Sample:
Project Implementation Plan (Project Charter)
(Insert name of project)
Version # (Insert number)
(Insert date)
(Insert project name)1
Table of Contents
Table of Contents
Document Control
Document History
Acronyms and Definitions
Approval and Signoff of the Pilot Project Implementation Plan (Project Charter)
Project Definition
Project Background
Project Description
Project Sponsor
Project Goal & Objectives
Project Deliverables
Approach & Timelines
Assumptions, Constraints, and Critical Success Factors
Project Scope
Project Organization
Organization Chart
Roles and Responsibilities
Committees
Management and Project Control
Project Co-ordination
Change Management & Scope Control
Documentation Management
Time (Workplan) Management
Cost Management
Quality Management
Communication Management
Risk Management
Issue Management
Funding Strategy
(Insert project name)1
Document Control
Project Title / (Insert title)Project Manager / (Insert name and contact information)
Project Sponsor(s) / (Insert names of one or more executive sponsors)
Principal Author / (Insert name and contact information)
Contributing Authors and Distribution / (Insert name and role e.g. Project Director – pilot site 1)
(Insert name and role e.g. Project Director – pilot site 2)
(Insert name and role e.g. Project Manager)
Version / (Insert number e.g. 1.0)
Status / (Insert status e.g. Draft, Final)
Document History
Version / Date / Changes Made By / Description of Changes / Comments1.0 / (Insert date) / ( Insert name) / (Insert content)
Acronyms and Definitions
Acronym / Definition(Insert acronym or term) / (Insert definition)
Examples:
CCHSA / Canadian Council on Health Services Accreditation
CIHI / Canadian Institute for Health Information
CMIRPS / Canadian Medication Incident Reporting and Prevention System
CWG / Collaborative Working Group
EHR / Electronic Health Record
EMPI / Enterprise Master Patient Index
FTE / Full-time Equivalent
HA / Health Authority
HIAL / Health Information Access Layer
IHI / Institute for Healthcare Improvement
IOM / Institute of Medicine
IRIS / Incident Management & Reporting Information System
IV / Intravenous
MOH / Ministry of Health
NPSA / National Patient Safety Agency
PSLS / BC Patient Safety and Learning System
RDD / Requirements Definition Document
SCN / Special Care Nursery
WHO / World Health Organization
Front-line Staff / Physicians, nurses, and other care providers.
(Insert project name)1
Approval and Signoff of the Pilot Project Implementation Plan (Project Charter)
(Insert nameand role, e.g. Project Sponsor) / Date(Insert name and role, e.g. Project Sponsor) / Date
(Insert name and role, e.g. Project Sponsor) / Date
(Insert name and role, e.g. Project Sponsor) / Date
(Insert name and role, e.g. Project Sponsor) / Date
(Insert name and role, e.g. Project Sponsor) / Date
(Insert name and role, e.g. Project Sponsor) / Date
(Insert project name)1
Project Definition
Project Background
(Insert a description of the background for the project to help readers to understand the project and its rationale. The description can be as long or as short as you think is necessary.)
Example:
PSLS Pilot Project
The BC Patient Safety and Learning System (PSLS) Project is now in its third phase. Formerly called the BC Incident Reporting and Management Information System (IRIS) Project, Phase III – the Pilot Phase – follows Phase I – Feasibility Study and Phase II – Package Selection. In the Phase III the new PSLS will be implemented at two proposed pilot sites; one in the Neonatal Intensive Care Unit (NICU) (formerly Special Care Nursery) at BC Women’s Hospital, part of Children’s & Women’s Health Centre of BC, an agency of the Provincial Health Services Authority (PHSA), and the second at Tower 8 – Vascular and General Surgery at Vancouver General Hospital, part of the Vancouver Coastal Health Authority (VCHA). Once the two pilots are successfully completed, PHSA and VCHA plan to roll out the PSLS across their organizations in a planned manner, with provincial implementation to follow over the next several years. The pilot project will serve as proof of concept for introducing a web-based, electronic incident reporting system throughout the BC healthcare system, and will validate the proposed approach to implementation. Experience from other jurisdictions implementing this type of system suggests that the change management component of this project will be integral to its success, hence the decision to pilot the system and implementation approach prior to rolling it out province-wide.
In addition to proving concept and validating our implementation approach, the pilot phase of the PSLS project will allow us to configure and tailor the electronic system for the BC healthcare context, and establish a plan for implementation across the province. The pilot method involves conducting concurrent, limited implementations of the PSLS in each of the two identified healthcare organizations. Front-line staff (physicians, nurses, and other care providers), safety event investigators, managers, administrators, risk management staff, client relations representatives, and executive leaders at each pilot site organization are the target audiences participating in this phase of the project. During pilot implementation, the system will be installed and tested, users and managers will be prepared to adopt the new system, and necessary organizational changes related to policies, processes and roles will be completed. A fellow in the Canadian Health Services Research Foundation’s Executive Training for Research Application (EXTRA) Program is conducting an intervention project focused on the PHSA pilot, guiding the change management activities for the pilot project in order to ensure an evidence-based approach to the interventions, to measure both pre- and post-pilot indicators, and to effect sustainable change. The results of the piloted intervention project will then inform and help shape the provincial implementation plan, while realizing several benefits.
BC Patient Safety and Learning System (BC PSLS)
The BC Patient Safety and Learning System Project (BC PSLS) is a collaborative undertaking involving all six BC Health Authorities (HA’s), specifically the Provincial Health Services Authority (PHSA), Vancouver Coastal Health Authority (VCHA), Vancouver Island Health Authority (VIHA), Fraser Health Authority (FHA), Northern Health Authority (NHA), and the Interior Health Authority (IHA), along with BC’s healthcare facility insurer, the Health Care Protection Program (HCPP). The BC PSLS Project is supported by the BC Leadership Council, which is comprised of all HA Chief Executive Officers and the Deputy Minister of Health. The BC Patient Safety Task Force (PSTF) composed of medical and nursing leaders from each HA, is responsible for overseeing the Project and directing the Project Office. At the HA level, executive sponsorship is provided by the respective Vice Presidents responsible for quality and safety portfolios; Project leadership is provided by HA directors of quality, safety and risk management.
The primary goal of the BC PSLS Project is to make healthcare safer, while improving the quality of care. This goal will be accomplished through the implementation of a province-wide web-based safety incident reporting and management information system that will support identification, investigation, and analysis of all safety and risk-related incidents (including safety hazards and near misses), capture and facilitate response to client feedback (including complaints, compliments and requests for information), and enable claims management. Such reporting and related functions are fundamental to improving patient safety, as they provide a means through which learning from experience may occur. The results of data analysis and investigation can be used to formulate and disseminate recommendations for change in order to prevent future problems and promote a safer healthcare system. The BC PSLS will support reporting and learning from events occurring across the continuum of care, in hospitals, care facilities and the community.
The specific Project objectives are to: enhance user understanding, improve communication, increase efficiency, create and support a culture of safety, apply expertise, engage staff and leaders in the education process, leverage opportunities to collaborate with other programs and initiatives, collaborate with international agencies to learn from and share experiences, and leverage opportunities to link with other registries.
Although the BC PSLS Project is centered around and relies on a web-based reporting and learning tool, it is not simply an information technology implementation project; it is a significant change initiative. In order to be successful, the Project must consider and address all aspects of change and apply appropriate methodology to effect such change. Where possible, change initiatives will be linked to other requirements, such as those identified by the Canadian Council on Health Services Accreditation (CCHSA) regarding patient safety practices. Using a comprehensive approach to education and communication, seven levers of change will be employed to create a comprehensive change management plan. Specifically, these change activities involve processes, skills, structures, performance measures, policies, culture, and rewards.
Success of the BC PSLS implementation will be determined by the degree to which the following outcomes are achieved: Improved event and near miss reporting with specific actions resulting in reduced or eliminated safety-related problems, provision of more timely feedback to users and leaders on events, improved efficiency for event, complaint and claims management, provision of support to managers, promotion of teamwork and communication, provision of a better source of data for analysis, promotion of more effective use of resources, reduced costs, increased and improved information-sharing, a created and supported culture of safety and learning, assistance for clinicians and administrators to learn from their experiences, and enhanced productivity.
Consistent with Infoway’s Innovation and Adoption program objectives, BC PSLS implementation will result in replicable technical solutions with the capacity to be sustained within the healthcare system, the potential for system growth to include other user groups and functions, data that can guide clinical practice decisions, and a rich and consistent data source enabling large-scale evaluation. The sequential continuous improvement approach will result in an interoperable electronic event record system which can be readily implemented in all communities.
Importance
In our complex healthcare system, there are times when care providers, in their efforts to help their patients, inadvertently cause them harm. Over the past decade, studies from nations around the world have consistently demonstrated high rates of accidental injury and preventable death (WHO, 2005a), and an estimated 37%–51% of these adverse events are thought to be preventable (Baker, Norton, Flintoft, Blais, Brown, Cox et al., 2004; Brennan, Leape, Laird, Hebert, Localio, Lawthers et al., 1991; Davis, Lay-Yee, Briant, Ali, Scott, Schug, 2002; Leape, Brennan, Laird, Lawthers, Localio, Barnes et al., 1991; Thomas, Studdert, Burstin, Orav, Zeena, Williams et al, 2000; Vincent, Neale, & Woloshynowych, 2001; Wilson, Runciman, Gibberd, Harrison, Newby, Hamilton, 1995). The Canadian Adverse Events Study (Baker et al.) reported that 7.5% of patients admitted to hospitals in Canada experience some sort of adverse event associated with care. Looking at patient safety beyond the Canadian experience further demonstrates the seriousness of the problem. In the United States, the Institute of Medicine report, To Err is Human (Kohn, Corrigan, & Donaldson, 2000), stated that more people die as a result of medication errors alone than motor vehicle accidents, breast cancer or Acquired Immune Deficiency Syndrome (AIDS). When combined with deaths due to hospital-acquired infections and adverse drug reactions, deaths in hospital caused by the healthcare system have been estimated to be the third leading cause of death in the United States (Starfield, 2000). Researchers from Australia, New Zealand, and Britain have reported similar findings (Davis et al.; Vincent et al.; Wilson et al.). Patient safety has increasingly become a concern, both internationally and here in Canada; certainly the issue is receiving significant attention in British Columbia.
Millar (2001) notes that “as well as being a major cause of death, medical error is a major cause of morbidity and extra costs in the system” (p. 80). In June 2004, the Canadian Institute for Health Information (CIHI) released a report, Healthcare in Canada, which stated that 1.1 million added days in hospital and $750 million in extra healthcare spending may be attributable to adverse events (including medical errors) annually (Canadian Institute for Health Information [CIHI], 2004).
The cost to healthcare providers is also significant. People who choose careers in healthcare genuinely want to help their patients, and certainly do not mean to cause them harm (Edmondson, Roberto, & Tucker, 2002; National Steering Committee on Patient Safety, 2002). Healthcare providers are demoralized when patients and their families show a lack of trust in their care, and devastated when they are involved in a serious adverse event that results in harm to a patient. Burnout, turnover, and absenteeism have all been connected to low staff satisfaction with their work environments. Given the present and predicted future shortages of nurses, physicians, and other healthcare professionals, this issue has important ramifications for both recruitment and retention (Auditor General of British Columbia, 2004).
In order to address patient safety problems and make healthcare safer, organizations first must know what is going on within their institutions and programs. Staff and leaders need effective tools to facilitate reliable and timely reporting, analysis, learning and responsiveness. “A major element of programs to improve patient safety is having the capacity and capability to capture comprehensive information on adverse events, errors and near misses so that it can be used as a source of learning and as the basis for preventive action in the future” (WHO, 2005b, p. 22). Incident reporting systems are one means through which this objective may be met. However, reporting systems alone are not enough. A culture of safety must exist, one where the values of safety and quality are part of the fabric of the organization, top priorities of leaders and visible in the day-to-day activities of staff. Staff and leaders must have relationships such that leaders trust that staff will be vigilant and report safety concerns promptly, and staff to trust that leaders will respond positively and address the problems.
The success of the pilot project is essential to securing support and funding for provincial implementation over the upcoming two to three years. Although leaders at all levels recognize the importance of patient safety and related improvements and initiatives, the BC PSLS Project—like most projects—must compete with other critical demands for funding and resources. While the case can easily be made anecdotally or on the basis of qualitative reports from a large number of sources, the “business case” for safety is much more difficult to make due to a severe lack of research-based or concrete evidence in the literature or from other organizations. Thus systematically collected evidence is needed.
Healthcare Context
Accountability for patient safety has increasingly become a focus of accrediting agencies in most countries. In Canada, the Canadian Council on Health Services Accreditation (CCHSA) is the country’s major accrediting body. “The role of the CCHSA…is to support health services organizations across Canada in achieving and continually improving the quality of care and services provided to their clients” (Canadian Council on Health Services Accreditation [CCHSA], 2003, p. 1). In 2003, the BC Ministry of Health (MoH) established the PSTF to identify and examine patient safety issues within the BC Health Authorities and to lead change initiatives aimed at making healthcare safer for British Columbians. Recognizing the need for an effective reporting and learning system, the PSTF is overseeing a collaborative project involving all six BC Health Authorities in the selection and implementation of a province-wide electronic incident reporting information system (BC PSLS). Although the project will use computers to provide reporting and analysis functionality, its focus is not information technology but cultural change. The project is being closely observed by the BC MoH, the Canadian Patient Safety Institute, and patient safety leaders in other Canadian provinces.
Possible Implications of Project Implementation
The implementation of the PSLS system offers an opportunity to concurrently introduce and strengthen patient safety practices that will help move organizations across the province towards safety cultures that embrace reporting and learning. The international interest in both reporting systems and safety culture, as demonstrated by recent reports by organizations such as the World Health Organization (WHO) and National Patient Safety Agency (NPSA), means that the learning that arises from the PSLS Project may be used to inform similar patient safety initiatives in Canada and world-wide. By integrating research and evaluation processes to examine and report on both implementation and outcomes, significant contribution may be made to the body of evidence-based knowledge on patient safety, which is currently lacking.
Project Description
(Insert a description of the project, including its purpose)
Example:
The purpose of the BC PSLS is to provide an automated tool to assist healthcare providers to manage and share learning from events, and to foster development of other patient safety strategies to create a culture of safety that will ultimately make healthcare safer for patients in BC. The system will engage users in identifying safety concerns and will facilitate timely reporting, resolution, feedback and study of events, including incidents, claims, and client feedback, across all programs and services within all HA’s and will eventually include an electronic interface to HCPP.
The pilot project is focused on two sites one each at PHSA and VCHA , one at the Neonatal Intensive care unit (NICU) at BC Women’s Hospital and the other at Tower 8 – Vascular and General Surgery at VancouverGeneralHospital.
Project Sponsor
(Insert a description of the project sponsor or sponsors)