IHI TOOL: Quality Improvement Project Charter
Institute for Healthcare Improvement • ihi.org 3
Example: QI Project Charter
Team: Team Coordinator: Rachel Creegan, Foster Care Children’s Nurse/Child Protection Advisor; Team
Member: Tonya Powell, Child Protection Administrative Assistant; Team Member/Process Owner: Janet
Watson, Children and Young People’s Health Network Secretary; Improvement Coach: Edgar Montes, Nurse
Consultant Vulnerable Children and Young People and Improvement Advisor
Project: Improving the Health Needs Assessment Process for Children
Sponsor: Alisha Green, Head of Children’s Services/Child Health Commissioner
Project Start Date: October 5, 2016
Last Revised: November 12, 2016
What are we trying to accomplish?
Problem
Health care providers often have concerns about children’s wellbeing when they encounter the health care
system, but the process for referring children for a Health Needs Assessment and intervention by Child
Protective Services is unreliable, meaning we may be missing some children who need help.
Project Description (defines what)
We will seek to improve the rate of referral of children for a Health Needs Assessment.
Rationale (defines why)
In a spot review of files, only about 75 percent of children who had an initial referral discussion also had a
follow-up Health Needs Assessment.
Expected Outcomes and Benefits
If successful, this project will improve outcomes for children who we are currently missing with Child
Protective Services (CPS); it will improve CPS’s ability to serve children; and it will improve staff morale to
have a clear, consistent, and reliable process to act upon their observations about children’s health needs. We
hope to have a redesigned process map and a referral form upon completion of the project.
Aim Statement
All (100 percent of) children who have an initial referral discussion to Child Protective Services will be
considered for a Health Needs Assessment; 95 percent of these children will get an assessment, if there is an
identified need, by January 2017.
How will we know that a change is an improvement?
Outcome Measure(s)
• Percent of Child Protective Services case file audits showing evidence of Health Needs Assessment
• Percent of staff who demonstrate understanding about Health Needs Assessment
• Staff satisfaction with Health Needs Assessment process
Process Measure(s)
• Percent of children per week who meet the criteria for Health Needs Assessment
• Percent of children per week who have a completed Health Needs Assessment