Performance Improvement Project Team Charter A Performance Improvement Project (PIP) team charter is a document that outlines each PIP team's mission, scope of operation, objectives, time frame and consequences. A team charter can be developed by the Quality Assurance and Performance Improvement (QAPI) Steering Committee and presented to the PIP team, or the PIP team can create their own charter and present it to the QAPI Steering Committee. Regardless of the way the PIP team charter is developed, the endorsement of a PIP team's charter by the QAPI Steering Committee is a critical factor in giving the team the direction and protection it needs to succeed. Teams need to know what the QAPI Steering Committee expects of them, but just as important is the idea that non-team members need to know what the QAPI Steering Committee expects of the team. Before creating a Performance Improvement Project team charter, have the team answer the following questions. The answers the team provides will help them establish autonomy to do the work and identify boundaries to keep them focused on the task(s) at hand. Following this format will help reduce confusion and keep the team focused on defining its purpose.

1. What is the purpose or mission of this team?

2. What is the final product of this team? You may not know at the beginning of the project but it should become clear in some form of process change that becomes sustainable over time.

3. How will the team concretely measure its success?

4. Who is the team sponsor? Identify the individual the team will go to that can intervene for them and identify who is on the QAPI Steering Committee. This ensures ongoing support for the activities, and the team sponsor will help keep the team on track through their review of team activities.

5. Are there any deadlines and, if so, what are they? Is there a "sunset clause" for this team? If so, what is it?

6. How often is the team expected to meet? How many hours of work per week/month is the team authorized to schedule? What are the budget limitations for this team?

7. Are there money and other resource limitations, final recommendations or decisions by the team? If so, what are they?

8. Who are the members of this team, including the team leader and facilitator? Remember, direct caregivers, such as nursing assistants, are needed. Direct caregivers are closest to the problem. Where will they find the time to work with the team?

This material was prepared by TMF Health Quality Institute, the Medicare Quality Improvement Organization for Texas, under contract with the Centers for Medicare & Medicaid Services (CMS), an agency of the U.S. Department of Health and Human Services. The contents do not necessarily reflect CMS policy. 10SOW-TX-C7-13-111

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Quality Improvement Team Charter

Project Name:

Team Leader:

Team Members (resident/family included?):

Aim Statement:

Sponsor:

Frequency of reports:

Timelines/deadlines:

Other: (Resource limitations?)

Quality Improvement Team Charter

SAMPLE

Project Name: Antipsychotic Medication Reduction Team

Team Leader: Susie Smith, Activities Director

Team Members (resident/family included?): Social Worker, night nurse, weekend C.N.A., evening C.N.A., ADON,

Pharmacy Consultant, Psychiatrist’s NP and Ombudsman

Aim Statement: The purpose of this Performance Improvement Project (PIP) is to identify the root causes for

unnecessary antipsychotic medication use, and determine and test the process changes necessary to

sustain the following goal:

All antipsychotic medications will be used only with an FDA-approved indication, when necessary, for the

resident’s highest level of functioning. These medications will be administered using a Gradual Dose

Reduction (GDR) plan while ensuring non-pharmacological approaches are in place. Resident, family

and/or the responsible party’s input will be included as well.

Sponsor: DON

Frequency of reports: Weekly, more often if necessary

Timelines/deadlines: Root Cause Analysis (RCA) completed within two weeks. First PDSA (Plan-Do-Study-Act)

cycle completed within one day following RCA. Project completed within one month.

Other: (Resource limitations?) If/when barriers are identified they should be reported to the sponsor as soon as

possible. Any expense exceeding $100 is to be brought to the sponsor for review, including staff time for

training if identified as a test of change/PDSA.