Leadership in healthcare organizations

Create a detailed, integrated project charter to address a healthcare gap, need, or improvement at your practicum site.

Introduction
In NHS-FPX8040, you prepared a preliminary project charter. At that time, you may not have secured your practicum site or preceptor yet. Now that these are in place, in this course you will delve more deeply into creating a project charter appropriate for your practicum site’s needs. You may be able to use some of the project charter work you did in the previous course. At the same time, you may find you need to completely retool your work as it may no longer be appropriate for your practicum site. This is the changing nature of doctoral projects. As we learn more information, doctoral projects change. Your ability to manage this ambiguity and change will be critical to your successfully completing your doctoral program.

In this assessment, you will create a detailed, integrated project charter to address a healthcare gap, need, or improvement at your practicum site. You will need to obtain input from your practicum site about how you can help to meet their needs. After submitting your project charter, you will receive your faculty member’s feedback on your charter’s alignment with department objectives, academic rigor, coherency, and readiness for Institutional Review Board (IRB) submission.

Demonstration of Proficiency
By successfully completing this assessment, you will demonstrate your proficiency in the course competencies through the following assessment scoring guide criteria:

Competency 1: Create a project charter to address a clinical or organizational problem or take advantage of an opportunity for improvement within a health care setting.
Clearly describe the people who will be involved in and affected by a project.
Clearly describe an overview of all aspects of a project plan.
Clearly describe the strengths, weaknesses, opportunities, and threats related to a project plan.
Clearly describe the ethical considerations, constraints, external dependencies, and communication strategy of a project plan.
Clearly describe the outcome measures related to a project plan.
Clearly describe the data collection procedures related to a project plan.
Describe a project that could, within 8 to 12 weeks, produce a meaningful, sustainable change in practice or process that can be empirically evaluated, with minimal or no risk to participants or the organization.
Synthesize scholarly, authoritative evidence supporting each part of the project charter.
Competency 4: Address assessment purpose in a well-organized text, incorporating appropriate evidence and tone in grammatically sound sentences.
Write clearly and coherently, using communication style and vocabulary appropriate for scholarly work.
Correctly reference and cite scholarly and/or authoritative sources.
Preparation
To successfully prepare for this assessment, you will need to:

Ensure that your project aligns with your practicum site expectations and the DNP expectations for doctoral projects.
Consult this resource for guidance: Acceptable vs. Unacceptable SoNHS DNP Projects [PDF].
Definition of Research.
Conduct a comprehensive review of the literature to gather data that will support your identified need, intervention, and assessment “instrument(s)”:
Focus your research on current resources available through peer-reviewed articles and professional and government websites. Current means less than five years old.
Use these research guides for help in identifying scholarly and authoritative sources:
Nursing Doctoral (DNP) Research Guide.
Evidence-Based Practice in Nursing & Health Sciences.
Instructions
Note: The assessments in this course must be completed in the order presented; subsequent assessments should be built on both your earlier work and your instructor’s feedback on earlier assessments. If you choose to submit assessments prematurely, without considering and integrating your instructor’s feedback, your assessment may be returned ungraded, resulting in your loss of an assessment attempt.

This assessment has been identified as a Signature Assessment. Signature assessments serve a dual purpose: to meet the competencies in the course where the signature assessment appears and acquire skills needed to demonstrate competencies specific to the completion of the Doctoral Project Report. Learners must successfully meet the established criteria for demonstrating competence on this assessment in order to successfully complete the course (see University Policy 3.4.07 Grading). Completion of this course is a program-specific requirement. Consequently, learners must pass this course in order to remain in good academic standing (see University Policy 3.01.04 Academic Standing).

This assessment also includes review by a Secondary Reviewer to ensure the work meets doctoral expectations for writing, content, connection to the discipline, scholarship, quality, integrity, and ethical compliance. Secondary review is both an essential program expectation and important opportunity for learners. A hallmark of doctoral learners, in particular, is openness to critique and responsiveness to feedback. Like any scholarly endeavor (e.g., journal article, book chapter, or dissertation), the doctoral project will benefit from the integration of feedback from a reviewer and a process of ongoing revision at each stage of development. Learners may also reasonably expect to incorporate revisions and refinements of components of earlier completed signature assessments as they advance through the program to ensure the coherence and alignment of their completed project. A doctoral-level project should, therefore, be viewed as a work-in-progress that is not completed until the final Dean review and approval is issued.

As you begin work, you may find the following activities helpful to completing a scholarly, successful project charter. Note: These activities are not mandatory; they are optional:

Seek out free writing workshops and other resources available through the Capella Writing Center. The Writing Center’s workshops address such topics as: correct APA usage, paper organization, synthesis of material, and so on.
Note: Remember that this keystone course will help determine whether you are ready to proceed with your doctoral project. You will want to do everything you can to ensure that your critical thinking, research, and writing skills are at the doctoral level.
For this assessment, you will populate the three parts of the Project Charter Template [DOCX] with detailed information. Use the Project Charter Proposal Checklist [PDF] to ensure all content is included. Faculty will use the checklist to provide additional feedback.

Part 1 includes these sections:
General Project Information.
Project Team.
You may find the work you did in the Team Effectiveness in Health Care Settings assessment helpful to you as you complete this portion of your Project Charter.
Stakeholders.
Part 2 is the Project Overview and includes these components:
Project Description/
Write the project description in a narrative style. Avoid bullet points and incomplete sentences.
Evidence to Support Need (background and significance).
Be sure to provide the most relevant, data-driven evidence to support key points.
Project Purpose/Business Case.
SMART Objectives (Specific, Measurable, Attainable, Relevant, Time-Bound).
Deliverables.
Project Scope.
Project Milestones.
Part 3 includes these sections:
Note: You may find the work you did in your Ethics Analysis assessment helpful as you complete this section of your project charter.

SWOT Analysis.
Known Major Risks.
Ethical Considerations.
Constraints.
External Dependencies.
Communication Strategy:
Consider questions like these in your communication strategy: Will you hold an in-person or video conference-kickoff meeting? How will you communicate with all involved parties (email, telephone, periodic meetings, project tools, et cetera)?
Proposed Outcomes.
Data Collection Plan.
Example Assessment: You may use the following to give you an idea of what a Proficient or higher rating on the scoring guide would look like:

Project Charter – Secondary Review

Learner’s Name

Capella University

NURS-FPX9100: Project Charter – Secondary Review

Instructor Name

January 1, 2020

Project Charter – Secondary Review

Part 1

General Project Information

Project Name MSUDBN: Medical Surgical Unit Discharge Before Noon

Executive Sponsors

The Director of Nursing was chosen both for political support and for her knowledge of Joint

Commission requirements.

The Chief of Surgery will provide political support.

The Administrative Director of the Medical Surgical Unit (MSU) was chosen for political support for

provider and practitioner buy-in.

Department Sponsors

The attending surgeon manages the medical care of patients within the MSU. The attending surgeon was

chosen for their knowledge of daily MSU processes, policy, and procedures.

The nurse practitioner (NP) supervisor oversees scheduling and general NP management within the

MSU. This person ensures that proper care protocols are followed and has a direct influence on NP

patient care management.

The clinical director of the MSU manages direct care staff in the MSU. This person will be instrumental

in advocating staff buy-in.

The chair of the quality and patient safety committee is a staff nurse who conducts monthly

interdisciplinary quality improvement and patient safety (QI/PS) meetings at the organizational level.

Project Aim

Late-afternoon hospital discharges cause admission bottlenecks which negatively affect the flow

of patients who need hospital admission. Delays in discharge are widespread in health care and have

been linked to increased length of stay, lower patient satisfaction scores, and adverse outcomes (Kaye, et

al., 2017). Therefore, hospitals are taking a renewed look at early discharge as a way to reduce

admission delays and achieve optimal patient flow.

The aim of the project is to improve patient flow through the MSU of AZ Hospital by

eliminating discharge bottlenecks in the unit. This will comply with the Joint Commission 2009

Leadership operations Standard LD.04.03.11, which rationalizes that “managing the flow of patients

throughout their care is essential to prevent overcrowding” (Schyve, 2009, p. 31).

Focus

MSUDBN will use Six Sigma methodology DMAIC (Define, Measure, Analyze, Improve,

Control) process of improvement to increase the number of discharges by noon in the MSU of AZ

Hospital. A completed Emergency Department (ED) throughput analysis report and supporting literature

will be used to define the need for more discharges by noon in the MSU. The patient’s journey through

the MSU will be analyzed to determine points at which patients are required to wait. The root cause for

delays will be determined with the help of a fishbone exercise and will be worked on by all MSU staff

members. The project manager will conduct focus groups and simultaneous PDSA (Plan, Do, Study,

Act) cycles to generate appropriate interventions to improve the efficiency of the discharge process and

arrive at a standardized discharge process. Solutions will be implemented, measured, and refined.

Sustainability will be maintained through the implementation of standard operating procedures,

guidelines, and statistical process control (SPC).

The patient discharge process is complex, requiring different groups including physicians,

nurses, ancillary service staff, patients, and their families to coordinate. Complex processes tend to be

high in variability. The Six Sigma methodology focuses on reducing defects and variations. Six Sigma

uses a “structured approach to uncover the root cause of a problem using the Define, Measure, Analyze,

Improve and Control (DMAIC) method by: defining the problem; measuring the defect; analyzing the

causes; improving the process by removing major causes; and controlling the process to ensure defects

do not recur” (El-Eid et al., 2015, p. 2). The Six Sigma methodology was chosen for this project because

the goal is to eliminate variation in the discharge process of the MSU. Standardizing the process by

establishing set criteria for patient discharges by noon will decrease variation in the process among the

staff and providers thereby decreasing ED holds and improving patient satisfaction with the discharge

process.

The PDSA cycle is an iterative model for improving a process involving four steps. In the first

step, the who, what, when, and where of the plan is developed in which predicted outcomes are outlined

and tasks are assigned. The plan is implemented in the do phase. The data and results of the

implementation are analyzed in the study phase. In the act phase, the plan is either adopted, adapted, or

abandoned based on the outcome from the study phase. If the plan is not adopted, changes are made to

the plan based on learnings from the previous PDSA cycle and a new PDSA cycle is initiated. This

process is repeated till a plan is adopted (Christoff, 2018).

Project Team

Title Department Credentials Role

Project

Manager Charge Nurse MSU MSN

The team leader of this initiative will be responsible for the

initial analysis, design, implementation, and test as per the

guidelines and schedule stated in the schedule of work.

Team

Members

Attending

Surgeon MSU MD

The attending surgeon is an expert in the care of

preoperative and postoperative patients, in addition to

surgeries. The attending surgeon will provide medical

oversight of any policy or protocol changes that impact the

patient discharge process in the MSU. The attending surgeon

will also champion the initiative among physician

colleauges.

Clinical

Director MSU RN, BSN

The clinical director will oversee the work of the MSU staff

in a managerial capacity and care processes. The MSU

clinical director will be inovled in policy revisions that

impact nursing directly and will be involved in

disseminating information to the staff.

Staff Nurse

Project

Champions

MSU RN

The MSU staff nurse provides direct patient care. In

addition, the bedside nurse is the main advocate for the MSU

patients and their family. The MSU nurse will foster change

at the bedside during shift report and medical rounds. They

will serve as role models and assist in staff education and

policy revisions. Staff nurse champions will also be in

charge of weekly compliance audits and data collection.

Respiratory

Therapy MSU RRT

The respiratory therapist provides support for critical

respiratory needs. The respiratory therapist will provide

inputs in policy change decisions and serve as a champion

for the respiratory care staff that rotates through the unit.

Stakeholders

Stakeholder Benefits

Patients

The patients benefit from decreased wait time. An established discharge process will keep them

informed about their discharge readiness in advance, which will allow them to arrange

transportation or complete discharge or billing paperwork in advance.

Emergency Department The ED benefits from reduced ED holds due to increased bed availability in the MSU.

MSU Staff

The MSU staff benefits from fewer discharge bottlenecks enabled by the new standardized

discharge process.

Part 2

Project Overview

Project Description

The ED of AZ hospital performed an analysis of ED throughput between April and June 2019. The results of the analysis

showed increase in the number of ED holds, which led to increased wait times for patients. The results also showed an increase in the

number of patients leaving the ED without being seen by a provider. The call to action was for all inpatient units to implement process

improvements to increase the number of available beds. The MSU at AZ hospital intends to answer that call with the process

improvements proposed in this Project Charter.

A charge nurse of the MSU will act as the team leader for the MSUDBN. The charge nurse is an employee of the organization

and works full time in the MSU. The team leader will obtain approval for the project from the clinical director of the MSU. The team

leader of this initiative will be responsible for the initial analysis, design, implementation and test according to the guidelines and

schedule stated in the schedule of work (Table 2). The fishbone model will be placed in the staff breakroom for convenient access and

all MSU staff will be encouraged to participate in the fishbone exercise. Focus groups will be conducted by team members to discuss

findings from the fishbone exercise and will, over the course of the following week, perform rapid PDSA cycles to finalize a

standardized discharge process.

Baseline data will be collected to determine the current percentage of patients discharged by noon in the MSU, length of stay

(LOS) data in the MSU, percentage of the patients leaving without being seen in the ED, ED holds and wait time data. With staff input

from the fishbone analysis the team will identify potential solutions to increase patient discharges by noon in the MSU. The new

standardized discharge process will be established and communicated to the staff during the week of 9/29/2019. Implementation of the

new criteria along with twice daily huddles will start on 10/1/2019. On 10/13/2019 an interim data report of MSU discharges before

noon will be communicated to the staff through postings in the workroom. Final data analysis and results will be completed the week of

10/20/2019.

Project expenses are expected to be minimal and will include lamination of two 8×11 cards displaying the new standardized

discharge process ($5.00), material for fishbone poster ($15.00), and staff celebratory thank you lunch at the end of the project ($75.00).

The project budget is $100.00. All project work is anticipated to occur during regular staff work time hours.

Table 2. Schedule of Work

SCHEDULE OF WORK

DATES HOURS DMAIC ACTIVITY DELIVERABLE

8/22 – 8/30

The team leader will obtain approval for

the project from the clinical director of

the MSU.

Conduct presentation for MSU staff to

highlight ED throughput analysis report

and its call to action for other inpatient

departments to improve discharge process

efficiency.

Determine feasibility of data collection

plan including a pilot data collection

Project charter

9/2 – 9/7

Pilot data collection tool

Begin collecting pre-implementation data

Baseline data

summary

9/8 – 9/14

Disseminate the results of baseline data

collection

Post fishbone diagram for staff input

Standardized

discharge

process to

increase the

number of

discharges by

noon in the MSU

9/15 – 9/21

Conduct focus groups to review fishbone

diagram results. Focus groups will

determine root cause of delayed

discharges or discharge bottlenecks in the

MSU.

Rapid PDSA cycles will determine what

policies need to be changed or improved

to develop a standardized discharge

process. Plan for twice daily huddles to

discuss the effects of and further refine

PDSA cycles

9/22/ – 9/28 4

Finalize new standardized discharge

process

Finalize statistical process control tools to

ensure post-implementation sustainability

Laminate new

standardized

discharge

process cards

9/29 – 10/5 6

E-mail communication of plan for twice

daily huddles to review adherence to the

new standardized discharge process

Begin twice-daily review huddles

10/6 – 10/12 6 Implementation week one

Data collection and interim analysis

Histogram and

Line graphs

week one

10/13/ – 10/19 4

Implementation week two

Data collection

Begin final presentation write up

Histogram and

Line graphs

week two

10/21 – 10/23 6

Implementation week three, data

collection and final data analysis

Histogram and

Line graphs

week three

10/25 6

Present summary to staff with

recommendations

Summary

Histogram and

line graph and

post

implementation

baseline

summary data

Evidence to Support Need

Patient arrivals in the ED increases over the course of the day resulting in the increase in the number of patients admitted to

inpatient units such as the MSU. Delays in discharging patients from inpatient units results in patients being held in the ED. Focusing

on discharges before noon in inpatient units has been demonstrated to improve ED flow by lessening the number of ED holds prior to

the time that the ED is busiest (McKenna, et al., 2019).

Studies conducted on the subject of discharges before noon have demonstrated a clear positive effect on hospital throughput

metrics. Durvasula et al. (2015) employed quantitative methods to gauge if an interdisciplinary approach to discharge planning could

increase the percentage of discharges occurring before 11:00 a.m. The intervention consisted moving discharge process steps to the

night before the discharge and giving the discharge order before 9:00 a.m. on the morning of the discharge. Prior to the intervention, the

rate of discharges before 11:00 a.m. was 8% and increased to 11% after implementation of the new discharge process. The study

demonstrated that a multidisciplinary approach to discharge is a low cost, safe, and effective way to increase discharges before 11:00

a.m. and improve hospital throughput.

Chaiyachati and Chia (2016) measured the effects of targeted discharge interventions on a hospital’s overall patient flow using a

quantitative research study. The intervention involved daily morning discharge rounds to identify who could possibly be discharged the

next day. Discharge preparation began immediately after identification for discharge the next day. The proportion of discharges before

11:00 a.m. was measured and compared to hospital departure times. The baseline determined from a retrospective review of data 1

month prior to the study was compared to the new baseline determined from the data 3 months after implementation. The conclusion

demonstrated that targeted interventions could significantly improve early discharges.

Health care organizations have been driven to adopt strategies aimed at reducing patient length of stay since the introduction of

the prospective payment system by Medicare in 1983 which made changes to the way hospitals were reimbursed. Reimbursements were

changed from a per-diem basis to a flat payment based on the diagnosis. Reducing the length of stay was a cost effective way for the

hospitals to remain competitive (McKenna, et al., 2019). The completion of this project will ensure that AZ Hospital complies with the

Joint Commission 2009 Leadership Standard LD.04.03.11 which rationalizes that “managing the flow of patients throughout their care

is essential to prevent overcrowding” (Schyve, 2009, p. 31).

Project Purpose/Business Case

The MSU is in a level three tertiary care hospital. The unit consists of 40 beds serving approximately 7,700 patients a year. The

unit is staffed by a team of hospitalists who cover 12 hour shifts. The team includes nurses, respiratory therapists, case managers,

nursing assistants, and housekeeping. The hospital serves an urban community.

The primary beneficiaries from the MSUDBN project will be patients. They will benefit from shorter wait times after the

discharge order is given in the MSU. The increased bed availability will also benefit patients upstream in the ED, resulting in shorter

admission times and fewer patients leaving the ED without being seen by a provider. The staff in the MSU will benefit from a

standardized discharge process. AZ Hospital will benefit from the increase in revenues afforded by improved hospital throughput.

SMART Objectives (Specific, Measurable, Attainable, Relevant, Time-Bound)

Objective 1: By week three, the project team will develop and implement a new standardized discharge process targeted at increasing

the percentage of discharges by noon in the MSU.

Objective 2: By week six, there will be 80% staff compliance with the new standardized discharge process with each patient handoff.

Objective 3: By the end of 12 weeks there will be a 20% increase in the discharges before noon in the MSU.

Deliverables

Deliverables included the results of a baseline analysis of discharge before noon percentage in the MSU, fishbone diagram,

bimonthly progress reports to the Chief of Surgery, the administrative director of the MSU, and MSU staff. Interim progress reports and

a summary of the final data will also be presented to stakeholders. The final results will also be presented to the multidisciplinary QI/PS

committee that meets quarterly. The final deliverable for the MSUDBN project will be a new standardized discharge process that will

increase the percentage of discharges before noon in the MSU.

Project Scope

The MSUDBN project was created to improve bed availability in the MSU by increasing the percentage of discharges before

noon, which in turn will help reduce ED holds during high patient volumes. The project’s affect will be minimal during times of low

patient volumes. The project is intended to contribute to internal process quality improvement. The project scope will not be expanded

beyond the MSU environment as this patient population consists of those coming in through the ED as well as the OR, and other

inpatient units. The project is not intended to be generalizable to other MSU’s. For this reason, the project is not intended to be

published in peer-reviewed literature or disseminated outside the organization.

Project Milestones

Key Occurrences for Week of:

8/22-8/30

• Project approval

• Complete ED throughput analysis report presentation for MSU staff on 8/25

• Develop project charter

• Develop and test a data collection tool

9/2-/9/7

• Pilot test data collection tool

• Begin collecting pre implementation and current state data on discharges before noon of all patients in MSU

9/8-9/14

• Baseline data analysis

• Fishbone exercise for staff

• Staff e-mail communication

9/15-9/21

• Focus groups on day and night shifts

• Perform rapid PDSA cycles to address root causes of discharge delays in the MSU

• Staff e-mail communication

9/22 – 10/5

• Finalize new standardized discharge process

• Communicat plan to staff via e-mail for twice daily huddles, review on a.m. and p.m. rounds.

• Post laminated discharge process in unit

• Begin implementation on 10/1/19

• First data collection on 10/4/19

10/6 – 10/20

• Interim report posted in work room

• E-mail reminder to NP’s to review new standardized discharge process

• Continue data collection

• Complete final data analysis

• Present summary to staff via e-mail and power point on departmental website

• Submit report to Chief of surgery and Administrator Director of the MSU

Part 3

SWOT Analysis

Strengths

• The proposed project will significantly reduce the wait time for patients in the hospital ensuring that none of the patients are

forced to leave without obtaining the required treatment.

• The project ensures a significant increase in the overall revenue generated by the hospital.

• The budget for the proposed project is minimal and the project is scheduled during normal work hours of the staff and does not

require them to put in additional work hours.

Weaknesses

• The proposed project and its processes are not universal and cannot be applied as is to another hospital. The processes would

require substantial changes as per the differing variables presented in another organization.

Opportunities

• After the initial implementation of the project, SPC can be utilized to closely monitor and control the post-implementation

variations in the protocols in the proposed project charter. The data obtained through statistical process control should be

frequently monitored and any variation can be rectified immediately using rapid PDSA cycles.

Threats

• Poor analyzation of the data obtained from SPC can hinder the progress of the project.

• Lack of communication between the staff members can hamper the flow of processes and lead to failure of the project.

• The successful implementation of the project can happen only if there are high patient volumes during the project duration.

Known Major Risks

Risk Level (High, Medium, Low) Risk

Lack of Communication

High

Mitgation strategy. Lack of communication among the staff members can have drastic effects

on the project. Miscommunication can cause misunderstanding between staff members and the

roles they play in the project. Project champions such as staff nurses responsible for data

collection and process implementation have an additional responsibility, which is to identify

any instances of miscommunication among team members and resolve it before it can affect the

project.

Improper Analyzation of Data

Medium

Mitagation strategy. Data can be poorly analyzed because of varying levels of expertise and

differing perspectives of individuals. In order to combat this issue, we can form focus groups

that can meet twice a month to discuss the results of the analysis as well as reach a consensus

on the implementation of a process depending on the data.

Ethical Considerations

The MSUDBN project will focus on improving the discharge process of patients in the MSU by increasing the percentage of

patients discharged before noon. This will be accomplished by making improvements to the existing discharge process and as such,

there are no foreseeable ethical violations for patients due to the improvements. The project charter will be submitted to the Internal

Review Board of AZ hospital to determine if its oversight is needed.

Constraints

Patient Volumes

The MSUDBN project aims to increase the availability of beds in the MSU by prioritizing discharges before noon. This in turn

will reduce the percentage of ED holds and the percentage of patients leaving the ED without being seen during times of high patient

volumes. However, the effectiveness of the project will be minimal duing times of low patient volumes. To ensure adequate patient

volumes, the implementation period for this project was set between the months of August and November, which have historically been

high volume months at AZ hospital.

External Dependencies

MSUDBN is an internal project within AZ hospital and will be conducted only within the MSU. The project does not have

external dependencies. The success of the project will depend on MSU staff buy-in and sustained efforts by them to develop, implement

and sustain the new standardized discharge process.

Communication Strategy

The presentation of the ED throughput analysis report will demonstrate to the MSU staff a clear need to improve the discharge

process in the MSU. The presentation of the analysis will also help paint a picture of what the future of the discharge process could look

like after the improvement is realized. The fishbone diagram will elicit multidisciplinary input, which will both involve and empower

the stakeholders to identify obstacles to the change. The analyze phase of DMIAC involves identifying barriers to the current process

using statistical tools and methods as well as graphs posted in the staff workroom and weekly e-mails. The focus groups will allow the

project team to conduct rapid PDSA cycles to address process deficiencies and develop a new standardized discharge process, which

will be printed out, laminated, and posted for easy access to staff members working on all shifts in the MSU. The new process will be

introduced during the implementation phase. Twice-daily huddles will be conducted to evaluate the discharge readiness of patients in

the MSU based on the new standardized discharge process. SPC will be used to maintain sustainability of the project.

Proposed Outcomes

Metric Outcome Measure Process Measure Countermeasure (optional)

Compliance with new

standardized discharge

process

20% increase in discharges before

noon at the MSU compared to the

pre-intervention baseline

• 100% staff compliance

with new discharge

protocol and procedures

• 100% staff compliance

with daily discharge

rounds at the prescribed

time

0% increase in readmission

rates

Data Collection Plan

Baseline data collection will begin during the second week of the project and will include data on the number of discharges by

noon, the length of stay, and discharge data of patients in the MSU. No patient identifiers will be used. The data will be collected by the

project leader from the electronic medical records database of AZ hospital. Interim data will be displayed in histogram or line graph

format in the work room and will also be emailed to the MSU staff. All data will be stored on the organization’s private, password-

protected H drive that can be accessed only by the project leader.

Data Collection Tool

The data collection tool will be developed in Excel. The data collected will be analyzed using filtering applications and

analytical functions. The analyzed data will be represented graphically in the form of histograms, line graph, bar graph or pie chart.

References

Chaiyachati, K. H., & Chia, D. (2016). Discharge rounds: Implementation of a targeted intervention for improving patient throughput on an

inpatient medical teaching service. Southern Medical Journal, 109(5), 313-317. http://dx.doi.org/10.14423/SMJ.0000000000000458

Christoff, P. (2018). Running PDSA cycles. Current Problems in Pediatric and Adolescent Health Care, 48(8), 198-201.

https://doi.org/10.1016/j.cppeds.2018.08.006

Durvasula, R., Kayihan, A., Del Bene, S., Granich, M., Parker, G., Anawalt, B. D., & Staiger, T. (2015). A multidisciplinary care pathway

significantly increases the number of early morning discharges in a large academic medical center. Quality Management in Healthcare,

24(1), 45-51. http://dx.doi.org/10.1097/QMH.0000000000000049

El-Eid, G. R., Kaddoum, R., Tamim, H., & Hitti, E. A. (2015). Improving hospital discharge time: a successful implementation of Six Sigma

methodology. Medicine, 94(12), e633. http://dx.doi.org/10.1097/MD.0000000000000633

Kaye, D. R., Richardson, C. R., Ye, Z., Herrel, L. A., Ellimoottil, C., & Miller, D. C. (2017). Association Between Patient Satisfaction and Short-

Term Outcomes After Major Cancer Surgery. Annals of Surgical Oncology, 24(12), 3486-3493. http://dx.doi.org/10.1245/s10434-017-

6049-2

Schyve, P. M. (2009). Leadership in healthcare organizations: A guide to joint commission leadership standards [White Paper].

https://psnet.ahrq.gov/issue/leadership-healthcare-organizations-guide-joint-commission-leadership-standards

McKenna, P., Heslin, S. M., Viccellio, P., Mallon, W. K., Hernandez, C., & Morley, E. J. (2019). Emergency department and hospital crowding:

causes, consequences, and cures. Clinical and Experimental Emergency Medicine, 6(3), 189-195. http://dx.doi.org/10.15441/ceem.18.022

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

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