Implementing Key Performance Indicators The Nursing Contribution
Mary Duff, Director of Nursing, Adjunct Associate Professor of Nursing, UCD.
Implementing Key Performance Indicators The Nursing Contribution
Mission Statement The values underlying the philosophy of St Vincent’s Healthcare Group (SVHG) in relation to our care of patients and staff are those of human dignity, compassion, justice, quality and advocacy, which are based on the mission and philosophy of the Religious Sisters of Charity, our shareholders. We strive to maintain excellence in clinical care, education and research. We will continue to develop the Healthcare Group in line with the above principles and with our responsibilities to the wider Irish healthcare system.
SVHG Organisational Structure Board Sub Committees o o o o
Finance o Board Nomination Audit o Risk Advisory Committee Remnueration o Clinical Governance Committee Mission
Group Management Co-ordination Initiatives o o o o
Finance HR ICT Health & Safety
Dublin Academic Medical Centre (DAMC)
Board of Directors Prof. Noel Whelan
Group Chief Executive Mr. Nicholas Jermyn Group Executive Group Medical Board Prof. Michael Keane o o o o
o Quality Risk and Consumer Affairs o Internal Audit o Clinical Audit
Medicine o Anaesthetics o Professional Unit Surgery Radiology o Ethics & Research Pathology
St Vincent’s University Hospital St Michaels Hospital General Manager Mr. Seamus Murtagh
St Vincent’s Private Hospital Acting CEO/General Manager Mr. Bill Maher
SVUH Executive Council SVUH Executive Council
CEO Mr. Michael Redmond
SVUH Key Figures 2010 Number of Beds
515
Average Daily Census
451
Out Patient Attendances (new & review)
128,599
Total Admissions
15,040
Day Case Activities
61,265
Day Case Rate
80.30%
Average Length of Stay
10.4
Pathology Tests
6,326,493
Radiology
167,808
% Occupancy Rate
102.20%
Emergency Dept Attendances
42,139
Benefits of Performance Management The Board has recognised effective performance management has many benefits: – – – – – – –
Improve patient care Improve productivity and efficiency Clarity and ownership of issues across the organisation Accountability, and with it responsibility Improved governance and management of risk Resilience to external scrutiny Clarity and leadership for staff in terms of expectations
SVUH Performance Management Programme SVUH KPI Set • SVUH corporate KPI set is reviewed annually with some indicators being dropped when targets have been achieved/new ones added to reflect priorities • KPI’s are discussed at all fora throughout SVUH: Senior Management Meetings Heads of Departments Meetings Specialty Specific Admission Group Meetings Staff Briefings Newsround – in Handout Monthly Monitoring Meetings with the HSE Network Manager
Joint Commission International (JCI) Mission statement: “To improve the Safety and Quality of care in the International community through the provision of Education, Publications, Consultations, Evaluations and Accreditation services”
• Focus on clinical & managerial monitors (KPIs) • Use of standards Implementing Key Performance Indicators The Nursing Contribution
Journey taken by Nursing Executive Team – One of 7 Team Based Performance Management pilots in SVUH 2006 – 2OO7 – Management by Objectives 2006 – 10 + 5 Objectives 2007 – Nursing Department KPI Set 2008 – ICU, Theatre, HSSD, Infection Prevention & Control, specialties/clinical areas
Implementing Key Performance Indicators The Nursing Contribution
Healthstat: What are the core, nursing influence-able metrics? • OPD Waiting times • In-patient Waiting times • Delayed Discharges • Staff WTE Variance from Staff ceiling • % of staff hours lost due to absenteeism • Day case rates • ED admission waiting times
Implementing Key Performance Indicators The Nursing Contribution
Mandatory training 2010 Supporting Details
Current Current Value
Target: XX% compliance with training requirements per ward/nursing area
Future
50% Trend:
There is over 50% compliance in all areas except Hand Hygiene at 48%, however sessions are taking place over the coming weeks. There should be an increase in compliance in the next quarter.
How to make a metric • Number of Mandatory courses for nurses • Multiplied by the number of nurses • Gives the denominator • Measure the number of completions for the numerator
Implementing Key Performance Indicators The Nursing Contribution
Current Nursing KPIs - 2011
Implementing Key Performance Indicators The Nursing Contribution
Heights, Weights and MUST 85 65 0
100 84 64
Heights, Weights and MUST
Implementing Key Performance Indicators The Nursing Contribution
Pressure Ulcers 0 2
1 3 4
Pressure Ulcers
Implementing Key Performance Indicators The Nursing Contribution
Falls 0
76
77
83 84
Falls
Implementing Key Performance Indicators The Nursing Contribution
Falls
Implementing Key Performance Indicators The Nursing Contribution
Falls
Pain Assessment 51 0
100 99 50
Pain Assessment
Hygiene Services
Implementing Key Performance Indicators The Nursing Contribution
Infection Prevention & Control
Implementing Key Performance Indicators The Nursing Contribution
Day Services (St Marks Ward)
Critical Success Factors • • • • • • •
SVHG 14 Strategic Goals + Objectives DATH’s Nursing Strategy (2009 - 2012) Management by Objectives Accreditation (JCI, HIQA,) Align with Healthstat Education & Training – ADONs Strong Leadership + Communication from the Top down ! Implementing Key Performance Indicators The Nursing Contribution
Clinical Information Management System (CIMS) SVUH Current Position
Implementing Key Performance Indicators The Nursing Contribution
Thank You !
Implementing Key Performance Indicators The Nursing Contribution
