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Measure What Matters Clinical Value CompassBalanced Scorecards

Microsystem Dashboards

Unit Name Date:

Organization Name:

Aim: Provide a clear path forward to identify key measures to track unit performance in real time and over time: Patient Outcomes (Clinical Value Compass)

Microsystem Performance (Balanced Scorecard)

Microsystem Dashboard/Instrument Panel ( and )

Linkage to Organization Strategy (Cascading Measures)

Background:Organized data displays provide feedback on system performance. Key measures which reflect the purpose and goals of the microsystem include measures regarding population and/or subpopulation outcomes (e.g. clinical value compass), and system performance measures (e.g. balanced scorecard) both of which reflect microsystem results toward desired outcomes. The unit dashboard/instrument panel provides a method to monitor a blend of current indicators (clinical value compass and balanced scorecard) of a microsystem to provide real time indications over time on how the unit is performing. It is important to remember that the microsystem level dashboard/instrument panel variables can change as improvements, priorities and process measures change.

Path Forward: Create Clinical Value Compass

Create Balanced Scorecard

Determine Organization’s Strategic Measures

Create Microsystem Dashboard/Instrument Panel

Cascading Measures

© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden Adapted July 2007 Vermont Oxford Network Page 1

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Functional

Patient/Family Satisfaction

Cost

Biological/Clinical

Use Key Value Compass and Key Balanced Scorecard Measures to create your dashboard

© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden/ Adapted July 2007 Vermont Oxford Network Page 2

Create clinical value compass (unit of analysis if patients) Whole population Subpopulation Disease specific subpopulation Individual patient

Your microsystem dashboard/instrument panel

* Recommend to track data over time (run charts, control charts, p-charts)

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Core Processes

Customer Satisfaction

Innovation and Learning

Financial

Use Key Value Compass and Key Balanced

Scorecard Measures to create your dashboard

© 2007 Trustees of Dartmouth College, Godfrey, Nelson, Batalden/ Adapted July 2007 Vermont Oxford Network Page 3

Create your balanced scorecard (unit of analysis is microsystem)

Determine where the 7 NIC/Q Themes Fit:SafeTimelyEffectiveEfficientEquitablePatient CenteredSocially Responsible

Determine macrosystem and mesosystem strategic goals

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Learning and Growth Aim: Implement/Continue Best Practices

Measure: 1. Establish Kangaroo Mother Care

Program 2. Transition Feeding Protocol 3. O2 Sat monitoring feedback to staff 4. Staffing Nurses from System partner in

Oregon Tracking Chg RN w/o assignment Tracking surgery days/off unit

procedures Participation in LIC

5. Nurse Extern/Intern /Fellowship

Programs 6. Developed Foundation /Funding for

staff to attend Education/conferences

Action plan:

Financial Performance Aim: Acheivement of NICU Net Operating Income as budgeted for 2007 —roll up to PAMC

Measure: 1. Patient days/volumes 4. Labor costs 2. Revenue 5. Transfers 3. Costs/stat (UOS) 6. LOS

Action plan: 1. Review of Financial performance monthly with NICU Finance Management meeting (4th Wed) . Includes supervisors, lead RT, educator, and ACNE for the Children’s Hospital.

2. Inventory and accounting review (supervisors/manager) 3. Labor cost /productivity review bi-weekly with ACNE (Monthly with supervisors)

NICU Scorecard Key Processes Aim: Culture of Safety: Safe/Timely/Effective/Efficient/Equitable/Patient and Family

Centered Measure: 1. Establish Quality & Safety

Council w/regular meetings 2. Culture of Safety Survey –share

results and develop action plan 3. Review UOR’s monthly; follow-

up with actions 4. Reviewing “Suggestion Box”

concerns . 5. Review JCAHO preparedness 6. Review Emergency Preparedness

plans

1. Established January 2007; meeting weekly

2. In process 3. Monthly reviews; forwarding

issues and concerns to appropriate persons or groups to follow-up

4. Create a template for feedback to those who submit suggestions/concerns

5. Establish report for JCAHO readiness

6. Review/revise and update current plan

Action plan:

See #4,5,6

C u s t o m e r S a t i s f a c t io n

A im : P a t i e n t /E m p lo y e e /P h y s i c ia n S a t i s f a c t i o n : L ik e l ih o o d o f R e c o m m e n d in g P r o v id e n c e t o O th e r s ;

M e a s u r e : H Y B .c o m f o r N I C U s p e c i f i c r e s u l t s K e n e x a E m p lo y e e O p i n io n S u r v e y

A c t io n p la n : I m p r o v e s c o r e s / d e v e lo p f o l lo w - u p D / C p h o n e

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