QI Project Charter & Measurement Plan

Purpose

This template helps teams start a clinical quality improvement (QI) project with clarity: a focused aim, clear scope, defined stakeholders and ownership, a measurement plan (outcome, process, balancing), a baseline data approach, milestones, communications, and a handover/sustainment checklist. Use it to avoid vague charters and improve the chances that evidence-based changes stick.

How to use this template

Fill each section with concise, measurable statements. Keep the charter short (1–2 pages) and attach the measurement plan as a living appendix. Review and update the plan regularly during your improvement cycle.

Sections

1) Project background

Why this project matters. Summarize the problem, key supporting data or evidence, and patient or organizational impact.

• Problem statement (1–2 sentences):
• Relevant background / evidence sources (e.g., guidelines, audits, incident data):
• Expected benefits (clinical, safety, experience, financial, operational):

2) SMART Aim

State a Specific, Measurable, Achievable, Relevant, Time-bound aim. Example: "Reduce average ED door-to-antibiotic time for septic patients from 120 to 60 minutes (50% reduction) within 6 months, measured by time-stamped EHR events."

Prompt:

• Specific: what will change and for which population?
• Measurable: what metric and target will show success?
• Achievable: why is the target realistic?
• Relevant: how does it align with organizational priorities?
• Time-bound: by when?

3) Scope and exclusions

Define included settings, patient groups, clinical pathways, and what is explicitly out of scope to prevent scope creep.

4) Key stakeholders & sponsors

List sponsor(s), project lead, frontline clinical leads, data/analytics owner, operational partners, patient representation (if applicable), and any external partners.

5) Process map snapshot

Attach or embed a simple process map (high-level swimlane or step list). Use this to identify where measures should be taken and where interventions will act.

Prompt: What are the critical handoffs, decision points, and places where delays or errors occur?

6) Measures — outcome, process, balancing

For each measure include: name, type (outcome/process/balancing), definition (numerator/denominator), data source, collection frequency, owner, baseline value, target, and method of display (run chart, p-chart, dashboard).

Outcome measures (what matters to patients)

• Example: 30-day readmission rate for CHF patients. Numerator: readmissions within 30 days; Denominator: index discharges; Source: discharge database; Frequency: monthly; Owner: QI data lead; Baseline: X%; Target: Y%.

Process measures (are we doing the intended work?)

• Example: % of eligible patients with antibiotic administered within 60 minutes. Numerator: number receiving antibiotics ≤60 min; Denominator: eligible patients; Frequency: weekly; Owner: ED nurse manager.

Balancing measures (unintended consequences)

• Example: % of transfers to ICU within 24 hours (to monitor for missed deterioration) or staff workload indicators.

7) Baseline data collection plan

Describe how you will collect baseline data before major changes. Define:

• Data sources (EHR fields, registries, audits, manual chart review)
• Time period for baseline (e.g., last 6 months)
• Sample size or sampling method if manual (e.g., 30 random charts)
• Data quality checks (validation rules, missing data handling)
• Owner and analyst contact

Tip: capture time-stamped events where possible and plan early run charts to visualize variation.

8) Key milestones & timeline

• Project kick-off (date)
• Baseline data complete (date)
• First PDSA cycle start/end (dates)
• Interim review points (weekly/biweekly/monthly)
• Evaluation & spread decision (date)

9) Communication plan

Audience, message, frequency, channel, and owner. Examples:

• Frontline staff: weekly huddle updates (owner: project lead)
• Department leadership: monthly scorecard (owner: sponsor)
• Patients/families (if applicable): informational handouts or advisory updates

10) Owner RACI

Use RACI to avoid confusion. Provide role, name, and R/A/C/I assignment. Example entries:

• Project Sponsor: Dr. Smith — Accountable (A)
• Project Lead: Nurse Jones — Responsible (R)
• Data Analyst: Alex Lee — Consulted (C)
• ED Nurses — Informed (I)

11) Handover & sustainment checklist

What must be in place before the project is considered sustained and ready to hand over to operations:

• Standard work and job aids documented and accessible
• Training completed and records stored
• Data collection automated or routine assigned with owner
• Control plan with thresholds and escalation path
• Dashboard or scorecard established and reviewed at a named meeting
• Audit or re-check schedule defined (e.g., quarterly)
• Assigned operational owner and budget if needed

Examples (short)

SMART aim: "Increase timely medication reconciliation on admission from 65% to 90% within 4 months for adult medical inpatients by implementing a standardized intake checklist and provider prompts."

Measures: Outcome = % of patients with completed med rec within 24 hours; Process = % of admissions with checklist completed; Balancing = average provider documentation time per admission.

Common pitfalls to avoid

• Vague aims (no metric or target)
• No data owner or unclear data sources
• Too many outcome measures and no process measures
• No plan for sustaining the change after the project team disbands

Next steps & suggested cadence

Complete the charter with named owners, finalize baseline data, run small PDSA cycles, and review measures weekly early in the project then transition to monthly monitoring once stable.

Attachment suggestions

• Process map or flowchart (visual)
• Raw baseline data extract or summary table
• PDSA log or template
• Patient-facing materials, if relevant

Quick tips

• Keep the charter actionable and visible; display a single-page summary at team huddles.
• Prioritize a small set of high-value measures rather than many low-value ones.
• Label data fields and sources clearly to enable automation later.