Chart
Audit
100%
M
Do not use abbreviation
% of most recent physician order/
progress not without “Do Not Use”
abbreviation used
Chart
Audit
100%
M
Patient Experience Survey
PI
>90
%
A
% of patients responding positively to
decision making survey questions
PI
10%
A
Transforming Person Centered Health Care
Citizen
Engagement &
Accountability
Performance Excellence/CDHA
M
M
Pg. O
Mar
2014
% of two client identifiers checked before
intervention or service provided
- Patient Fall Rate per month
Two client identifier
Feb
2014
M
Jan
2014
100%
Dec
2013
Chart
Audit
PSRS
Nov
2013
M
Oct
2013
100%
Sep
2013
Chart
Audit
Aug
2013
M
Chart
Audit
Jul
2013
100%
100%
100%
ICP
HH
audit
Jun
2013
Frequency
Q
Q
Q
Infection Control Rates (if applicable)
Hand Hygiene overall compliance
HH compliance before patient contact
HH compliance after patient contact
Documented Transfer of Information
(compliance to standard process for
area))
Episodic Care
To community based care
End of Service
Medication Reconciliation
- Med Rec Compliance Rates (if
applicable)
Falls Prevention (ROP)
- % of Falls Observation Completed
May
2013
Target
13/14
80%
75%
80%
Measures
A-Annually
B–Biannually
Q–Quarterly
M-Monthly
Trending Unfavourably
Apr
2013
Working Towards Goal
ELOS (days)
At Goal
Legend – Frequency of Data Collection
Quality & Patient Safety Team Scorecard
Data Source
Example of a
Sustainability
Innovating Health & Learning
Transformational Leadership
Patient/Family/Client
Complaints/Compliments
(date reviewed by team)
Patient, Family or Client Engagement
PSRS
Absenteeism (illness) FTEs
HSM
% of employees and physicians
responding positively to leadership
survey questions
% of staff, management and physician
responding positively to accountability
survey questions
% of staff completing front line
leadership program
# Inter-professional learning
opportunities
% staff completed required annual
competencies
% staff completed required annual
patient safety education
% staff completed required hand
hygiene education
% staff completed required hand O&HS
education
No show rates
Cancellations
Wait list times
Performance Excellence/CDHA
M
YES
M
Q
PI
20%
q2
years
PI
10%
q2
years
LMS
A
HSM
Q
LMS
100
A
LMS
100
A
LMS
100
A
LMS
100
A
Q
Q
Q
Pg. O
Mar
2014
Feb
2014
Jan
2014
Dec
2013
Nov
2013
Oct
2013
Sep
2013
Aug
2013
Jul
2013
Jun
2013
May
2013
Apr
2013
Frequency
Target
13/14
ELOS (days)
Data Source
Measures
Guidelines for Scorecard







The scorecard is to be used in conjunction with action template.
The purpose of the scorecard is to:
o align operational related team goals with Capital Health’s 2013 milestones and 2016 strategic goals
o track trends for improvement in your care/service area
o track and trend compliance to best practice, patient safety and accreditation Required Organizational Practices (ROPs)
o track and trend adverse events prevalence and or incidence of ie falls, pressure ulcers, medication reconciliations;
infection control measures; etc.
The scorecard is to be populated monthly, quarterly or annually depending on the indicator and availability of data.
The co-leads or those delegated by the co-lead are accountable for populating the scorecard.
The scorecard should be regularly discussed at the Q& PS team members.
Actions need to be taken to investigated and address concerning trends in indicators.
To be used as evidence for development of a quality improvement action plan and quality initiatives.
Instructions for Scorecard
1. Prior to use, please review Capital Health’s 2013 milestones, 2016 Strategic goals, patient safety indicators, Accreditation ROPs
and your program goals
2. Consider areas and opportunities of interest for quality improvement
3. Referring to the Data Navigation Guide for details of where and how to obtain data
4. Populate the Scorecard on a monthly, quarterly or annual basis depending of the frequency of data collection for each indicator
5. Track trends
6. Implement strategies for improvement based on evidence using the Action Template
Data Source Legend
IPC- Infection & Prevention Control CA- Chart Audit PI- Performance Indicators PSRS- Patient Safety Reporting system
HSM- Health Services Manager LMS- Learning Management System
Performance Excellence/CDHA
Pg. O
Performance Excellence/CDHA
Pg. O