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Project Scope and Plan
General Information: Ferris State University Nursing 495
Project Name: Standardized Sedation Monitoring Form
Project Manager Name: Laura Parker
Site: Spectrum Health United Memorial &Kelsey Hospital
Location: Greenville & Lakeview, MI
A. Project Overview: Describe the product or service of the project, the reason the project
will be undertaken, and the purpose of the project. Discuss the problem or opportunity
this project addresses. Include the quality and safety issue this project will address.
Support with current evidence-based practice literature or data specific to the project.
I work at a small rural community hospital that is affiliated with another hospital. These two
hospitals are part of the Spectrum Health system. The Spectrum health system is currently
working to have all policies and procedures the same throughout the system. But due to
differences in the hospitals in the system this is not always possible. There are differences in
processes even between the two hospitals in the system that I work for, United Memorial.
Currently there are two separate data gathering forms being used to review the cases when
procedural sedation was administered. I am proposing to combine the two different data
gathering methods for sedation cases into one process and to use just one form and also to
establish a way to display this data to report it to the Quality Department for both campuses at
United Memorial.
Procedures that require sedations are done daily at the facility that I work for. While these
procedures are very commonplace, there are still adverse or even sentinel events that could occur
from a patient undergoing sedation. There are certain steps involved in the sedation process that
need to be followed to ensure patient safety. The Joint Commission has standards addressing
procedures that require sedation. According to the Joint Commission website (2012), Standard
PC. 03.01.01 from the National Patient Safety Goals of 2008 was developed to set protocols for
hospitals in regards to what members of the health care team need to be involved throughout the
whole continuum of the sedation process and also in regards to the qualifications and monitoring
skills of the person that is administering the sedation. The most updated Joint Commission
National Patient Safety Goals for 2014 address three areas that need to be addressed prior to the
start of a procedure which include preprocedure verification, the marking of the procedural site,
and the time out process that should occur before the procedure starts. A procedural monitoring
process can help with evaluating the sedation procedures that are taking place in a facility and
determining if the proper actions are occurring before and throughout the procedure.
A health care system needs to have a consistent monitoring process, especially if more
than one hospital is include in the system. When there is more than one method for a process, it
can lead to discrepancies and errors that could in turn cause harm to a patient. According to
McCoy, Wakai, Blackburn, Barrett, Murphy, & Brenner (2013), procedures involving sedation
are being done in many more settings then the operating room. Many procedures are being done
in emergency rooms using procedural sedation under the direction and supervision of emergency
room physicians that used to be done in the surgery department under the supervision of the
anesthesiologist. While this is a benefit for patients to have these procedures done in the
emergency room, the physicians may be using different sedation policies or guidelines. “This
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lack of uniformity and standardization has led to varying practices, which are a potential risk to
patient safety” (McCoy et al,. 2013, para 3).
The sedation monitoring tools that are developed by this project will be used by the
United Memorial Healthy system in the departments that perform conscious sedation. These
departments include surgery, emergency, the intensive care unit and the general medical surgical
floor. My manager was assigned this project by the Director of Nurses (DON) at United
Memorial Hospital and she felt that this would be a good project for my assignment. This project
will improve health care outcomes by identifying the needed steps that have to happen during a
procedure to ensure that sedation is being administered safely. These monitoring tools will allow
supervisors to monitor what important actions are being overlooked or eliminated in these
procedures. The creation of a quality data monitoring dashboard will allow the organization to be
compliant with the Joint Commission standards for this topic.
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 and its conclusion.
Goal: To combine the procedural sedation monitoring requirements of two forms from two
hospitals within one health system into one form that follows the Joint Commission and
Spectrum Health’s standards for accurate and safe conscious sedation administration. To develop
a quality data dashboard to monitor established criteria that is required by the Joint Commission
by April 13, 2014.
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.
Objectives
1. Completion of literature review of standardized sedation monitoring by February 7th,
2014.
2. Completion of literature review of Joint Commission Standards for sedation monitoring
by February 7th, 2014.
3. Completion of rough draft of sedation monitoring form by February 12th , 2014
4. Submission of rough draft to department managers and physicians by February 21st ,
2014
5. Submission of final draft of sedation monitoring form to DON of United Memorial
Hospital by February 28th , 2014
6. Submission of approved sedation monitoring to obtain printed version of forms March
15th, 2014.
7. Education of reason for new forms and proper use of forms to appropriate staff members
by March 25th, 2014.
8. Determine date to begin use of standardized sedation monitoring form by March 30th,
2014.
9. Determine what standards need to be measured in quality data dashboard by March 30th,
2014.
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10. Development of sedation monitoring dashboard by March 31st, 2014.
11. Education of what data will be measured in dashboards and who the data will be reported
to by April 5th, 2014.
12. Determine date to begin measurement of quality data and use of dashboards by April 10th,
2014.
D. Comprehensive List of Projects 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.
List of Project Requirements/Activities/Tasks
1. Completion of literature review of standardized sedation monitoring by February 7th,
2014.
1.1 Identify key search words to RN project member by January 31st , 2014
1.2 RN project member to have evidence based research done by February 5th, 2014.
1.3 Collaborate with Denise Brock RN to review evidenced based research and
compare to the sedation review forms that are currently being used by February
7th, 2014.
Estimated Time: 5 hours
Team Members for WBS 1:
Laura Parker RN/Project Manager
Denise Brock RN/DON
2. Completion of literature review of Joint Commission Standards for sedation
monitoring by February 7th,, 2014.
2.1 Identify key search words to RN project member by January 31st, 2014
2.2 RN project member to have evidence based research done February 5th, 2014.
2.3 Collaborate with Denise Brock RN to review Joint Commission Standards and
compare to the sedation review forms that are currently being used by February
7th, 2014.
Estimated Time: 5 hours
Team Members for WBS 2:
Laura Parker RN/Project Manager
Denise Brock RN/DON
3. Completion of rough draft of sedation monitoring form by February 12th, 2014.
3.1 Compare two forms from each entity by February 7th, 2014.
3.2 Create one new form based on evidence-based research and Joint Commission
Standards by February 10th, 2014.
3.3 Review rough draft of form with Denise Brock by February 10th, 2014.
Estimated Time: 10 hours
Team Members for WBS 3:
Laura Parker RN/Project Manager
Denise Brock RN/DON
Karen Bowers RN/Quality Improvement Specialist
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Linda VanPortfliet Administrative Assistant Quality & Patient Safety
4. Submission of rough draft to department managers and physicians and approval of
forms by February 21st, 2014.
4.1 Identify appropriate managers and physicians who need to review forms by
February 9th, 2014.
4.2 Submit rough draft of form to appropriate managers and physicians by February
12th, 2014.
4.3 Send out initial correspondence via email or phone call to request appropriate
manager and physician approval by February 17th, 2014.
4.4 Follow up with physicians and managers to have approval of forms and address
any concerns by February 19th, 2014.
Estimated Time: 8 hours
Team Members for WBS 4:
Laura Parker RN/Project Manager
Denise Brock RN/DON/Manager of Med -Surg/Emergency/Outpatient procedures at
Kelsey
Eric Nelson RN/Manager of Surgery Department at United Memorial
Julie Snyder RN/Manager of Med-Surg/ICU/OB at United Memorial
Christine Klenk RN/Manager of Emergency Department at United Memorial
Steve Fahlen MD/ Director of Emergency Department at Kelsey
Matt Dewys MS/ Director of Emergency Department at United Memorial
Lory Read MD/Director of Med-Surg at Kelsey
Shawn Ruth MD/Director of Med-Surg/ICU at United Memorial
Kevin O’Connor MD/Director of Surgical Department at United and Kelsey
Cindy Rollenhagen Manager of Quality & Patient Safety
5. Submission of final draft of sedation monitoring form to CEO/DON of United
Memorial Hospital by February 28th, 2014.
5.1 Send email with attachment containing final draft of sedation forms that have
been approved by appropriate department managers and physicians by February
21st, 2014.
5.2 Address any concerns or suggestions from DON by and resubmit to DON for
final approval by February 24th, 2014.
Estimated Time: 3 hours
Team Members for WBS 5
Laura Parker Project Manager/RN
Brian Brasser CEO/DON on United Memorial and Kelsey Hospital
6. Submission of approved sedation monitoring to obtain printed version of forms by
March 15th, 2014.
6.1 Determine appropriate information that needs to be included in the form in order
for the forms to be used by March 5th, 2014
6.2 Determine date of when forms will be printed and ready to stock on appropriate
units by March 15th, 2014.
Estimate Time: 10 hours
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Team Members for WBS 6:
Laura Parker RN/Project Manager
Pat Whitcomb Director of Information Management United and Kelsey Hospital
Denise Brock RN/DON
Karen Bowers RN/Quality Improvement Specialist
Linda Van Portfliet Administrative Assistant Quality & Patient Safety
7. Education of reason for new forms and proper use of forms to appropriate units by March 25th,
2014.
7.1 Meet with appropriate department managers and determine which individuals will be
using the forms by March 3rd, 2014.
7.2 Discuss education needs for staff in regards to use of the forms and determine need to
involve the education department by March 10th, 2013.
7.3 Notify identified staff members about the new forms and how to use them by March
15th, 2014.
7.4 Meet with education department to notify of new forms and what the staff members
will need to be educated on in regards to safe procedural sedation by March 15th, 2014.
Estimated hours: 10
Team Members for WBS 7:
Laura Parker Project Manager/RN
Tammie Beach RN/Education Department for United and Kelsey
Misuk Robinson RN/Nursing Informatics United and Kelsey
Denise Brock RN/DON/Manager of Med-Surg/Emergency/Outpatient procedures at
Kelsey
Eric Nelson RN/Manager of Surgery Department at United
Julie Snyder RN/Manager of Med-Surg/ICU/OB at United
Christine Klenk RN/Manager of Emergency Department at United
8. Determine date to begin use of standardized sedation monitoring form by March 30th, 2014.
8.1 Discuss with department managers appropriate date to start using new forms by
March 20th, 2014.
8.2 Follow up and finalize appropriate start date for new forms by March 28th, 2014.
Estimated Time: 4 hours
Team Members for WBS 8:
Laura Parker Project Manager/RN
Tammie Beach RN/Education Department for United and Kelsey
Misuk Robinson RN/Nursing Informatics United and Kelsey
Denise Brock RN/DON/Manager of Med-Surg/Emergency/Outpatient procedures at
Kelsey
Eric Nelson RN/Manager of Surgery Department at United
Julie Snyder RN/Manager of Med-Surg/ICU/OB at United
Christine Klenk RN/Manager of Emergency Department at United
9. Determine what standards need to be measured in quality data dashboard by March 30th, 2014
9.1 Meet with Quality Department to determine required or desired reporting standards
by March 5th, 2014.
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9.2 Begin development of dashboards by Quality department by March, 17th, 2014.
9.3 Meet with Quality department to determine status of dashboards and review any
started dashboards and suggest any changes or additions by March 24th, 2014.
Estimated Time: 12 hours
Team Members for WBS 9:
Laura Parker RN/Project Manager
Karen Bowers RN/Quality Improvement Specialist
Linda Van Portfliet Administrative Assistant Quality & Patient Safety
Daniel Maloney Measurement Specialist Quality & Patient Safety Department
Cindy Rollenhagen Director of Quality & Patient Safety
10. Development of sedation monitoring dashboard by March 31st, 2014.
10.1 Have all proposals, suggestions and required elements in dashboard by March 24th,
2014.
10.2 Final approval of proposed dashboard done by March 28th, 2014.
Estimated hours: 10 hours
Team Members for WBS 10
Laura Parker RN/Project Manager
Karen Bowers RN/Quality Improvement Specialist
Linda Van Portfliet Administrative Assisstant Quality & Patient Safety
Daniel Malony Measurement Specialist Quality & Patient Safety
Cindy Rollenhagen Director of Quality & Patient Safety
11. Education of what data will be measured in dashboards and who the data will be reported to
April 5th, 2014.
11.1 Meet with appropriate managers to inform about new quality dashboard and the
monitored elements by March 28th, 2014.
11.2 Educate appropriate managers about which items will be required and what will
constitute a fall out and discuss the appropriate follow up by March 28th, 2014.
11.3 Determine which staff will be responsible for monitoring and reporting the data by
March 28th, 2014.
Estimated time: 10 hours
Team Members for WBS 11:
Laura Parker Project Manager/RN
Tammie Beach RN/Education Department for United and Kelsey
Misuk Robinson RN/Nursing Informatics United and Kelsey
Denise Brock RN/DON/Manager of Med-Surg/Emergency/Outpatient procedures at
Kelsey
Eric Nelson RN/Manager of Surgery Department at United
Julie Snyder RN/Manager of Med-Surg/ICU/OB at United
Christine Klenk RN/Manager of Emergency Department at United
12. Determine date to begin measurement of quality data and use of dashboards by April 5th,
2014
12.1 Goal is to have dashboards ready to use for April 10th, 2014.
12.2 Meet with identified person from the Quality department who will generate the
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reports from the dashboards to discuss purpose of dashboards by April 5th, 2014.
Estimated hours: 4
Team Members for WBS 12:
Laura Parker RN/Project Manager
Karen Bowers RN/Quality Improvement Specialist
Daniel Maloney Measurement Specialist Quality & Patient Safety
Linda Van Portfliet Administrative Assistant Quality & Patient Safety
E. Timeline: Identify time estimates by hours for each objective/deliverable in hours. These
are estimates only and will be updated as project progresses.
Timeline for objectives/deliverables and timeline estimates are listed in the section above
named Comprehensive List of Project/Requirements/Activities/Tasks.
F. Assumptions & Constraints: Identify all project assumptions and constraints.
Assumptions:
 That the appropriate managers and physicians can agree on one universal
form to be used for sedation monitoring
 That the project members can work together as a team
 That the project members will have the skills and knowledge required to
complete this project
 That the project team will be able to be able communicate with each other
effectively
 The timeline established is realistic and attainable
Constraints:
 Getting the appropriate feedback from department managers for form review due
to the busy schedules of the project members.
 Keeping the project timeline on schedule due to the amount of people required to
review and approve sedation forms
 Getting the staff who are involved in administering procedural sedation to become
engaged in the importance of following the required guidelines for safe
procedures
 Getting the required monitored data to the quality department in a timely fashion
in order to have dashboards ready for display to appropriate managers
 The differences in documentation methods between hospitals due to the fact that
Kelsey Memorial uses paper documentation in the surgery department.
 The cost of this project will be absorbed by my employer, since this was a project
assigned to my manager, so I will not have to request funds for this assignment.
 The quality of this project will be maintained per the standards of the Quality &
Safety department since there will be team members who are pivotal members
who are involved in the development and implementation of my project.
 The scope of this project has been defined and planned in the Comprehensive List
of Project/Requirements/Activities/Tasks. I anticipate that events will come up
like other team member’s schedules or issues getting the forms made up for use,
or issues with producing the dashboards that may cause events to be rescheduled.
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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
including aspects related to quality and safety? How will you know if the project was a
success? Support with evidence-based literature or nursing data.
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Value of Project
Increased use of sedation in other departments then OR requires the need for the
proper monitoring and ability to report the data. The American College of
Emergency Physicians (ACEP) recognizes that procedural sedation is being
frequently administered in emergency departments. This group sets the guidelines
for the care received in emergency rooms.
Institutional and departmental guidelines related to the sedation of patients
should include credentialing and verification of competency of providers,
selection and preparation of patients, informed consent, equipment and
monitoring requirements, staff training and competency verification, criteria
for discharge, and continuous quality improvement” (American College of
Emergency Physicians, 2013, para 10).
Importance and Benefit of Project
Improved patient safety is always a main goal for the United Memorial health
system. This will help the hospital to meet the required standards from the Center
for Medicare & Medicaid Service (CMS) in regards to this area of guidelines for
hospitals. The CMS has established guidelines in regards to pre and post
anesthesia evaluation. Standard 482.52 (b) (1) states “a pre-anesthesia evaluation
must be performed for each patient who receives general, regional, or monitored
anesthesia” (Center for Medicare & Medicaid Services, 2011, p.7). Another
branch of this guideline 482.52(a), encompasses that this pre-anesthesia sedation
needs to be done by an individual who is qualified to administer the anesthesia
and it has to be done and documented 48 hours within or immediately prior to a
procedure involving sedation that involves an inpatient or outpatient procedure
(CMS, 2011). There is also a guideline that addresses post-anesthesia evaluation
and what items need to be monitored. These items under guideline 482.12(c)(1)(i)
are respiratory rate, pulse oximetry, airway patency, heart rate, blood pressure,
mental status, temperature, pain, nausea and vomiting, and post-operative
hydration (CMS,2011).
Impact of Project on Patient Care and Patient Outcomes
Improved patient safety, decreased risk of adverse outcomes or sentinel events
due to procedures involving sedation.
The Joint Commission has developed standards in regards to areas to be tracked
and monitored in regards to procedural sedation. Some of these items consist of
medical staff credentialing and appropriate supervision of patient receiving
sedation, having the proper resuscitation equipment available, and enough staff
available to monitor and recover the patient (Joint Commission, 2012).
Ways to Measure Success of Project.
The development of the dashboards will allow the required data to be tracked and
the departments that are not following the proper procedures will be notified and
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the necessary improvements can be implemented.
By developing these standardized forms that include the guidelines established by the Joint
Commission, United Memorial and Kelsey Hospitals will be providing the most high quality and
safe care to the patients receiving procedural sedation. The dashboards will provide a way for the
department managers to be able to track percentage of accuracy with these established guidelines
and also fallouts in these areas. Identification of fall outs, allows for the needed education and
improvements to achieve the quality standards.
References
American College of Emergency Physicians (2013). Sedation in the emergency department.
Retrieved from http://www.acep.org/Content.aspx?id=75479
Center for Medicare & Medicaid Services (2011). CMS manual system. Retrieved from
https://www.cms.gov/Regulations-andGuidance/Guidance/Transmittals/downloads/R74SOMA.pdf
The Joint Commission (2012). Standards FAQ details. Retrieved from
http://www.jointcommission.org/mobile/standards/_information/jcfaqdetails.aspx?Sta
ndardsFAQId=138&StandardsFAQChapterId=78
The Joint Commission (2013). National patient safety goals effective January 1, 2014.
Retrieved from
http://www.jointcommission.org/assets/1/6/HAP_NPSG_Chapter_2014.pdf
McCoy, S., Wakai, A., Blackburn, C., Barrett, M., Murphy, A., & Brenner, M. (2013).
Structured sedation programs in the emergency department, hospital and other acute
settings: protocol for systematic review of effects and events. Systematic Review(2).
DOI: http://0-dx.doi.org.licat.ferris.edu/10.1186/2046-4053-2-89