify obstacles to the change. The analyze
phase of DMIAC involves identifying barriers to the current
process
using statistical tools and methods as well as graphs posted in
the staff workroom and weekly e-mails. The focus groups will
allow the
project team to conduct rapid PDSA cycles to address process
deficiencies and develop a new standardized discharge process,
which
will be printed out, laminated, and posted for easy access to
staff members working on all shifts in the MSU. The new
process will be
introduced during the implementation phase. Twice-daily
huddles will be conducted to evaluate the discharge readiness of

patients in
the MSU based on the new standardized discharge process. SPC
will be used to maintain sustainability of the project.
Proposed Outcomes
Metric Outcome Measure Process Measure Countermeasure
(optional)
Compliance with new
standardized discharge
process
20% increase in discharges before
noon at the MSU compared to the
pre-intervention baseline
• 100% staff compliance
with new discharge

protocol and procedures
• 100% staff compliance
with daily discharge
rounds at the prescribed
time
0% increase in readmission
rates
24

Baseline data collection will begin during the second week of
the project and will include data on the number of discharges by
noon, the length of stay, and discharge data of patients in the
MSU. No patient identifiers will be used. The data will be
collected by the
project leader from the electronic medical records database of
AZ hospital. Interim data will be displayed in histogram or line
graph
format in the work room and will also be emailed to the MSU
staff. All data will be stored on the organization’s private,
password-
protected H drive that can be accessed only by the project
leader.
The data collection tool will be developed in Excel. The data
collected will be analyzed using filtering applications and
analytical functions. The analyzed data will be represented

graphically in the form of histograms, line graph, bar graph or
pie chart.
25
References
Chaiyachati, K. H., & Chia, D. (2016). Discharge rounds:
Implementation of a targeted intervention for improving patient
throughput on an
inpatient medical teaching service. Southern Medical Journal,
109(5), 313-317.
http://dx.doi.org/10.14423/SMJ.0000000000000458

Christoff, P. (2018). Running PDSA cycles. Current Problems in
Pediatric and Adolescent Health Care, 48(8), 198-201.
https://doi.org/10.1016/j.cppeds.2018.08.006
Durvasula, R., Kayihan, A., Del Bene, S., Granich, M., Parker,
G., Anawalt, B. D., & Staiger, T. (2015). A multidisciplinary
care pathway
significantly increases the number of early morning discharges
in a large academic medical center. Quality Management in
Healthcare,
24(1), 45-51.
http://dx.doi.org/10.1097/QMH.0000000000000049
El-Eid, G. R., Kaddoum, R., Tamim, H., & Hitti, E. A. (2015).
Improving hospital discharge time: a successful implementation
of Six Sigma
methodology. Medicine, 94(12), e633.
http://dx.doi.org/10.1097/MD.0000000000000633

Kaye, D. R., Richardson, C. R., Ye, Z., Herrel, L. A.,
Ellimoottil, C., & Miller, D. C. (2017). Association Between
Patient Satisfaction and Short-
Term Outcomes After Major Cancer Surgery. Annals of Surgical
Oncology, 24(12), 3486-3493.
http://dx.doi.org/10.1245/s10434-017-
6049-2
Schyve, P. M. (2009). Leadership in healthcare organizations: A
guide to joint commission leadership standards [White Paper].
https://psnet.ahrq.gov/issue/leadership-healthcare-
organizations-guide-joint-commission-leadership-standards
McKenna, P., Heslin, S. M., Viccellio, P., Mallon, W. K.,
Hernandez, C., & Morley, E. J. (2019). Emergency department
and hospital crowding:
causes, consequences, and cures. Clinical and Experimental
Emergency Medicine, 6(3), 189-195.
http://dx.doi.org/10.15441/ceem.18.022

http://dx.doi.org/10.14423/SMJ.0000000000000458
https://doi.org/10.1016/j.cppeds.2018.08.006
http://dx.doi.org/10.1097/QMH.0000000000000049
http://dx.doi.org/10.1097/MD.0000000000000633
http://dx.doi.org/10.1245/s10434-017-6049-2
http://dx.doi.org/10.1245/s10434-017-6049-2
https://psnet.ahrq.gov/issue/leadership-healthcare-
organizations-guide-joint-commission-leadership-standards
http://dx.doi.org/10.15441/ceem.18.022

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