FINAL PROJECT CHARTER
Final Project Charter
Learner’s Name
Capella University
21st-Century Health Care Leadership
September, 2019
1
FINAL PROJECT CHARTER
Final Project Charter
SWOT Analysis
Strengths, weaknesses, opportunities, and threats (SWOT) analysis is a framework that helps an organization analyze an
organization’s competitive standing. It evaluates an organization based on its strengths, weaknesses, opportunities, and
threats. Strengths and weaknesses are current internal aspects, while opportunities and threats are future external factors
(“SWOT analysis,” 2018). In this assessment, a SWOT analysis is conducted to identify the SWOT of the Coronary Artery
Disease Reduction and Early Detection (CADRED) project, which focuses on reducing the mortality rate due to ST
elevation myocardial infarction (STEMI) through early diagnosis and treatment at SG Hospital. The conventional treatment
procedures for STEMI are fibrinolytic therapy and percutaneous coronary intervention (PCI).
Strengths
The project team is made up of individuals with demonstrated skills and remarkable experiences that are relevant to
the project.
The project will focus on the quality measures of the organization through an improvement in key statistics such as
mortality rate.
Using electronic health records (EHRs) will improve quality of care provided to patients.
The high-priority status of the project will ensure immediate intrahospital transfer for patients who require special
care, which will improve patient retention and the care given to patients.
Additionally, there are adequate referral protocols in place to prevent all forms of referral leakage.
Weaknesses
2
FINAL PROJECT CHARTER
Patients who have incomplete medical records may have more risks than estimated because of insufficient data about
contraindications.
There is no guarantee that patients will follow postprocedural guidelines such as stopping smoking or changing their
diet, which are necessary for them to maintain their health after PCI or fibrinolytic therapy.
Studies by Cheng et al. (2019) suggest that there is a high chance of incidence of restenosis after PCI. This may not
be diagnosed in patients after PCI if they do not return for subsequent checkups. This increased risk of restenosis is
seen in women, individuals with unstable angina, and individuals with myocardial infarction.
Postoperative symptoms such as anxiety and depression may be overlooked.
Opportunities
The use of EHRs and the latest ECG technology will provide sufficient significant data that will allow the
automation of the diagnosis process, leading to accurate results.
Psychological therapy may be recommended for patients who display postoperative symptoms such as anxiety and
depression, decreasing referral leakage.
Fibrinolytic therapy is effective at reducing the likelihood of medical conditions such as myocardial infarction that
have an elevated risk of occurrence in patients who smoke and have bad dietary habits.
The project also creates the opportunity to raise awareness about lifestyle choices that will help prevent coronary
artery diseases or help in successful recovery.
Threats
The risk of hemorrhagic complications following fibrinolytic therapy cannot be monitored effectively. This will
reduce the success rate of the therapy.
The treatment provided can be affected in certain rare cases in which patients may not show any clinical symptoms
of restenosis.
There may be a slight risk of allergic reactions to the contrast dye and an even smaller risk of infection after PCI.
Known Major Risks
3
FINAL PROJECT CHARTER
Commented [BI1]: SME comment: Yes these are risks to
the PATIENT, but this section refers more to categorizing the
risk as it pertains to project execution, not the actual therapy.
For example, things that may impede execution of the new
protocol might be: high staff turnover, multiple EMR systems
in play, patient population served (poor, indigent, cultural
disparity).
Other types of risks to consider would be administrative
personnel changes (i.e. new ED director), or say the hospital
was in the process of implementing a new EMR system, this
might present as a high risk item that could tie up resources.
So you see, this specific section pertains to risks to project
execution.
The threats and weaknesses that are related to the project execution have been ranked below based on their risk level.
Risk Level
(Low, Medium, Risk
High)
High
High
Medium
Medium
Low
Low
Risk of losing data and data manipulation when using EHRs
Risk of violating Health Insurance Portability and Accountability Act (HIPAA) guidelines
on data privacy and confidentiality
Risk of high employee turnover and the need to train new project team members on the
protocols and guidelines designed for the project
Risk of cultural disparity and ineffective communication between team members and
interdisciplinary teams
Risk of budget overruns and delays in schedule
Risk of nonacceptance of new EHR systems by project team members and nonadherence to
the guidelines designed for their implementation.
Commented [BI2R1]: The risks pertaining to the project
execution have been included in the table as explained in the
comment above.
Ethical Considerations
4
FINAL PROJECT CHARTER
The ethical considerations of this project are based on standards set by the institutional review board of SG Hospital
and the Health Insurance Portability and Accountability Act (HIPAA), which makes informed consent before any
procedure an absolute necessity.
All possible risks with a probability of occurrence that is greater than 1% should be discussed with patients before
they are asked to sign the consent form.
Patients who are 18 years of age and above solely retain the right to make personal decisions regarding their health
care.
Only the cardiologist who is part of the CADRED project has the authority to discuss the risks associated with
procedures and obtain consent from patients.
The confidentiality of all medical records must be maintained and protected as per HIPAA standards, and only the
project team members must have access to them. Prior permission through legal release forms must be obtained from
patients before using data. All activities in the hospital database must be tracked, and any transfer of data must be
approved by the project manager who will ensure compliance with HIPAA (Bowen, 2018).
Patients must have access to their protected health information (PHI) on request. The PHI should be shared only with
the patients’ consent, even with close family. It is communicated to the team that any violation of the patients’
privacy considerations is grounds for immediate termination.
Patients who are women and/or elderly should receive special considerations because of the higher risk they face
from the treatment procedure for STEMI. This is also applicable for patients with irregular angina and patients who
have previously suffered a myocardial infarction.
Constraints
5
FINAL PROJECT CHARTER
The project is expected to have minimal constraints because of the experience and expertise of the project team. One of the
major constraints of the project is diagnosing postoperative psychological problems such as anxiety and depression in
patients unless clear symptoms are noticed. Further, the treatment for the postoperative psychological problems is left to
patients’ discretion.
Another constraint is ensuring and monitoring patients’ adherence to suggested lifestyle changes. Such monitoring is not
viable in every case although noncompliance to recommended lifestyle changes could unduly reduce the success rate of the
project. This noncompliance to recommended lifestyle changes, however, does not impact the operational and economic
feasibility of the project as the choice of adhering to the suggested lifestyle changes is left to the patients’ discretion after
they are informed of the risks of nonadherence.
Commented [CC3]: Also consider the fidelity and feasibility
of the new process, is there resources to support?
Commented [BI4R3]: Information pertaining to the fidelity
and feasibility of the project has been added along with a
resource supporting the information as requested. However,
the resource supporting the information does not fall in the 5year time period.
The feasibility and implementation fidelity of the project can be affected by factors such as culture and race. According to
Durlak and DuPre (2008), the acceptability of treatment procedures and the level of implementation of the project can vary
in different community settings. However, thorough evaluation of existing data, comprehensive training, and the provision
of strong technical support can help the project team successfully execute the project.
External Dependencies
The success of the project is determined by the number of referrals to the team.
The project depends heavily on other departments for referrals. In case of complications, the required specialist will be
informed through the internal communication network. The required specialist will be on standby in specific cases where
complications are anticipated. Comprehensive EHRs of the patients must be maintained by all departments for ease of
transfer and to prevent the loss of pertinent information. External referrals from outgoing patients are also equally important,
and the PHI provided must be verified wherever necessary.
Communication Strategy
6
FINAL PROJECT CHARTER
Communication is a necessary skill in clinical practices and for the success of the project. It helps foster trust and
coordination within the team and improve patient satisfaction (Lewis et al., 2016). SG Hospital has a digital internal
communication network, which has made internal operations efficient. The project team has excellent interpersonal
communication skills that allow for effective communication between different team members, external departments, and
patients. The team follows the Situation-Background-Assessment-Recommendation technique, which is a communication
model employed during transitions. This technique helps communicate information in a structured manner within the team
and avoid miscommunication (Lewis et al., 2016).
Regular progress updates will be shared with the hospital team by the project manager through weekly team meetings. The
project manager will also give a detailed report of the progress of the project to the CEO, CCO, and the board of directors on
a monthly basis. This report will be a PowerPoint presentation and will cover all metrics that will evaluate the performance
of the project. Gantt charts will be used to record and display the timelines of all the cases and to understand if there are
better ways of scheduling for efficiency. Gantt charts will also be used to document the milestones of the project. There will
also be a comprehensive report after every 3 months, which will cover a detailed analysis of the project and projections for
the future.
Proposed Outcomes
Metric
Outcome Measure
Process Measure
Countermeasure (optional)
7
FINAL PROJECT CHARTER
In-hospital risk-adjusted
mortality
PCI risk-adjusted
bleeding
Perioperative mortality in
hospital among patients 18
years of age and older adjusted
for the level of risk to the total
number of patients 18 years of
age and older on whom PCI
was performed.
Patients 18 years of age and
older with a post-PCI bleeding
event as a ratio to the total
patients above 18 on whom PCI
was performed after admission.
The drugs administered on
the arrival of a patient are
recorded.
Door-to-balloon (D2B)
during emergency cardiac
care is recorded separately
for transferred patients
(patients on whom PCI was
performed after a referral
from a hospital without the
PCI facility) and nontransferred patients (patients
on whom PCI was performed
in the hospital of admission).
Procedural complications, if
any, that death is attributed to
are not recorded or tested for.
The drugs administered on
the arrival of a patient and
those prescribed at discharge
are recorded. Patients who
die within 24 hours of the
procedure are excluded.
Also, cases that indicate
undetected contraindications
due to oversight of
information or unverified
external data are not tested
for.
Patients’ medical history is
to be considered carefully,
and all preoperative tests and
perioperative monitoring
must be done as per protocol.
N/A
8
FINAL PROJECT CHARTER
30-day readmission rate
Number of patients 18 years of
age and older admitted for care
within 30 days of discharge to
the total number of patients 18
years of age and older
discharged from the hospital.
As per the 2010–2014 National
Readmission database, the 30day readmission rate in the U.S.
is 12.3%, and this results in a
cumulative cost increase of
47.9% (Kim et al., 2018).
Drugs administered on the
arrival of a patient and those
prescribed at discharge are
recorded along with the
patient’s testimony on their
adherence to recommended
lifestyle changes. The cause
of readmission is recorded.
N/A
Data Collection Plan
Data collection and maintenance are essential for the right diagnosis and treatment of any given case. A patient’s database
includes the patient’s medical history and results from lab tests and diagnostic tests. Secondary data on the patient’s history
will be transferred on a case-by-case basis when the referral is internal. When the referral is external, contraindications must
be verified through tests and recorded. The data from the required tests before, during, and after treatment are recorded in
EHRs. Primary data regarding health status are recorded by the cardiologist or the nurse to whom the duty is delegated. The
confidentiality of information will have the foremost consideration. It should be ensured that a legal release is obtained from
the patient before the data is used for evaluating the project, as mandated by HIPAA (Bowen, 2018). The transfer of all data
is recorded in the database in a systematic manner. This will help avoid oversights such as using data without patients’
consent. Data collection is vital in verifying the success of the project in terms of measured outcomes. This data will be used
to validate the importance of the project to the stakeholders. The data used for this purpose will be collected through Excel
for analysis and subsequent presentation.
Data Collection Tool
9
FINAL PROJECT CHARTER
Using Excel, develop a data collection tool, using appropriate headers for columns and rows.
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 demonstrate 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.
10
FINAL PROJECT CHARTER
References
Bowen, R. (2018). Patient data takes spotlight for privacy protection at HIMSS18. Briefings on HIPAA, 18(4), 1–4. Retrieved from
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F2023696895%3Faccountid%3D27965
Cheng, G., Chang, F., Wang, Y., You, P., Chen, H., Han, W., . . . Min, Z. (2019). Factors influencing stent restenosis after percutaneous
coronary intervention in patients with coronary heart disease: a clinical trial based on 1-year follow-up. Medical Science Monitor:
International Medical Journal of Experimental and Clinical Research, 25, 240–247. http://doi.org/10.12659/MSM.908692
Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program
outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3-4), 327–350.
http://doi.org/10.1007/s10464-008-9165-0
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-surgical nursing: Assessment
and management of clinical problems. Retrieved from https://books.google.co.in/books?id=fMCDQAAQBAJ&printsec=frontcover#v=onepage&q&f=false
Kim, L. K., Yeo, I., Cheung, J. W., Swaminathan, R. V., Wong, S. C., Charitakis, K., . . . Feldman, D. N. (2018). Thirty-day readmission
rates, timing, causes, and costs after ST-segment-elevation myocardial infarction in the United States: A national readmission database
analysis 2010–2014. Journal of the American Heart Association, 7(18). http://doi.org/10.1161/JAHA.118.009863
SWOT analysis. (2018). In Helicon (Ed.), The Hutchinson unabridged encyclopedia with atlas and weather guide. Abington, UK:
Helicon.
11
FINAL PROJECT CHARTER
12
FINAL PROJECT CHARTER
Final Project Charter
Learner’s Name
Capella University
21st-Century Health Care Leadership
September, 2019
1
FINAL PROJECT CHARTER
Final Project Charter
SWOT Analysis
Strengths, weaknesses, opportunities, and threats (SWOT) analysis is a framework that helps an organization analyze an
organization’s competitive standing. It evaluates an organization based on its strengths, weaknesses, opportunities, and
threats. Strengths and weaknesses are current internal aspects, while opportunities and threats are future external factors
(“SWOT analysis,” 2018). In this assessment, a SWOT analysis is conducted to identify the SWOT of the Coronary Artery
Disease Reduction and Early Detection (CADRED) project, which focuses on reducing the mortality rate due to ST
elevation myocardial infarction (STEMI) through early diagnosis and treatment at SG Hospital. The conventional treatment
procedures for STEMI are fibrinolytic therapy and percutaneous coronary intervention (PCI).
Strengths
The project team is made up of individuals with demonstrated skills and remarkable experiences that are relevant to
the project.
The project will focus on the quality measures of the organization through an improvement in key statistics such as
mortality rate.
Using electronic health records (EHRs) will improve quality of care provided to patients.
The high-priority status of the project will ensure immediate intrahospital transfer for patients who require special
care, which will improve patient retention and the care given to patients.
Additionally, there are adequate referral protocols in place to prevent all forms of referral leakage.
Weaknesses
2
FINAL PROJECT CHARTER
Patients who have incomplete medical records may have more risks than estimated because of insufficient data about
contraindications.
There is no guarantee that patients will follow postprocedural guidelines such as stopping smoking or changing their
diet, which are necessary for them to maintain their health after PCI or fibrinolytic therapy.
Studies by Cheng et al. (2019) suggest that there is a high chance of incidence of restenosis after PCI. This may not
be diagnosed in patients after PCI if they do not return for subsequent checkups. This increased risk of restenosis is
seen in women, individuals with unstable angina, and individuals with myocardial infarction.
Postoperative symptoms such as anxiety and depression may be overlooked.
Opportunities
The use of EHRs and the latest ECG technology will provide sufficient significant data that will allow the
automation of the diagnosis process, leading to accurate results.
Psychological therapy may be recommended for patients who display postoperative symptoms such as anxiety and
depression, decreasing referral leakage.
Fibrinolytic therapy is effective at reducing the likelihood of medical conditions such as myocardial infarction that
have an elevated risk of occurrence in patients who smoke and have bad dietary habits.
The project also creates the opportunity to raise awareness about lifestyle choices that will help prevent coronary
artery diseases or help in successful recovery.
Threats
The risk of hemorrhagic complications following fibrinolytic therapy cannot be monitored effectively. This will
reduce the success rate of the therapy.
The treatment provided can be affected in certain rare cases in which patients may not show any clinical symptoms
of restenosis.
There may be a slight risk of allergic reactions to the contrast dye and an even smaller risk of infection after PCI.
Known Major Risks
3
FINAL PROJECT CHARTER
Commented [BI1]: SME comment: Yes these are risks to
the PATIENT, but this section refers more to categorizing the
risk as it pertains to project execution, not the actual therapy.
For example, things that may impede execution of the new
protocol might be: high staff turnover, multiple EMR systems
in play, patient population served (poor, indigent, cultural
disparity).
Other types of risks to consider would be administrative
personnel changes (i.e. new ED director), or say the hospital
was in the process of implementing a new EMR system, this
might present as a high risk item that could tie up resources.
So you see, this specific section pertains to risks to project
execution.
The threats and weaknesses that are related to the project execution have been ranked below based on their risk level.
Risk Level
(Low, Medium, Risk
High)
High
High
Medium
Medium
Low
Low
Risk of losing data and data manipulation when using EHRs
Risk of violating Health Insurance Portability and Accountability Act (HIPAA) guidelines
on data privacy and confidentiality
Risk of high employee turnover and the need to train new project team members on the
protocols and guidelines designed for the project
Risk of cultural disparity and ineffective communication between team members and
interdisciplinary teams
Risk of budget overruns and delays in schedule
Risk of nonacceptance of new EHR systems by project team members and nonadherence to
the guidelines designed for their implementation.
Commented [BI2R1]: The risks pertaining to the project
execution have been included in the table as explained in the
comment above.
Ethical Considerations
4
FINAL PROJECT CHARTER
The ethical considerations of this project are based on standards set by the institutional review board of SG Hospital
and the Health Insurance Portability and Accountability Act (HIPAA), which makes informed consent before any
procedure an absolute necessity.
All possible risks with a probability of occurrence that is greater than 1% should be discussed with patients before
they are asked to sign the consent form.
Patients who are 18 years of age and above solely retain the right to make personal decisions regarding their health
care.
Only the cardiologist who is part of the CADRED project has the authority to discuss the risks associated with
procedures and obtain consent from patients.
The confidentiality of all medical records must be maintained and protected as per HIPAA standards, and only the
project team members must have access to them. Prior permission through legal release forms must be obtained from
patients before using data. All activities in the hospital database must be tracked, and any transfer of data must be
approved by the project manager who will ensure compliance with HIPAA (Bowen, 2018).
Patients must have access to their protected health information (PHI) on request. The PHI should be shared only with
the patients’ consent, even with close family. It is communicated to the team that any violation of the patients’
privacy considerations is grounds for immediate termination.
Patients who are women and/or elderly should receive special considerations because of the higher risk they face
from the treatment procedure for STEMI. This is also applicable for patients with irregular angina and patients who
have previously suffered a myocardial infarction.
Constraints
5
FINAL PROJECT CHARTER
The project is expected to have minimal constraints because of the experience and expertise of the project team. One of the
major constraints of the project is diagnosing postoperative psychological problems such as anxiety and depression in
patients unless clear symptoms are noticed. Further, the treatment for the postoperative psychological problems is left to
patients’ discretion.
Another constraint is ensuring and monitoring patients’ adherence to suggested lifestyle changes. Such monitoring is not
viable in every case although noncompliance to recommended lifestyle changes could unduly reduce the success rate of the
project. This noncompliance to recommended lifestyle changes, however, does not impact the operational and economic
feasibility of the project as the choice of adhering to the suggested lifestyle changes is left to the patients’ discretion after
they are informed of the risks of nonadherence.
Commented [CC3]: Also consider the fidelity and feasibility
of the new process, is there resources to support?
Commented [BI4R3]: Information pertaining to the fidelity
and feasibility of the project has been added along with a
resource supporting the information as requested. However,
the resource supporting the information does not fall in the 5year time period.
The feasibility and implementation fidelity of the project can be affected by factors such as culture and race. According to
Durlak and DuPre (2008), the acceptability of treatment procedures and the level of implementation of the project can vary
in different community settings. However, thorough evaluation of existing data, comprehensive training, and the provision
of strong technical support can help the project team successfully execute the project.
External Dependencies
The success of the project is determined by the number of referrals to the team.
The project depends heavily on other departments for referrals. In case of complications, the required specialist will be
informed through the internal communication network. The required specialist will be on standby in specific cases where
complications are anticipated. Comprehensive EHRs of the patients must be maintained by all departments for ease of
transfer and to prevent the loss of pertinent information. External referrals from outgoing patients are also equally important,
and the PHI provided must be verified wherever necessary.
Communication Strategy
6
FINAL PROJECT CHARTER
Communication is a necessary skill in clinical practices and for the success of the project. It helps foster trust and
coordination within the team and improve patient satisfaction (Lewis et al., 2016). SG Hospital has a digital internal
communication network, which has made internal operations efficient. The project team has excellent interpersonal
communication skills that allow for effective communication between different team members, external departments, and
patients. The team follows the Situation-Background-Assessment-Recommendation technique, which is a communication
model employed during transitions. This technique helps communicate information in a structured manner within the team
and avoid miscommunication (Lewis et al., 2016).
Regular progress updates will be shared with the hospital team by the project manager through weekly team meetings. The
project manager will also give a detailed report of the progress of the project to the CEO, CCO, and the board of directors on
a monthly basis. This report will be a PowerPoint presentation and will cover all metrics that will evaluate the performance
of the project. Gantt charts will be used to record and display the timelines of all the cases and to understand if there are
better ways of scheduling for efficiency. Gantt charts will also be used to document the milestones of the project. There will
also be a comprehensive report after every 3 months, which will cover a detailed analysis of the project and projections for
the future.
Proposed Outcomes
Metric
Outcome Measure
Process Measure
Countermeasure (optional)
7
FINAL PROJECT CHARTER
In-hospital risk-adjusted
mortality
PCI risk-adjusted
bleeding
Perioperative mortality in
hospital among patients 18
years of age and older adjusted
for the level of risk to the total
number of patients 18 years of
age and older on whom PCI
was performed.
Patients 18 years of age and
older with a post-PCI bleeding
event as a ratio to the total
patients above 18 on whom PCI
was performed after admission.
The drugs administered on
the arrival of a patient are
recorded.
Door-to-balloon (D2B)
during emergency cardiac
care is recorded separately
for transferred patients
(patients on whom PCI was
performed after a referral
from a hospital without the
PCI facility) and nontransferred patients (patients
on whom PCI was performed
in the hospital of admission).
Procedural complications, if
any, that death is attributed to
are not recorded or tested for.
The drugs administered on
the arrival of a patient and
those prescribed at discharge
are recorded. Patients who
die within 24 hours of the
procedure are excluded.
Also, cases that indicate
undetected contraindications
due to oversight of
information or unverified
external data are not tested
for.
Patients’ medical history is
to be considered carefully,
and all preoperative tests and
perioperative monitoring
must be done as per protocol.
N/A
8
FINAL PROJECT CHARTER
30-day readmission rate
Number of patients 18 years of
age and older admitted for care
within 30 days of discharge to
the total number of patients 18
years of age and older
discharged from the hospital.
As per the 2010–2014 National
Readmission database, the 30day readmission rate in the U.S.
is 12.3%, and this results in a
cumulative cost increase of
47.9% (Kim et al., 2018).
Drugs administered on the
arrival of a patient and those
prescribed at discharge are
recorded along with the
patient’s testimony on their
adherence to recommended
lifestyle changes. The cause
of readmission is recorded.
N/A
Data Collection Plan
Data collection and maintenance are essential for the right diagnosis and treatment of any given case. A patient’s database
includes the patient’s medical history and results from lab tests and diagnostic tests. Secondary data on the patient’s history
will be transferred on a case-by-case basis when the referral is internal. When the referral is external, contraindications must
be verified through tests and recorded. The data from the required tests before, during, and after treatment are recorded in
EHRs. Primary data regarding health status are recorded by the cardiologist or the nurse to whom the duty is delegated. The
confidentiality of information will have the foremost consideration. It should be ensured that a legal release is obtained from
the patient before the data is used for evaluating the project, as mandated by HIPAA (Bowen, 2018). The transfer of all data
is recorded in the database in a systematic manner. This will help avoid oversights such as using data without patients’
consent. Data collection is vital in verifying the success of the project in terms of measured outcomes. This data will be used
to validate the importance of the project to the stakeholders. The data used for this purpose will be collected through Excel
for analysis and subsequent presentation.
Data Collection Tool
9
FINAL PROJECT CHARTER
Using Excel, develop a data collection tool, using appropriate headers for columns and rows.
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 demonstrate 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.
10
FINAL PROJECT CHARTER
References
Bowen, R. (2018). Patient data takes spotlight for privacy protection at HIMSS18. Briefings on HIPAA, 18(4), 1–4. Retrieved from
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F2023696895%3Faccountid%3D27965
Cheng, G., Chang, F., Wang, Y., You, P., Chen, H., Han, W., . . . Min, Z. (2019). Factors influencing stent restenosis after percutaneous
coronary intervention in patients with coronary heart disease: a clinical trial based on 1-year follow-up. Medical Science Monitor:
International Medical Journal of Experimental and Clinical Research, 25, 240–247. http://doi.org/10.12659/MSM.908692
Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program
outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3-4), 327–350.
http://doi.org/10.1007/s10464-008-9165-0
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-surgical nursing: Assessment
and management of clinical problems. Retrieved from https://books.google.co.in/books?id=fMCDQAAQBAJ&printsec=frontcover#v=onepage&q&f=false
Kim, L. K., Yeo, I., Cheung, J. W., Swaminathan, R. V., Wong, S. C., Charitakis, K., . . . Feldman, D. N. (2018). Thirty-day readmission
rates, timing, causes, and costs after ST-segment-elevation myocardial infarction in the United States: A national readmission database
analysis 2010–2014. Journal of the American Heart Association, 7(18). http://doi.org/10.1161/JAHA.118.009863
SWOT analysis. (2018). In Helicon (Ed.), The Hutchinson unabridged encyclopedia with atlas and weather guide. Abington, UK:
Helicon.
11
FINAL PROJECT CHARTER
12
Email From Instructor
Hello Class,
I hope you are enjoying Labor Day Weekend. Welcome to week 9. This week we will be
working hard on Project Chart Part 3. I have posted this announcement in the beginning of class
but also wanted to repost it this week for those who missed it. Please watch the video below
which outlines the charter due this week.
SWOT analysis Provides organizations with a clear, easy-to-read map of internal and external
factors that may help or harm a project, by listing and organizing a
project's strengths, weaknesses, opportunities, and threats.
Strength- Project strengths could include things like executive support or financial resources.
Weaknesses- discuss three potential obstacles to a successful project outcome. Examples could
be staff compliance, buy in, COVID-19, etc
Opportunities- 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.
You will then rank the SWOT weaknesses and threats and discuss how they might be mitigated.
Ethical Considerations•
•
•
Identify your population.
Discuss if the research study includes participants from any of the following vulnerable
populations protected by federal regulations or guidelines such as minors, prisoners,
pregnant women, students receiving services under the Individuals with Disabilities
Education Act, developmentally disabled persons, economically or educationally
disadvantaged persons. If it does let’s talk ASAP!
Discusses ethical concerns relating to human participant risk. whether an activity could
potentially result in negative consequences for the participant due to invasion of privacy
or breach of confidentiality. Discuss how you will minimize the risk level by protecting
confidentiality or collecting data that is anonymous. How are you protecting their name,
identify, and health information collected? Will you use a deidentification code? Will the
data collection sheet be stored in a locked desk? Consider the regulations of your
practicum site IRB.
•
Discuss if your practicum site requires IRB approval. If so discuss if it will be an expedited
or full level review.
•
For Capella IRB, you will state that you will obtain Capella IRB approval or approval as
non-human subject research (you do not know which one the IRB will approve of as of
yet so state either or).
Constraints
List here any limits to personnel, funding, scheduling, or other options, such as a predetermined
budget, limited staff, or deadline. Most of these project will not need funding, if so just state that
now funding is needed. Discuss the study limitations. What factors that might limit internal
validity. What efforts will be taken to minimize and or adjust for the limitations?
External dependencies
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.
Communication strategy
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.
Outcomes
Here you need to discuss you project outcomes. Here is an example of my outcomes for Cauti
Per the Hospital Inpatient Quality Reporting requirement mandated by the Center for Medicare
and Medicaid Services (CMS), facilities are obligated to monitor and report CAUTI for each patient care
location through the CDC’s National Healthcare Safety Network. The following outcomes will be
measured:
1. CAUTI Rate (CR) = (number of CAUTI [NC] / catheter days [CD] × 1000)
2. Device Utilization Rate (DUR) = (catheter days [CD] / patient days [PD])
3. Number of catheter days
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.
Data Collection Tool
Develop a data collection tool for future use in Excel using appropriate headers for columns and
rows
Please let me know if you have any questions.
Final Project Charter
Instructions
Continue to draw from the gap, need, or opportunity for improvement identified in
the leadership interview to complete Part 3 of the Project Charter Template.
In addition to completing Part 3, remember to revise Parts 1 and 2 based on
instructor feedback from the previous assignments. You are also required to
create and submit a data collection tool in Excel and submit as an appendix to
your project charter. Refer to the helpful links in Resources as you complete your
assignment.
The following requirements correspond to the criteria in the assignment scoring
guide, so be sure to address each point:
1. Analyze organizational or system strengths, weaknesses, opportunities, and
threats (SWOT) in relation to the selected project aim.
o
Support the SWOT analysis with contextual information specific to the
organization or health care system.
o
Identify and rate major known risks (low, medium, high risk) that
could be barriers to the project.
o
Explain major assumptions for the project, including a description of
logistical constraints that may affect the fidelity of the project.
2. Summarize pertinent ethical considerations that may be encountered during
the project.
o
Address protected health information, HIPAA, human subject
considerations, equitable care, and appropriate use of data.
3. Describe the communication strategies that will be used during the project.
o
Specify how the project manager will communicate to the executive
sponsor, project team members, and stakeholders, including frequency
of status updates, project team meetings, and so on.
o
Include descriptions of any visual tools or processes that will be used
in communication such as Gemba walks, Gantt charts, dashboards, or
safety cross.
4. List proposed outcomes and corresponding metrics to measure the outcomes.
o
Operationally define outcome measures.
o
Operationally define process measures.
5. Describe the purpose and use of the data collection plan.
o
Include a description of primary or secondary data, source, data
integrity, and data security plan.
o
Attach a data collection tool in Excel appropriate for the data source
and time frame for the project; include this as an appendix.
6. Convey purpose, in an appropriate tone and style, incorporating supporting
evidence and adhering to organizational, professional, and scholarly writing
standards.
Example assignment: You may use the assignment example, linked in the
Resources, to give you an idea of what a Proficient or higher rating on the
scoring guide would look like.
Additional Requirements
•
•
•
•
•
Written communication: Write clearly, accurately, and professionally,
incorporating sources appropriately.
Length of paper: Complete all fields of the Project Charter Template
succinctly but thoroughly.
Resources: Include sources where appropriate within the template and add
references to the reference list on the last page.
APA format: Cite your sources using current APA format.
Font and font size: Times Roman, 12 points.
Final Project Charter Scoring Guide
Due Date: End of Unit 9
Percentage of Course Grade: 20%.
CRITERIA
NONPERFORMANCE
BASIC
PROFICIENT
DISTINGUISHED
Analyze
organizational or
systemic strengths,
weaknesses,
opportunities, and
threats relative to
the identified project
aim.
15%
Does not analyze
organizational or
systemic
strengths,
weaknesses,
opportunities,
and threats
relative to the
identified project
aim.
Explains but does not
analyze
organizational or
systemic strengths,
weaknesses,
opportunities, and
threats relative to the
identified project aim.
Analyzes
organizational
or systemic
strengths,
weaknesses,
opportunities,
and threats
relative to the
identified
project aim.
Analyzes organizational or
systemic strengths, weaknesses,
opportunities, and threats relative
to the identified project aim,
demonstrating exceptional
scholarship and academic rigor.
Summarize pertinent
ethical concerns
that may be
encountered during
the project.
15%
Does not
summarize
pertinent ethical
concerns that
may be
encountered
during the
project.
Summarizes pertinent
ethical concerns that
may be encountered
during the project but
summary lacks depth
or clarity.
Summarizes
pertinent ethical
concerns that
may be
encountered
during the
project.
Summarizes pertinent ethical
concerns that may be
encountered during the project
and draws insightful conclusions
based on professional ethical
standards.
Describe strategies
that will be used to
communicate
project progress to
team members and
stakeholders.
14%
Does not
describe
strategies that
will be used to
communicate
project progress
to team
members and
stakeholders.
Describes strategies
that will be used to
communicate project
progress to team
members and
stakeholders but
description is unclear
or incomplete.
Describes
strategies that
will be used to
communicate
project progress
to team
members and
stakeholders.
Describes strategies that will be
used to communicate project
progress to team members and
stakeholders; articulates clear
goals or outcomes for proposed
strategies.
Explain the rationale
for communications
strategies that will
be used in the
project.
14%
Does not explain
the rationale for
communications
strategies that
will be used in
the project.
Identifies but does not
explain the rationale
for communications
strategies that will be
used in the project.
Explains the
rationale for
communications
strategies that
will be used in
the project.
Explains the rationale for
communications strategies that
will be used in the project,
including specific examples.
List proposed
outcomes and the
corresponding
metrics to measure
outcomes.
14%
Does not list
proposed
outcomes and
corresponding
metrics to
measure
outcomes.
Partially lists
proposed outcomes
and corresponding
metrics to measure
outcomes.
Lists proposed
outcomes and
corresponding
metrics to
measure
outcomes.
Lists proposed outcomes and
corresponding metrics to
measure outcomes, incorporating
local, regional. and national
benchmarks for comparison.
Describe the
purpose and use of
the data collection
plan.
14%
Does not
describe the
purpose and use
of the data
collection plan
Identifies but does not
describe the purpose
and use of the data
collection plan.
Describes the
purpose and
use of the data
collection plan.
Describes the purpose and use of
the data collection plan that
considers ethical stewardship for
data use.
CRITERIA
Convey purpose, in
an appropriate tone
and style,
incorporating
supporting evidence
and adhering to
organizational,
professional, and
scholarly writing
standards.
14%
NONPERFORMANCE
Does not convey
purpose in an
appropriate tone
and style. Does
not incorporate
supporting
evidence nor
adhere to
organizational,
professional, or
scholarly writing
standards.
BASIC
PROFICIENT
DISTINGUISHED
Conveys purpose, in
an appropriate tone
or style. Clear,
effective
communication is
inhibited by
insufficient supporting
evidence and/or
minimal adherence to
organizational,
professional, or
scholarly writing
standards.
Conveys
purpose, in an
appropriate
tone and style,
incorporating
supporting
evidence and
adhering to
organizational,
professional,
and scholarly
writing
standards.
Conveys clear purpose, in a tone
and style well-suited to the
intended audience. Supports
assertions, arguments, and
conclusions with relevant,
credible, and convincing
evidence. Exhibits strict and
nearly flawless adherence to
organizational, professional, and
scholarly writing standards,
including APA style and
formatting.
NHS8040
u07a1 - Project Charter Part 2
Learner: Sam , Monboe
OVERALL COMMENTS
RUBRICS
CRITERIA 1
(17%)
Summarize the proposed project.
COMPETENCY
Develop a project charter that addresses a potential gap, problem, or opportunity within a health care system.
NON_PERFORMANCE: Does not summarize the proposed project.
BASIC: Summarizes the proposed project but overlooks key information.
PROFICIENT: Summarizes the proposed project.
DISTINGUISHED:
Summarizes the proposed project and provides clear, professional information and expectations for change.
Comments:
You have summarized the project aims of a patient safety program to prevent surgical errors, communication
among caregivers, patient identification, the safety and usage of medication, and the prevention of hospitalacquired infections. This is very broad. In order to meet the requirements of this charter this needs to be
narrowed down. For example, the aim is to improve CAUTI rates through a CAUTI prevention protocol. Or
improve medication errors through barcode scanning. This is written too large to meet the details. Its multiple
projects in one.
CRITERIA 2
(17%)
Explain the objective evidence to substantiate the need for the proposed project.
COMPETENCY
Develop a project charter that addresses a potential gap, problem, or opportunity within a health care system.
NON_PERFORMANCE:
Does not explain the objective evidence to substantiate the need for the proposed project.
BASIC:
Explains the objective evidence to substantiate the need for the proposed project but explanation lacks
detail or is missing key information.
PROFICIENT: Explains the objective evidence to substantiate the need for the proposed project.
DISTINGUISHED:
Explains the objective evidence to substantiate the need for the proposed project. Articulates a clear vision
for change that anticipates stakeholder concerns and acknowledges potential risks.
Comments:
You have good literature in this section regarding patient safety in general, but this needs to be more specific
with data on safety issues such as if you were doing medication errors, what is the data on errors nationally,
locally, what is the goal. How doe you prevent errors?
CRITERIA 3
(17%)
Justify choice of three SMART objectives related to the proposed project.
COMPETENCY
Develop a project charter that addresses a potential gap, problem, or opportunity within a health care system.
NON_PERFORMANCE:
Does not justify choice of three SMART objectives related to the proposed project
BASIC: Explains but does not justify choice of three SMART objectives related to the proposed project.
PROFICIENT: Justifies choice of three SMART objectives related to the proposed project.
DISTINGUISHED:
Justifies choice of three SMART objectives related to the proposed project using clear, concise reasoning
that demonstrates a comprehensive understanding of the selected issue.
Comments:
You have SMART objectives but these are very broad. This needs to be narrowed down. For example if you
were implementing barcode scanning for medication errors your objectives would be to purchase the barcode
scanning system, educate pharmacy and staff.
CRITERIA 4
(17%)
Summarize what the project will and will not address.
COMPETENCY
Develop a project charter that addresses a potential gap, problem, or opportunity within a health care system.
NON_PERFORMANCE: Does not summarize what the project will and will not address.
BASIC: Identifies but does not summarize what the project will and will not address.
PROFICIENT: Summarizes what the project will and will not address.
DISTINGUISHED:
Summarizes what the project will and will not address. Articulates clear goals or outcomes and considers
potential risks. .
Comments:
You have done a good job of summarizing what you project will and will not address with patient safety. I will
not deduct points from this section or the next section, but please note for future this project has to be
narrowed down to meet the criteria in part 3.
CRITERIA 5
(16%)
Summarize the project deliverables, including milestones.
COMPETENCY
Develop a project charter that addresses a potential gap, problem, or opportunity within a health care system.
NON_PERFORMANCE: Does not summarize the project deliverables, including milestones.
BASIC: Identifies but does not summarize the project deliverables, including milestones.
PROFICIENT: Summarizes the project deliverables, including milestones.
DISTINGUISHED:
Summarizes the project deliverables, including milestones. Draws well-reasoned conclusions and
articulates underlying assumptions and uncertainties.
Comments:
CRITERIA 6
(16%)
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and
adhering to organizational, professional, and scholarly writing standards.
COMPETENCY
Communicate in a manner that is scholarly, interprofessional, and respectful of the diversity, dignity, and
integrity of others.
NON_PERFORMANCE:
Does not convey purpose in an appropriate tone and style. Does not incorporate supporting evidence nor
adhere to organizational, professional, or scholarly writing standards.
BASIC:
Conveys purpose, in an appropriate tone or style. Clear, effective communication is inhibited by insufficient
supporting evidence and/or minimal adherence to organizational, professional, or scholarly writing
standards.
PROFICIENT:
Conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to
organizational, professional, and scholarly writing standards.
DISTINGUISHED:
Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions,
arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly
flawless adherence to organizational, professional, and scholarly writing standards, including APA style
and formatting.
Comments:
Supplemental Feedback
SUPPLEMENTAL CRITERIA 1
Purpose
Compose a text that articulates meaning relevant to the main topic, scope, and purpose of
the prompt
BEGINNING: This text is unrelated to the assignment prompt.
DEVELOPING:
This text is related to the assignment prompt but does not demonstrate an understanding of the main topic,
scope, and purpose.
SKILLED:
This text responds to the assignment prompt and appropriately addresses the main topic, scope, and
purpose.
ADVANCED:
This text presents a focused response to the assignment prompt and demonstrates a thorough
understanding of the main topic, scope, and purpose.
Comments:
SUPPLEMENTAL CRITERIA 2
Organization
Develop text using organization, structure, and transitions that demonstrate understanding
of relationship between main and subtopics
BEGINNING:
This text does not include a thesis statement and is organized inappropriately for the assignment.
DEVELOPING:
The thesis statement in this text is unclear and/or the text is presented in paragraphs with unclear main
idea(s) and/or transitional phrases.
SKILLED:
This text includes a thesis statement and is organized into paragraphs, with clear main ideas and effective
transitional phrases.
ADVANCED:
This text reflects a strong thesis statement. Additionally, this text is organized with skillful transitions into
paragraphs with clear main ideas, sufficient evidence, analysis, and linking information.
Comments:
SUPPLEMENTAL CRITERIA 3
Evidence
Integrate into text appropriate use of scholarly sources and evidence
BEGINNING: This text included plagiarized information.
DEVELOPING:
This text lacks synthesis of information from sources and/or the credibility of the sources is questionable,
with many flaws in APA citation style.
SKILLED:
The included evidence was integrated and synthesized from outside sources, most of which are scholarly,
with minimal flaws in APA citation style.
ADVANCED:
The evidence in this text was integrated and synthesized from credible, scholarly, and professionally sound
sources, with minimal flaws in APA citation style.
Comments:
SUPPLEMENTAL CRITERIA 4
Tone
Apply in text the standard writing conventions for the discipline, including structure, voice,
person and tone
BEGINNING: Text uses language inappropriate for the intended audience.
DEVELOPING:
This text does not meet writing conventions for the discipline and lacks appropriate voice, person, and/or
tone for the intended audience.
SKILLED:
This text meets writing conventions for the discipline and there were minimal issues in appropriate use of
voice, person, or tone for the intended audience.
ADVANCED:
This text exhibits strict adherence to writing conventions for the discipline and uses appropriate voice,
person, and tone for the intended audience.
Comments:
SUPPLEMENTAL CRITERIA 5
Sentence Structure
Produce text with minimal grammar, usage, spelling, and mechanical errors
BEGINNING:
Text meaning is unclear due to errors in sentence structure, grammar, usage, word choice, spelling, or
mechanics in 75% or more of text.
DEVELOPING:
Text meaning is interrupted due to sentence structure, grammar, usage, word choice, spelling, or mechanical
errors in 25%-75% or more of text.
SKILLED:
Text conveys clear meaning with minimal issues in grammar, usage, word choice, spelling, or mechanical
errors in 10%-25% of text.
ADVANCED:
Text complexity and concision conveys clear meaning, with grammar, usage, word choice, spelling, or
mechanical errors in 10% or less of text.
Comments:
Learner’s Name:
August 28, 2021
One of the main goals of all healthcare providers is achieving the highest level of patient-centered care by improving the
patient experience at the facility hence fostering better health outcomes. To achieve this goal, ensuring patient safety is a
major aspect that ought to be fostered in the bid to achieving excellent patient-centered care. Vincent and Coulter (2002)
note that clinicians fail to incorporate patient safety in their initiatives to improve patient experiences because they have no
information about patient safety being part of their roles in clinical care. Some of the ways that patient safety can be
achieved is by giving patients access to their EHR data and explaining to them the clinical notes to seek their input
(Vincent & Coulter, 2002), ensuring a safe experience for the patient in form of putting in measures that will ensure that
the patient does not suffer any preventable harms, caring for the hospital environment (Vincent & Coulter, 2002), creating
timely, yet simple scheduling for patient appointments so that long wait times are minimized and only experienced in case
of emergencies and lastly, giving the patient caregivers a chance to participate in the service delivery for their patient. The
RAIPS (Robust Approach to Improving Patient Safety) project aims at adopting a robust approach in mitigating patient
safety issues by focusing on surgical errors, communication among caregivers, patient identification, the safety and usage
of medication, and the prevention of hospital-acquired infections. One surgical staff, two nurses, a cardiologist, one
environmental services staff, and a project manager will be part of this project. While the project manager will monitor all
activities, the proper use of medication, protocol, and method of communication among the employees will be critical in
ensuring the process's safety (Joint Commission, 2018). The project’s executive sponsors are D.G and R.E-Chief Executive
Officer and Medical Administrator of Sam’s Hospital System, while the department sponsors are AHRQ- Agency for
Healthcare Research and Quality funds grants for research in making health care safer, higher quality, more accessible,
equitable, and affordable (AHRQ, n.d).
Nolan (2000) articulates the importance of implementing system changes that will see that the quality of service at
healthcare facilities is improved. In his work, he proposes strategies to come up with safe care systems some of which will
facilitate the prevention of errors, timely correction of errors by making the errors visible, and mitigating the error effects
especially for the errors that are not intercepted before getting to the patient. System changes will usually facilitate
accuracy in patient identification, and prompt communication among caregivers alongside the prevention of hospitalacquired infections (Burke, 2003). This supports the need for the RAIPS project at Sam’s Hospital whose aim is to adopt a
robust approach in mitigating patient safety issues by focusing on surgical errors, communication among caregivers,
patient identification, the safety and usage of medication, and the prevention of hospital-acquired infections. According to
Vincent and Coulter (2002), the major step in ensuring patient safety is patient involvement. They further note that most
healthcare facilities tend to ignore the patient’s perspective when it comes to patient safety in the sense that they ignore
the value of the patient’s input when it comes to the implementation of any quality improvement strategy (p. 76). The
patient’s perspective is important because it gives the caregivers an idea of how to customize the service as per the
patients need hence communicate more effectively among themselves, correctly identify the patient, avoid surgical errors,
hence prevent other unwanted harms to the patient both during their stay at the hospital and once they are discharged
(Vincent & Coulter, 2002). These findings also support the RAIPS project need at Sam’s Hospital as they directly relate
to the project aim.
The RAIPS project will focus on the reduction and eradication of surgical errors, enhanced communication among
caregivers, and accuracy in patient identification, fostering safe medication usage, and implementing measures to prevent
hospital-acquired infections. If all these variables are worked on, there is a surety that a high level of patient safety will be
established at Sam’s Hospital, improving patient experiences and outcomes hence more trust and loyalty across
communities. Since the hospital will attain a good reputation for its care, more referrals will lead to more people in the
community preferring it as the caregiver of choice hence improved revenue for further growth and development of the
facility to keep on providing the best care in all specialties.
The SMART objectives that will guide to achieving the overall purpose of the RAIPS project are:
1. The head of the surgical team will ensure that all surgeons are trained monthly for 12 months on the common errors that could come up during
surgery and how to prevent them or handle them when they occur so that surgical errors are significantly reduced by 100% within a year of the
commencement of this project.
2. The Head of communication will liaise with the IT department to oversee the formation of an enhanced communication system within the Sam’s
Hospital that will foster efficient communication among the caregivers so that there is 100% seamless transfer of critical information about their
patients when exchanging shifts and providing overall care to the patients within a year of the commencement of this project.
3. The communication department will similarly update the hospital’s EHR so that patient records are always up to date and their identification is
made to be 100% accurate. This should have been achieved with 6 months of the date of commencement of this project.
4. All caregivers will continuously be reminded to maintain healthy and open communication with the patients while involving the patients at each
step of care to educate the patients on the safety and usage of the medications they are being prescribed to significantly reduce wrong medication
usage by 95% within 6 months of the date of commencement of this project.
5. All caregivers will be trained monthly for 12 months on patient care especially those in the intensive care unit on what measures they can put in
place to prevent hospital-acquired infections and to see to it that incidences are reduced by 95%. They will also be tasked with informing the patient
on the role they have to play to ensure that they are safe from hospital-acquired infections.
Deliverables
The surgical team at Sam’s hospital will be constantly trained to completely eradicate incidences of surgical errors. Additionally, all caregivers will be
expected to update patient EHRs anytime they interact with the patient to enhance communication within Sam’s Hospital. Lastly, since the project is
expected to be completed within a year, compliance audits will be conducted every month from the first month of its inception to ensure that each team
member is handling their tasks as expected.
Project Scope
As earlier articulated, the RAIPS project aims to adopt a robust approach in mitigating patient safety issues by focusing on surgical errors, communication
among caregivers, patient identification, the safety and usage of medication, and the prevention of hospital-acquired infections. It will be achieved by
involving the relevant team members; the surgical team, the communication department, and all caregivers as they have a direct role to play in the realization
of the project goals. Patient education on hospital-acquired infections and medication usage may take much longer to achieve a 100% success rate because
different patients have different levels of understanding hence strict monitoring by caregivers may still be required.
Timeline
Launch of the project plan by the Project Manager on
the 1st of September 2021
Seeking approval of the project from the CEO and MA
at Sam’s Hospital on 2nd September 2021
Assignment of the project team by the project manager,
CEO, and MA on the 5th of September 2021. The team
will entail a cardiothoracic surgeon, radiologist, an ED
nurse, a floor nurse, and an environmental technician.
Guidelines issue and briefing about the RAIPS project
to the team on 11th September 2021
Variables measurement Report on 16th September 2021
The variables to be measured are the daily number and
types of surgical errors for the past 1 year, the state of
communication among caregivers, the accuracy level
of patient identification, the rate of safety and usage of
medication, and the rate of hospital-acquired infections
at the facility
Project Launch on the 1st of October 2021
Stakeholder meeting and review of progress on 30 th
December 2021
Monthly reports from the team members from 31 st
October to the end of the project.
Completion Date
2nd September 2021
3rd September 2021
10th September 2021
15th of September 2021
30th of September 2021
31st October 2021
2nd January 2022
31st August 2022
Agency for Healthcare Research and Quality +(n.d.). AHRQ tips for grant applicants. Retrieved from AHRQ Tips for Grant Applicants | Agency for
Healthcare Research and Quality
Burke, J. P. (2003). Infection control-a problem for patient safety. New England Journal of Medicine, 348(7), 651-656.
Joint Commission (2018). Joint Commission publishes nation patient safety goals. Retrieved from Joint Commission publishes 2018 National Patient Safety
Goals | The Bulletin (facs.org)
Nolan, T. W. (2000). System changes to improve patient safety. BMJ, 320(7237), 771-773.
Vincent, C. A., & Coulter, A. (2002). Patient safety: what about the patient?. BMJ Quality & Safety, 11(1), 76-80.
FINAL PROJECT CHARTER
Final Project Charter
Learner’s Name
Capella University
21st-Century Health Care Leadership
September, 2019
1
FINAL PROJECT CHARTER
Final Project Charter
SWOT Analysis
Strengths, weaknesses, opportunities, and threats (SWOT) analysis is a framework that helps an organization analyze an
organization’s competitive standing. It evaluates an organization based on its strengths, weaknesses, opportunities, and
threats. Strengths and weaknesses are current internal aspects, while opportunities and threats are future external factors
(“SWOT analysis,” 2018). In this assessment, a SWOT analysis is conducted to identify the SWOT of the Coronary Artery
Disease Reduction and Early Detection (CADRED) project, which focuses on reducing the mortality rate due to ST
elevation myocardial infarction (STEMI) through early diagnosis and treatment at SG Hospital. The conventional treatment
procedures for STEMI are fibrinolytic therapy and percutaneous coronary intervention (PCI).
Strengths
•
•
•
•
•
The project team is made up of individuals with demonstrated skills and remarkable experiences that are relevant to
the project.
The project will focus on the quality measures of the organization through an improvement in key statistics such as
mortality rate.
Using electronic health records (EHRs) will improve quality of care provided to patients.
The high-priority status of the project will ensure immediate intrahospital transfer for patients who require special
care, which will improve patient retention and the care given to patients.
Additionally, there are adequate referral protocols in place to prevent all forms of referral leakage.
Weaknesses
2
FINAL PROJECT CHARTER
•
•
•
•
Patients who have incomplete medical records may have more risks than estimated because of insufficient data about
contraindications.
There is no guarantee that patients will follow postprocedural guidelines such as stopping smoking or changing their
diet, which are necessary for them to maintain their health after PCI or fibrinolytic therapy.
Studies by Cheng et al. (2019) suggest that there is a high chance of incidence of restenosis after PCI. This may not
be diagnosed in patients after PCI if they do not return for subsequent checkups. This increased risk of restenosis is
seen in women, individuals with unstable angina, and individuals with myocardial infarction.
Postoperative symptoms such as anxiety and depression may be overlooked.
Opportunities
•
•
•
•
The use of EHRs and the latest ECG technology will provide sufficient significant data that will allow the
automation of the diagnosis process, leading to accurate results.
Psychological therapy may be recommended for patients who display postoperative symptoms such as anxiety and
depression, decreasing referral leakage.
Fibrinolytic therapy is effective at reducing the likelihood of medical conditions such as myocardial infarction that
have an elevated risk of occurrence in patients who smoke and have bad dietary habits.
The project also creates the opportunity to raise awareness about lifestyle choices that will help prevent coronary
artery diseases or help in successful recovery.
Threats
•
•
•
The risk of hemorrhagic complications following fibrinolytic therapy cannot be monitored effectively. This will
reduce the success rate of the therapy.
The treatment provided can be affected in certain rare cases in which patients may not show any clinical symptoms
of restenosis.
There may be a slight risk of allergic reactions to the contrast dye and an even smaller risk of infection after PCI.
Known Major Risks
3
FINAL PROJECT CHARTER
The threats and weaknesses that are related to the project execution have been ranked below based on their risk level .
Risk Level
(Low, Medium,
High)
High
High
Medium
Medium
Low
Low
Risk
Risk of losing data and data manipulation when using EHRs
Risk of violating Health Insurance Portability and Accountability Act (HIPAA) guidelines
on data privacy and confidentiality
Risk of high employee turnover and the need to train new project team members on the
protocols and guidelines designed for the project
Risk of cultural disparity and ineffective communication between team members and
interdisciplinary teams
Risk of budget overruns and delays in schedule
Risk of nonacceptance of new EHR systems by project team members and nonadherence to
the guidelines designed for their implementation.
Ethical Considerations
4
FINAL PROJECT CHARTER
•
•
•
•
•
•
•
The ethical considerations of this project are based on standards set by the institutional review board of SG Hospital
and the Health Insurance Portability and Accountability Act (HIPAA), which makes informed consent before any
procedure an absolute necessity.
All possible risks with a probability of occurrence that is greater than 1% should be discussed with patients before
they are asked to sign the consent form.
Patients who are 18 years of age and above solely retain the right to make personal decisions regarding their health
care.
Only the cardiologist who is part of the CADRED project has the authority to discuss the risks associated with
procedures and obtain consent from patients.
The confidentiality of all medical records must be maintained and protected as per HIPAA standards, and only the
project team members must have access to them. Prior permission through legal release forms must be obtained from
patients before using data. All activities in the hospital database must be tracked, and any transfer of data must be
approved by the project manager who will ensure compliance with HIPAA (Bowen, 2018).
Patients must have access to their protected health information (PHI) on request. The PHI should be shared only with
the patients’ consent, even with close family. It is communicated to the team that any violation of the patients’
privacy considerations is grounds for immediate termination.
Patients who are women and/or elderly should receive special considerations because of the higher risk they face
from the treatment procedure for STEMI. This is also applicable for patients with irregular angina and patients who
have previously suffered a myocardial infarction.
Constraints
5
FINAL PROJECT CHARTER
The project is expected to have minimal constraints because of the experience and expertise of the project team. One of the
major constraints of the project is diagnosing postoperative psychological problems such as anxiety and depression in
patients unless clear symptoms are noticed. Further, the treatment for the postoperative psychological problems is left to
patients’ discretion.
Another constraint is ensuring and monitoring patients’ adherence to suggested lifestyle changes. Such monitoring is not
viable in every case although noncompliance to recommended lifestyle changes could unduly reduce the success rate of the
project. This noncompliance to recommended lifestyle changes, however, does not impact the operational and economic
feasibility of the project as the choice of adhering to the suggested lifestyle changes is left to the patients’ discretion after
they are informed of the risks of nonadherence.
The feasibility and implementation fidelity of the project can be affected by factors such as culture and race. According to
Durlak and DuPre (2008), the acceptability of treatment procedures and the level of implementation of the project can vary
in different community settings. However, thorough evaluation of existing data, comprehensive training, and the provision
of strong technical support can help the project team successfully execute the project.
External Dependencies
The success of the project is determined by the number of referrals to the team.
The project depends heavily on other departments for referrals. In case of complications, the required specialist will be
informed through the internal communication network. The required specialist will be on standby in specific cases where
complications are anticipated. Comprehensive EHRs of the patients must be maintained by all departments for ease of
transfer and to prevent the loss of pertinent information. External referrals from outgoing patients are also equally important,
and the PHI provided must be verified wherever necessary.
Communication Strategy
6
FINAL PROJECT CHARTER
Communication is a necessary skill in clinical practices and for the success of the project. It helps foster trust and
coordination within the team and improve patient satisfaction (Lewis et al., 2016). SG Hospital has a digital internal
communication network, which has made internal operations efficient. The project team has excellent interpersonal
communication skills that allow for effective communication between different team members, external departments, and
patients. The team follows the Situation-Background-Assessment-Recommendation technique, which is a communication
model employed during transitions. This technique helps communicate information in a structured manner within the team
and avoid miscommunication (Lewis et al., 2016).
Regular progress updates will be shared with the hospital team by the project manager through weekly team meetings. The
project manager will also give a detailed report of the progress of the project to the CEO, CCO, and the board of directors on
a monthly basis. This report will be a PowerPoint presentation and will cover all metrics that will evaluate the performance
of the project. Gantt charts will be used to record and display the timelines of all the cases and to understand if there are
better ways of scheduling for efficiency. Gantt charts will also be used to document the milestones of the project. There will
also be a comprehensive report after every 3 months, which will cover a detailed analysis of the project and projections for
the future.
Proposed Outcomes
Metric
Outcome Measure
Process Measure
Countermeasure (optional)
7
FINAL PROJECT CHARTER
In-hospital risk-adjusted
mortality
PCI risk-adjusted
bleeding
Perioperative mortality in
hospital among patients 18
years of age and older adjusted
for the level of risk to the total
number of patients 18 years of
age and older on whom PCI
was performed.
Patients 18 years of age and
older with a post-PCI bleeding
event as a ratio to the total
patients above 18 on whom PCI
was performed after admission.
The drugs administered on
the arrival of a patient are
recorded.
Door-to-balloon (D2B)
during emergency cardiac
care is recorded separately
for transferred patients
(patients on whom PCI was
performed after a referral
from a hospital without the
PCI facility) and nontransferred patients (patients
on whom PCI was performed
in the hospital of admission).
Procedural complications, if
any, that death is attributed to
are not recorded or tested for.
The drugs administered on
the arrival of a patient and
those prescribed at discharge
are recorded. Patients who
die within 24 hours of the
procedure are excluded.
Also, cases that indicate
undetected contraindications
due to oversight of
information or unverified
external data are not tested
for.
Patients’ medical history is
to be considered carefully,
and all preoperative tests and
perioperative monitoring
must be done as per protocol.
N/A
8
FINAL PROJECT CHARTER
30-day readmission rate
Number of patients 18 years of
age and older admitted for care
within 30 days of discharge to
the total number of patients 18
years of age and older
discharged from the hospital.
As per the 2010–2014 National
Readmission database, the 30day readmission rate in the U.S.
is 12.3%, and this results in a
cumulative cost increase of
47.9% (Kim et al., 2018).
Drugs administered on the
arrival of a patient and those
prescribed at discharge are
recorded along with the
patient’s testimony on their
adherence to recommended
lifestyle changes. The cause
of readmission is recorded.
N/A
Data Collection Plan
Data collection and maintenance are essential for the right diagnosis and treatment of any given case. A patient’s database
includes the patient’s medical history and results from lab tests and diagnostic tests. Secondary data on the patient’s history
will be transferred on a case-by-case basis when the referral is internal. When the referral is external, contraindications must
be verified through tests and recorded. The data from the required tests before, during, and after treatment are recorded in
EHRs. Primary data regarding health status are recorded by the cardiologist or the nurse to whom the duty is delegated. The
confidentiality of information will have the foremost consideration. It should be ensured that a legal release is obtained from
the patient before the data is used for evaluating the project, as mandated by HIPAA (Bowen, 2018). The transfer of all data
is recorded in the database in a systematic manner. This will help avoid oversights such as using data without patients’
consent. Data collection is vital in verifying the success of the project in terms of measured outcomes. This data will be used
to validate the importance of the project to the stakeholders. The data used for this purpose will be collected through Excel
for analysis and subsequent presentation.
Data Collection Tool
9
FINAL PROJECT CHARTER
Using Excel, develop a data collection tool, using appropriate headers for columns and rows.
•
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 demonstrate 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.
10
FINAL PROJECT CHARTER
References
Bowen, R. (2018). Patient data takes spotlight for privacy protection at HIMSS18. Briefings on HIPAA, 18(4), 1–4. Retrieved from
http://library.capella.edu/login?qurl=https%3A%2F%2Fsearch.proquest.com%2Fdocview%2F2023696895%3Faccountid%3D27965
Cheng, G., Chang, F., Wang, Y., You, P., Chen, H., Han, W., . . . Min, Z. (2019). Factors influencing stent restenosis after percutaneous
coronary intervention in patients with coronary heart disease: a clinical trial based on 1-year follow-up. Medical Science Monitor:
International Medical Journal of Experimental and Clinical Research, 25, 240–247. http://doi.org/10.12659/MSM.908692
Durlak, J. A., & DuPre, E. P. (2008). Implementation matters: A review of research on the influence of implementation on program
outcomes and the factors affecting implementation. American Journal of Community Psychology, 41(3-4), 327–350.
http://doi.org/10.1007/s10464-008-9165-0
Lewis, S. L., Bucher, L., Heitkemper, M. M., Harding, M. M., Kwong, J., & Roberts, D. (2016). Medical-surgical nursing: Assessment
and management of clinical problems. Retrieved from https://books.google.co.in/books?id=fMCDQAAQBAJ&printsec=frontcover#v=onepage&q&f=false
Kim, L. K., Yeo, I., Cheung, J. W., Swaminathan, R. V., Wong, S. C., Charitakis, K., . . . Feldman, D. N. (2018). Thirty-day readmission
rates, timing, causes, and costs after ST-segment-elevation myocardial infarction in the United States: A national readmission database
analysis 2010–2014. Journal of the American Heart Association, 7(18). http://doi.org/10.1161/JAHA.118.009863
SWOT analysis. (2018). In Helicon (Ed.), The Hutchinson unabridged encyclopedia with atlas and weather guide. Abington, UK:
Helicon.
11
FINAL PROJECT CHARTER
12
PROJECT CHARTER PART 1
Project Charter Part 1
Student:
C University
21st Century Health Care Leadership
August 14, 2021
1
PROJECT CHARTER PART 1
Project Charter Part 1
General Project Information
Project Name
RAIPS (Robust Approach to Improving Patient Safety)
D.G.- Chief Executive Officer of Sam’s Hospital System
R.E.- Medical Administrator of Sam’s Hospital System
Executive Sponsors
The CEO ensures a balance in planning and managing the daily operations of the organization
while leading strategic initiatives for future success. He’s also involved with project initiatives
regarding all activities that concersn patient safety and patient experience through budgetary
support and leadership guidance (HMDG, 2021).
The Medicall Administrator ensures clinical governance and quality improvement. She serves
as an advisor to the CEO in times of quality initiaves that will foster patient safety and quality
outcomes (Dwyer, 2010).
Department Sponsors
AHRQ- The Agency for Healthcare Research and Quality funds grants for research in making
health care safer, higher quality, more accessible, equitable, and affordable. The AHRQ
supports multidisciplinary initiates geared towards improving patient experience. (AHRQ,
n.d.).
Project Aim
To adopt a robust approach in mitigating patient safety issues
2
PROJECT CHARTER PART 1
RAIPS project will focus on surgical errors, patient identification, communication among
caregivers, the safety and usage of medication, and the prevention of hospital acquired
infections. This will include one sugigical staff, two nurses, cardiologist, one Environmental
Services staff, and a project manager. While the project manage will oversee all the activities,
the right use of medication, the right procedure, and the system of communication among the
staff will be important to ensure safety is paramount to the process (Joint Commission, 2018).
Focus
Project Team
Title
Project
Manager
Cardiologist
Radiologist
Nurse 1
Project
Manager
Cardiothoracic
Surgeon
Radiologist
ED Nurse
Department
Executive
Director/
Quality and
Safety
Cardiology
Radiology
Nursing
Credentials
MSN, RN
NEA-BC
Role
J. S. works with all the quality committees, as well as
policy committees – Systemwide Nursing Policy &
Procedure, Nursing Services Quality Improvement,
System Quality Oversight Committee, Patient Safety
Oversight Committee, etc.
MD, DO
T. W. Performs patient exams and order or conduct
diagnostic testing. Develop ongoing treatment and
disease-management plans. Prescribe medicine and
coordinate referrals as necessary. Has served the
hospital since 25years. He’s served as served patients
with critical needs and has a great experience with
different projects that involves patient safety.
MD, DO, RT
P.O. has served a variety of hospitals in his field. His
medical images analysis has become a top nodge, and
has made an impact in the healing of thousands of
patients, and he has also worked on serval teams on
patient safety projects.
RN
KT. Has emergentcy room experience for over 20yrs.
She’s worked with different team and communicated
with other physicians, patients, nurse manages, and
families. She brings a great deal of experience to the
project team.
3
PROJECT CHARTER PART 1
Nurse 2
Floor Nurse
Janitor
Environmenta
Technician
Nursing
EVS
RN
A.T. is a health care tech who has a great deal of
experience with patients. He is involved with charting,
and dispensing the right medication to patients based on
doctor’s orders. He worked for the hospital since 2000.
GED
W.N. has functioned in her capacity for over 10yrs. Her
duties include disinfecting and creating a clean
environment for the patients. Patient safety also has to
do with the safe environment.
Stakeholders
Board of Directors
The Project Team
The project team will fully rely on the Board of Directors for strategic direction. The team
will communicate with the Board through an effective communication as spelled out by the
policy of the organization.
Patients
The patients’ feedback will be an essential part of the outcome of the project. The project
team will solicit feedback through text messages and patient surveys. To properly engage
the patients, the project team will do a round with every patient to ascertain immediate
feedback.
Others
Other stakeholders such as partnering with other governmental agencies and accredation
teams will help to improve the outcomes of the project. The team will hold a strategy
meeting to discuss other stakeholders to include.
4
PROJECT CHARTER PART 1
References:
5
PROJECT CHARTER PART 1
Agency for Healthcare Research and Quality +(n.d.). AHRQ tips for grant applicant. Retrieved from AHRQ Tips for Grant Applicants
| Agency for Healthcare Research and Quality
6
PROJECT CHARTER PART 1
Dwyer, A. (2021). Roles, attributes and career paths of medical administrators in public hospitals: survey of Victorian metropolitan
Directors of Medical Services. Australian Health Review. 34(4), pp. 506-13. www. Roles,_attributes_and_career_p.pdf
Healthcare Management Degree Guide. (2021). What are the major responsibilities of health care chief executive officer? Retrieved
from What Are the Major Responsibilities of a Health Care Chief Executive Officer? - Healthcare Management Degree Guide
(healthcare-management-degree.net)
Joint Commission (2018). Joint Commission publishes nation patient safety goals. Retrieved from Joint Commission publishes 2018
National Patient Safety Goals | The Bulletin (facs.org)
7
NHS8040
u03a1 - Interview and Leadership Analysis
Learner: Sam , Monboe
OVERALL COMMENTS
RUBRICS
CRITERIA 1
(17%)
Evaluate the primary leadership style of a selected leader in a health care management
position.
COMPETENCY
Evaluate a leader and their experiences with a practice or process change within a health care or public health
delivery system.
NON_PERFORMANCE:
Does not evaluate the primary leadership style of a selected leader in a health care management position.
BASIC:
Describes but does evaluate the primary leadership style of a selected leader in a health care management
position.
PROFICIENT:
Evaluates the primary leadership style of a selected leader in a health care management position.
DISTINGUISHED:
Evaluates the primary leadership style of a selected leader in a health care management position; notes
strengths and growth opportunities.
Comments:
Your hard work is evident. You have evaluated the primary leadership style as an Authentic leader of a health
care management leader. You recognized the strengths as well as opportunities of improvement such as her
truthfulness or frustration with those who are now.
CRITERIA 2
(17%)
Assess a leader’s role in an organization as it relates to quality, safety, and evidence-based
standards.
COMPETENCY
Evaluate a leader and their experiences with a practice or process change within a health care or public health
delivery system.
NON_PERFORMANCE:
Does not assess a leader’s role in an organization as it relates to quality, safety, and evidence-based
standards.
BASIC:
Assesses a leader’s role in an organization as it relates to quality, safety, and evidence-based standards but
the discussion is unclear or incomplete.
PROFICIENT:
Assesses a leader’s role in an organization as it relates to quality, safety, and evidence-based standards.
DISTINGUISHED:
Assesses a leader’s role in an organization as it relates to quality, safety, and evidence-based standards;
provides relevant examples of successes, strategies, or best practices that support assertions.
Comments:
Wonderful! You successfully assessed a leader’s role in an organization and effectively discussed
the leadership role and how it influences quality, safety, and evidence-based standards. The examples that
you provided reflected best practices and success strategies. For example you have listed many committees
she is a part of, Wow all of these? "quality committees at WakeMed as well as policy committees –
Systemwide Nursing Policy & Procedure, Nursing Services Quality Improvement, System Quality Oversight
Committee, Patient Safety Oversight Committee".
CRITERIA 3
(17%)
Explain the rationale for the selection of a leader to serve as a preceptor.
COMPETENCY
Evaluate a leader and their experiences with a practice or process change within a health care or public health
delivery system.
NON_PERFORMANCE:
Does not explain the rationale for the selection of a leader to serve as a preceptor.
BASIC:
Identifies a leader but does not explain the rationale for the selection of the leader to serve as a preceptor.
PROFICIENT: Explains the rationale for the selection of a leader to serve as a preceptor.
DISTINGUISHED:
Explains the rationale for the selection of a leader to serve as a preceptor and provides a qualitative
evaluation of the selected leader's qualifications and accomplishments.
Comments:
CRITERIA 4
(17%)
Identify a gap, problem, or opportunity for a capstone project.
COMPETENCY
Analyze a health care issue from a leadership perspective, applying quality improvement principles and
evidence based standards.
NON_PERFORMANCE: Does not identify a gap, problem, or opportunity for a capstone project.
BASIC:
Identifies a gap, problem, or opportunity for a capstone project but the work is unclear or incomplete.
PROFICIENT: Identifies a gap, problem, or opportunity for a capstone project.
DISTINGUISHED:
Identifies a gap, problem, or opportunity for a capstone project that is clear, concise, and demonstrates a
comprehensive understanding of the issue.
Comments:
I do not see this area addressed in your assessment, what you discussed in your paper is not a gap in
practice. In this section, you were to identify a gap, problem, or opportunity for a capstone project. The issue
needed to be clear and concise. You should have also demonstrated a comprehensive understanding of the
issue.
CRITERIA 5
(16%)
Summarize a leader’s ability to provide ethical stewardship and oversight regarding the
ethical use of organizational information.
COMPETENCY
Develop a data-management plan, including a plan for ethical stewardship for data use and communication.
NON_PERFORMANCE:
Does not summarize a leader’s ability to provide ethical stewardship and oversight regarding the ethical use
of organizational information.
BASIC:
Partially describes a leader’s ability to provide ethical stewardship and oversight regarding the ethical use of
organizational information.
PROFICIENT:
Summarizes a leader’s ability to provide ethical stewardship and oversight regarding the ethical use of
organizational information.
DISTINGUISHED:
Summarizes a leader’s ability to provide ethical stewardship and oversight regarding the ethical use of
organizational information, including specific examples to support assertions.
Comments:
You have not summarized your leader’s ability to provide ethical stewardship and oversight regarding the
ethical use of the organizational information. In this section you also needed to include specific examples to
support assertions from your leadeer. You have provided references to support what this means, but no
examples from your potential preceptor
CRITERIA 6
(16%)
Convey purpose, in an appropriate tone and style, incorporating supporting evidence and
adhering to organizational, professional, and scholarly writing standards.
COMPETENCY
Communicate in a manner that is scholarly, interprofessional, and respectful of the diversity, dignity, and
integrity of others.
NON_PERFORMANCE:
Does not convey purpose in an appropriate tone and style. Does not incorporate supporting evidence nor
adhere to organizational, professional, or scholarly writing standards.
BASIC:
Conveys purpose, in an appropriate tone or style. Clear, effective communication is inhibited by insufficient
supporting evidence and/or minimal adherence to organizational, professional, or scholarly writing
standards.
PROFICIENT:
Conveys purpose, in an appropriate tone and style, incorporating supporting evidence and adhering to
organizational, professional, and scholarly writing standards.
DISTINGUISHED:
Conveys clear purpose, in a tone and style well-suited to the intended audience. Supports assertions,
arguments, and conclusions with relevant, credible, and convincing evidence. Exhibits strict and nearly
flawless adherence to organizational, professional, and scholarly writing standards, including APA style and
formatting.
Comments:
Please make sure to use APA 7th edition. You paper is not in APA. Please look at your APA manual. You do
not need a table of contents. You must use level 1 and 2 headings. Also please check indentation of
paragraphs. Also check indentation of 1 reference that is missing.
Supplemental Feedback
SUPPLEMENTAL CRITERIA 1
Purpose
Compose a text that articulates meaning relevant to the main topic, scope, and purpose of
the prompt
BEGINNING: This text is unrelated to the assignment prompt.
DEVELOPING:
This text is related to the assignment prompt but does not demonstrate an understanding of the main topic,
scope, and purpose.
SKILLED:
This text responds to the assignment prompt and appropriately addresses the main topic, scope, and
purpose.
ADVANCED:
This text presents a focused response to the assignment prompt and demonstrates a thorough
understanding of the main topic, scope, and purpose.
Comments:
SUPPLEMENTAL CRITERIA 2
Organization
Develop text using organization, structure, and transitions that demonstrate understanding
of relationship between main and subtopics
BEGINNING:
This text does not include a thesis statement and is organized inappropriately for the assignment.
DEVELOPING:
The thesis statement in this text is unclear and/or the text is presented in paragraphs with unclear main
idea(s) and/or transitional phrases.
SKILLED:
This text includes a thesis statement and is organized into paragraphs, with clear main ideas and effective
transitional phrases.
ADVANCED:
This text reflects a strong thesis statement. Additionally, this text is organized with skillful transitions into
paragraphs with clear main ideas, sufficient evidence, analysis, and linking information.
Comments:
SUPPLEMENTAL CRITERIA 3
Evidence
Integrate into text appropriate use of scholarly sources and evidence
BEGINNING: This text included plagiarized information.
DEVELOPING:
This text lacks synthesis of information from sources and/or the credibility of the sources is questionable,
with many flaws in APA citation style.
SKILLED:
The included evidence was integrated and synthesized from outside sources, most of which are scholarly,
with minimal flaws in APA citation style.
ADVANCED:
The evidence in this text was integrated and synthesized from credible, scholarly, and professionally sound
sources, with minimal flaws in APA citation style.
Comments:
SUPPLEMENTAL CRITERIA 4
Tone
Apply in text the standard writing conventions for the discipline, including structure, voice,
person and tone
BEGINNING: Text uses language inappropriate for the intended audience.
DEVELOPING:
This text does not meet writing conventions for the discipline and lacks appropriate voice, person, and/or
tone for the intended audience.
SKILLED:
This text meets writing conventions for the discipline and there were minimal issues in appropriate use of
voice, person, or tone for the intended audience.
ADVANCED:
This text exhibits strict adherence to writing conventions for the discipline and uses appropriate voice,
person, and tone for the intended audience.
Comments:
SUPPLEMENTAL CRITERIA 5
Sentence Structure
Produce text with minimal grammar, usage, spelling, and mechanical errors
BEGINNING:
Text meaning is unclear due to errors in sentence structure, grammar, usage, word choice, spelling, or
mechanics in 75% or more of text.
DEVELOPING:
Text meaning is interrupted due to sentence structure, grammar, usage, word choice, spelling, or mechanical
errors in 25%-75% or more of text.
SKILLED:
Text conveys clear meaning with minimal issues in grammar, usage, word choice, spelling, or mechanical
errors in 10%-25% of text.
ADVANCED:
Text complexity and concision conveys clear meaning, with grammar, usage, word choice, spelling, or
mechanical errors in 10% or less of text.
Comments:
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