Project Charter
The Project Charter outlines the aim and scope of the improvement project, establishes measures of success and is
used to ensure leadership support and alignment with corporate priorities. This document should be completed
during the ‘Define the Problem’ project phase (see Appendix A for TOH Quality Improvement Framework), and act
as a reference as the project progresses to ensure the work stays true to the original project intent.

Project Title Revision Date Version

Diversity and Inclusion in April 2022 1.0
Executive Sponsor Most Responsible Person (MRP) Projec
TBD (Ellen Alle?) Maria Crutchley Maria
A. Problem Statement
Use the 5W2H method to write your problem statement:
What is the problem? Why is it a problem? Highlight the “pain”;
Where do we observe the problem? (location); Who is impacted? (patients, business);
When did we first observe the problem?
How did we observe the problem? Symptoms; How often do we observe the problem? (Magnitude and trend).
We have different ethnic groups in the Endoscopy unit. Many staffs do not accept any culture
but their own. You have one point of view and looking at other points of view can be difficult
to find a common ground for understanding. The problem is communication is important. The
lack of understanding of culture prevents people to understand each other in the endoscopy
unit. That is, nurse to nurse, nurse to patient. The problem existed since I became staff at the
TOH. It is in the past and it still exists. The problem can be accidental and can cause harm.
A. Project Objective
What are we trying to accomplish? What parts of the overarching problem will we focus on?
Not knowing people’s cultures, it can cause friction between individuals. This friction would be
misunderstood and individuals could be insulted.
A. Aim Statement

Frame as SMART goal (Specific, Measurable (numerical target for improvement), Attainable, Relevant, Time-
bound)
DO TOGETHER

A. Project Scope
Describe the boundaries of the project. What is the mandate of the project team? What outcomes / issues / areas
will not be addressed by the project? Are there limitations to time / cost available to project?
In Scope:

Out of Scope:

 Page 1 of 4
Revised May 2021 v1.1
 
Project Charter
A. Key Project Partners
List other departments or areas required for project collaboration. Who will be impacted positively or negatively?

A. Related Initiatives
Project Relationship Key Contact

A. Measures of Success
Identify the metrics and targets you are trying to improve with this project. How will we know if we are making an
impact?
Outcome Measure(s):

Process Measure(s):

A. Preliminary Project Timeline (High Level)

Anticipated project term: Estimate time to complete each of the project phases (see TOH QI Framework).
Project Phase Time Frame – Start and Comments
1. Define the Problem
1. Analyze the Situation
1. Test & Trial Improvements
1. Lock-In Improvement
1. Evaluate & Spread
A. Signatures
The signatures of the people below document approval of the formal Project Charter. The project manager is
empowered by this charter to proceed with the project as outlined in the charter.

Role Name Signature Date

Project Executive Sponsor
Most Responsible Person
Project Manager (s):

 Page 2 of 4
Revised May 2021 v1.1
 
Project Charter
Appendix 1

TOH Improvement Framework

 Page 3 of 4
Revised May 2021 v1.1
 
Project Charter
Appendix 2
Description of Roles and Responsibilities
Executive Sponsor: Provides overall direction on the project. Responsibilities include: approve the project
charter and plan; secure resources for the project; confirm the project’s goals and objectives; keep abreast of major
project activities; make decisions on escalated issues; and assist in the resolution of roadblocks.
Most Responsible Person (MRP): Provides support and direction on the project. Responsibilities include:
approve the project charter and plan; ensure resources for the project are in place; confirm the project’s goals and
objectives; keep abreast of all project activities; escalate issues to sponsor as required; and assist in the resolution
of roadblocks.
Project Manager: Leads in the planning and development of the project; manages the project to scope.
Responsibilities include: develop the project plan; identify project deliverables; identify risks and develop risk
management plan; direct the project resources (team members); scope control and change management; oversee
quality assurance of the project management process; maintain all documentation including the project plan;
report and forecast project status; resolve conflicts within the project or between cross-functional teams; ensure
that the project’s product meets the business objectives; and communicate project status to stakeholders.
Team Member: Works toward the deliverables of the project. Responsibilities include: understand the work to
be completed; complete research, data gathering, analysis, and documentation as outlined in the project plan;
inform the project manager of issues, scope changes, and risk and quality concerns; proactively communicate
status; and manage expectations.
Subject Matter Expert: Provides expertise on a specific subject. Responsibilities include: maintain up-to-date
experience and knowledge on the subject matter; and provide advice on what is critical to the performance of a
project task and what is nice-to-know.

 Page 4 of 4
Revised May 2021 v1.1