Transforming Person Centered Health Care
Infection Control Rates
MRSA # carriers on unit
MRSA # of transmissions per month
New cases of c. diff on unit per month
- VRE # carriers on unit
-VRE # of transmissions per month
- Surgical infection rates (if applicable)
Hand Hygiene (HH)– overall compliance
- HH compliance before pt contact
- HH compliance after pt contact
Documented TOA or TOI (compliance)
- TOA shift to Shift
- TOA Unit to Unit (includes episodic care)
Pressure Ulcer Prevention (ROP)
- Braden Scale (on admission)
Compliance Rates
- Pressure Ulcer Prevalence Rates
Medication Reconciliation
- Med Rec Compliance Rates
- Unintentional Discrepancies (if applicable)
- Undocumented Intentional (if applicable)
- Success Index (if applicable)
Falls Prevention (ROP)
- % of Falls Assessment Completed
- Patient Fall Rate per month
- % of falls causing injury
VTE Prophylaxis Ordered ( PPO )
Wait time (if applicable)
Version 2 updated May 2013
IPC
IPC
IPC
IPC
IPC
IPC
IPC
IPC
IPC
IPC
CA
CA
CA
0
M
M
M
M
M
M
Q
Q
Q
100
100
M
M
0
0
100
CA
M
M
CA
CA
CA
CA
100
0
0
M
M
M
M
CA
CA
CA
CA
PI
100
M
M
M
Q
Q
Mar
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
Measures
A-Annually
B–Biannually
Q–Quarterly
M-Monthly
Trending Unfavourably
Baseline
Working Towards Goal
Data Source
At Goal
Legend – Frequency of Data Collection
Feb
2014
Example of a Quality & Patient Safety Team Scorecard
Innovating Health &
Learning
Transformational Leadership
Citizen Engagement &
Accountability
HSM/
PSRS
HSM
Y/N
Absenteeism (illness) FTEs
HSM
Q
# Inter-professional learning
opportunities
# (%) staff completed required annual
patient safety education
# (%) staff completed required annual
hand hygiene education
# (%) staff completed required annual
O&HS education
Version 2 updated May 2013
90%
90%
↑10
%
A
A
A
Q
PI
↑20
%
A
PI
↑20
%
A
LMS
A
HSM
Q
HSM
A
LMS
A
LMS
A
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
Patient Experience Survey
- Inpatient
- Ambulatory
-% of patients responding positively to
decision making survey questions
Patient/Family/Client
Complaints/Compliments
Patient, Family or Client Engagement
% of employees and physicians
responding positively to leadership
survey questions
% of staff, management and physicians
responding positively to accountability
survey questions
# (%) staff completing front line
leadership program
PI
HSM
HSM
PI
Baseline
Data Source
Measures
Sustainability
Readmission Rate
% of patients discharge by 1100 AM
ALC days
Case Mix Group – Typical (# days)
CMG#
CMG #
CMG #
PI
PI
PI
ALOS/ELOS/TARGET
PI
PI
PI
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
Baseline
Data Source
Measures
Q
Q
Q
Q
Q
Q
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 ,
Patient Experience surveys, Employee and Physician Surveys and your program goals
2. Consider areas and opportunities of interest for quality improvement
Version 2 updated May 2013
3.
4.
5.
6.
Referring to the Data Navigation Guide for details of where and how to obtain data
Populate the Scorecard on a monthly, quarterly or annual basis depending of the frequency of data collection for each indicator
Track trends
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
Version 2 updated May 2013