implementing key performance indicators key performance indicators the nursing contribution...
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Implementing Key Performance IndicatorsThe Nursing Contribution
Implementing
Key Performance IndicatorsThe Nursing Contribution
Mary Duff, Director of Nursing, Adjunct Associate Professor of Nursing, UCD.
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Mission StatementThe 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.
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Board of DirectorsProf. Noel Whelan
Board Sub Committees
o Financeo Audito Remnuerationo Mission
o Board Nominationo Risk Advisory Committeeo Clinical Governance Committee
Group Chief ExecutiveMr. Nicholas JermynGroup ExecutiveGroup Management
Co-ordination Initiatives
o Finance o HRo ICTo Health & Safety
o Quality Risk and Consumer Affairso Internal Audito Clinical Audit
Group Medical BoardProf. Michael Keane
o Anaestheticso Professional Unito Ethics & Research
o Medicineo Surgeryo Radiologyo Pathology
St Vincent’s University Hospital
Acting CEO/General Manager Mr. Bill Maher
St Michaels Hospital
General ManagerMr. Seamus Murtagh
St Vincent’s Private Hospital
CEOMr. Michael Redmond
Dublin Academic Medical Centre (DAMC)
SVHG Organisational Structure
SVUH Executive CouncilSVUH Executive Council
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SVUH Key Figures 2010
167,808Radiology
61,265Day Case Activities15,040Total Admissions
6,326,493Pathology Tests
102.20%% Occupancy Rate
42,139Emergency Dept Attendances
10.4Average Length of Stay80.30%Day Case Rate
128,599Out Patient Attendances (new & review)451Average Daily Census515Number of Beds
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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
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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 MeetingsHeads of Departments MeetingsSpecialty Specific Admission Group MeetingsStaff Briefings Newsround – in HandoutMonthly Monitoring Meetings with the HSE Network Manager
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Implementing Key Performance IndicatorsThe Nursing Contribution
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
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Implementing Key Performance IndicatorsThe 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
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Implementing Key Performance IndicatorsThe 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
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Implementing Key Performance IndicatorsThe Nursing Contribution
Mandatory training 2010
Supporting Details Current Future
Current Value 50%
Target: XX% compliance with training requirements per ward/nursing area
Trend:
There is over 50% compliance in all areas except Hand Hygiene at48%, 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
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Implementing Key Performance IndicatorsThe Nursing Contribution
Current Nursing KPIs - 2011
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Heights, Weights and MUST
640846510085
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Implementing Key Performance IndicatorsThe Nursing Contribution
Heights, Weights and MUST
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Pressure Ulcers
43210
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Implementing Key Performance IndicatorsThe Nursing Contribution
Pressure Ulcers
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Falls
848377
760
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Implementing Key Performance IndicatorsThe Nursing Contribution
Falls
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Implementing Key Performance IndicatorsThe Nursing Contribution
Falls
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Falls
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Pain Assessment
5009951100
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Pain Assessment
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Implementing Key Performance IndicatorsThe Nursing Contribution
Hygiene Services
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Implementing Key Performance IndicatorsThe Nursing Contribution
Infection Prevention & Control
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Day Services (St Marks Ward)
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Implementing Key Performance IndicatorsThe Nursing Contribution
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 !
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Implementing Key Performance IndicatorsThe Nursing Contribution
Clinical Information Management System
(CIMS)
SVUH Current Position
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Thank You !
Implementing Key Performance IndicatorsThe Nursing Contribution