Project Scope and Plan (PSP)

General Information:

Project name: ____Transfer Communication Improvement Project_______

Project Manager name: ______Jennifer R. Williams___________
Site___Memorial Medical Center____Location______Ludington, MI______

a. Project Overview: Describe the product or service of the project, the reason project
was undertaken, and the purpose of the project. Discuss the problem or opportunity this
project addresses. Support with current scholarly references or data specific to the
project.

This project will provide a product to both increase and improve communication between
Memorial Medical Center and the local Extended Care Facilities (ECFs). The product will be a
transfer form created with certain specifications to identify ECF patient’s needs when transferred
to the hospital setting. This hospital currently only utilizes forms for hospital transfer to ECFs.

The problem identified, by both staff and this committee, is the lack of communication between
facilities and the hospital when the situation is reversed. The inability to identify patient’s needs
when they are transferred to the ER, ambulatory surgery, or the outpatient clinic can often affect
the patient’s right to receive the most efficient, accurate, and appropriate care.

This type of form can not only create a better care environment for the patients but will also
allow health care staff to provide immediate care to individuals related to their specified needs.
In addition, health care workers will be able to determine if there is a “change in condition” from
the patients baseline care needs.

The creation of this form will also have an alternative goal; to create an information source and
improved communication between the organizations. The form will include information
pertinent to the continuation of care.

Research shows that transition of nursing home residents to and from the hospital can be
problematic. Davis states that “while many conditions are beyond control, development of
standardized forms, targeted education, and constant monitoring have successfully reduced the
number of problems between hospital and nursing home, and fostered recognition that, although
the tasks and cultures differ, the two should be united in an effort to provide optimal care”(2005).

Our Clinical Quality department is based on the nursing case management model. As nurse case
managers, it is our responsibility to coordinate care, maintain quality, and contain costs while
focusing on the outcomes of care (Yoder-Wise, 2006). “The case manager is client-focused and
outcome –oriented” (Yoder-Wise, 253). This statement is the exact element that led us to the
idea to create the best environment possible for the patients transferred to our hospital from ECF.
Outcomes will improve, with increased communication of patients direct care needs, when a
transfer to the hospital is considered necessary.
Davis, N., Smith, S., & Tyler, S. (2005). Improving transition and communication

between acute care and long-term care: A system for better continuity of care.

Annals of Long Term Care. Retrieved from

http://www.annalsoflongtermcare.com/article/4100

Yoder-Wise, P. S. (2006). Leading and Managing in Nursing (4 ed.). St Louis, Missouri: Mosby.

b. Project Goal(s): Describe the project goal(s) using SMART (specific, measurable,
accurate and agreed to, realistic and time bound) formula. These goals will be used to
measure and determine the project’s success at its conclusion.

To create and implement an informational transfer form for transfers from ECFs to the
ER, ambulatory surgery, and outpatient services by, April 9, 2010.

c. Project Objectives/Deliverables: List the specific items or services that must be

produced in order to fulfill the goal of the project. Objectives/deliverables should be
measurable results, measurable outcomes or specific products or services. List and
number in a logical order to complete the project.

1. Complete reviewable draft of transfer form by 2/5/10

2. Introduce transfer form draft and request input from local ECFs by 2/12/10
3. Complete final draft of transfer form by 2/19/10
4. Receive final agreement approval from ECFs by 2/26/10
5. Introduce transfer form to forms committee by 3/5/10
6. Receive approval of transfer form from forms committee by 3/19/10
7. Educate and in-service Hospital and ECFs on appropriate use of form by 4/2/10
8. Initiate use of transfer form by 4/9/10

d. Comprehensive List of Project Requirements/Activities/Tasks: List by

corresponding objective the necessary specifications of the objective/deliverable.
Example 1.1, 1.2, 1.3, 1.4, etc This is a breakdown of the objectives/deliverables into
their most basic components. Consider this the action plan of the project.

1.1 Meet with committee to discuss contents of form.

1.2 Complete list of content needs for the form.
1.3 Assign committee member to create draft of form.
2.1 Set meeting with ECFs for review of draft.
2.2 Create list of suggestions from ECF.
2.3 Decide which changes to utilize of input from ECFs.
3.1 Make appropriate changes to form.
3.2 Review form and confirm changes.
4.1 Set meeting with ECFs for final approval of form.
4.2 Confirm that individual ECFs are willing to utilize form.
5.1 Introduce form to forms committee.
6.1 Monitor progress of forms committee approval to maintain timeline.
7.1 Set up education meeting with ECFs on form use.
7.2 Set up education meetings with appropriate department’s in-hospital.
7.3 Complete education with hospital staff.
7.4 Complete education with ECF staff.
8.1 Create copies of form for ECFs.
8.2 Disperse forms to ECFs.
8.3 Set start date for initiation of forms.
8.4 Initiate form use for all transfers to hospital.

e. Timeline: Identify time estimates for each objective/deliverable. These are estimates
only and will be updated as project progresses.

1.1 January 18, 2010

1.2 January 20, 2010
1.3 January 22, 2010
2.1 February 11, 2010
2.2 February 11. 2010
2.3 February 12, 2010
3.1 February 22, 2010
3.2 February 23, 2010
4.1 February 25, 2010
4.2 February 26, 2010
5.1 March 2, 2010
6.1 March 5 and 12, 2010
7.1 March 23, 2010
7.2 March 25 and April 1, 2010
7.3 March 25, 2010
7.4 April 1, 2010
8.1 March 22, 2010
8.2 March 23, 2010
8.3 March 23, 2010
8.4 April 5, 2010

f. Assumptions & Constraints: Identify all project assumptions and constraints.

Assumptions:

Forms committee approval- The assumption that the forms committee will approve the
form.

Nursing facility agreement and compliance- The assumption that the ECFs will be
agreeable to the use of the form with each transfer.
Ability to follow timeline- The assumption that all tasks will be completed timely on or
around goal dates.
Constraints:

Forms committee has limited meeting availability- The forms committee only meets at
certain times and dates during the month; process may be delayed if there is a need to
await approval for this form.

Multiple nursing facilities involved making initiation extensive and increasing chance of
non-compliance- Related to the multiple nursing facilities that transfer to our
organization; it may be difficult to maintain compliance and agreement with all ECFs.

g. Success Criteria: Provide the “value” of the project. Why is this project important
and of what benefit it is? What impact will it have on client care and client outcomes?
How will you know if the project was a success?

This project will allow health care workers to provide comprehensive, appropriate, and
timely continuity of care. Patients transferred from nursing facilities to the ER,
ambulatory surgery, and outpatient care will have important information regarding their
care communicated more effectively with the initiation of this project. Patient outcomes
will improve related to informed health care workers and their ability to provide
individualized care in an efficient manner with the information that they receive from the
facility. The project success will be evaluated by hospital employee feedback, improved
ER transition times, and improved efficiency with therapy referrals, all related to the
ability to determine the patient’s baseline immediately after transfer to Memorial Medical
Center.

Signatures:

Project Manager___________Jennifer Williams__________________________

Nurse Manager/Supervisor/___________Jody French______________

Phone: 231-845-2329

Email: jfrench@mmcwm.com