Performance Indicators System Study in Healthcare

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Patient Population

The outcome measures apply to an adult mental health facility with two units, unit Bravo and unit Charlie. The target patient population is adult patients diagnosed with mental illness.

The Performance Data Scorecard

Measure	Outcome	Drivers
Employee empowerment	– A quality workforce – Quality workplace conditions – Improved clinical skills	– Communication – Self/performance management – Reward/recognition – Training & development
Customer loyalty	– Timeliness – Quality – Service/collaboration – Patient/family involvement	– Timely care delivery – Patient safety/patient-centered care – High responsiveness – Customer satisfaction
Operational effectiveness	– Accurate data collection – Accreditation	– Data collection systems/tools – Length of stay – Readmission rate
Financial viability	– Cost savings – Timely payments	– Inventory turnover – Net revenue increase

Outcome Measures

Performance – this indicator measures the extent to which the care rendered meets patient, family, or provider expectations. The selected outcome measures for this indicator include:

The proportion of clients/families satisfied with the care/service as measured with 30-day user appraisals.
The percentage of acute referrals treated within 24 hours.

Quality – because of the refractory nature of mental illnesses, hospital readmission rates, and committals are indicators of the quality of care provided. Its outcome measures include:

The total readmissions at the two units within a 30-day post-discharge period as a percentage of psychiatric cases handled per annum.
The number of cases put under involuntary committals or seclusion relative to the total hospitalizations per year.

Patient safety – adverse events, suicides, and homicides can indicate the patient risks associated with an intervention. The two selected outcome measures for this indicator include:

The number of clients under electroconvulsive therapy (ECT) who get fractures, tooth loss, and myocardial infarctions
The number of client-reported medical error cases received by the case manager in 30 days

Employee engagement – effective engagement programs enhance staff motivation, retention, and capacity, translating into greater unit efficiency. The outcome measures for this indicator include:

The proportion of the institution’s annual budget spent on staff engagement activities
The overall staff turnover rate per annum

Necessary Processes

Performance

The identified outcome measures of performance are patient/family satisfaction rates and referrals assessed per day. First, service evaluations by the mental health consumers indicate the client’s “experiences with services, service providers, and service coordination” or satisfaction levels (McEwan & Goldner, 2001, p. 4). Therefore, higher levels of satisfaction indicate performance improvement, i.e., the care provided meets the needs and expectations of the patient/family. Second, waiting time is a good indicator of healthcare accessibility. Quick intervention can prevent exacerbation of mental illness. Therefore, the rate at which acute referrals are assessed determines care accessibility, a core dimension of performance.

Quality

Quality also has two outcome measures, i.e., readmission rate and incidence of involuntary committals. The high 30-day readmission rate implies poor quality care, inadequate care continuity, or inefficient post-discharge support (McEwan & Goldner, 2001). On the other hand, the use of involuntary committals or restraints suggests an inability to provide appropriate/quality care and inadequate staff skills to supervise patients.

Patient Safety

The identified outcome measures for patient safety are the adverse events experienced by clients and medical error rates. Medical complications such as “myocardial infarction, bone fracture, aspiration, and teeth damage” are linked to the use of ECT in patients diagnosed with mental illnesses (McEwan & Goldner, 2001, p. 7). Thus, these complications drive patient safety measures. Additionally, medical errors arising from the adverse effects of neuroleptic prescription, administration, or non-adherence can be a good outcome measure for patient safety.

Employee Engagement

The two outcome measures for employee engagement include staff engagement spending and turnover rates. First, a substantial budgetary allocation made to areas such as employee training and development, compensation, and good performance awards to boost morale and capacity will indicate adequate employee engagement. Secondly, engaged employees are less likely to leave an institution than disengaged ones (Lockwood, 2007). Therefore, the staff turnover rate will indicate the efficiency of the current engagement programs.

Additional Indicators

Care continuity is a vital indicator of intervention efficiency in mental care settings. It can be described as the capacity to offer “uninterrupted, coordinate care” across institutions/settings over a given period through case management (McEwan & Goldner, 2001, p. 8). One outcome measure for care continuity is the number of clients received by case managers after discharge. The rationale here is that continuity methods help support coordinated care for clients with complex needs. A streamlined continuity of care also reduces emergency room visits. Therefore, the nurse leader could monitor the number of ER visits made by patients diagnosed with mental illness annually. High ER visits would indicate a disruption in the continuity of care or inadequate social support.

A post-discharge follow-up of patients with chronic psychiatric episodes is another outcome measure for the continuity of care. A responsive support mechanism is required to preclude 30-day readmissions after discharge. Therefore, ensuring high psychiatric service contacts with vulnerable client groups would enhance treatment outcomes. Conversely, a high number of cases lost to follow-up is high would indicate a poor tracking of patients or care continuity breakdown.

Another core measure for this indicator is the integration of persons diagnosed with mental illness into the community upon discharge. Inpatient clients receiving care at tertiary facilities should be integrated into their rural communities after discharge. A successful return and integration of these persons is a good measure of community/family capacity to support the patients and collaborate with caregivers. Therefore, monitoring how well the clients integrate back into the community will enable the nurse leader to measure the efficiency of continuity of care mechanisms.

Advantages

Implementing a performance data scorecard in a healthcare setting comes with multiple benefits. First, a scorecard gives a framework for aligning strategic objectives with patient-centered care. According to Inamdar and Kaplan (2002), a balanced scorecard enables institutions to translate their “missions, values, visions, and strategies” into performance measures in the areas of finance, staff development, internal processes, and client needs (p. 184). The performance scorecard created will enable the mental health unit to actualize its goals through concrete performance measures in the domains of quality, employee engagement, performance, and patient safety. Huang, Chen, Yang, Chang, and Lee (2004) write that a scorecard operates as a “strategic management system” with clear implementation processes (p. 144). Therefore, the second benefit of the scorecard is that it will enable the organization to adopt strategic processes and activities to support its operations in the four areas.

Third, the scorecard created will enhance multidisciplinary communication and collaboration with the Bravo and Charlie units. Using this scorecard, each individual within the units will assume a certain responsibility in implementing the strategy. Therefore, it will support greater accountability through improved performance comparisons between departments within the institution. Fourth, the assessment of the outcomes and drivers would require a reporting system to evaluate the progress. Thus, it will foster continuous improvement by creating a learning culture in the organization. Fifth, the scorecard will guide resource allocation towards interventions that enhance the accessibility of mental health services, continuous quality improvement, regulatory compliance, and patient safety, among others (Inamdar & Kaplan, 2002).

Current Trends

In healthcare, employee engagement is associated with improved “patient satisfaction, safety, and quality” (Lowe, 2012, p. 31). One current trend is the increasing role of leadership/supervision in a top-down implementation of engagement programs. In this case, the top management, e.g., hospital managers, spearhead continuous intrinsic engagement efforts, including training and development, to enhance efficiency and reduce nursing turnover. The various teams/employees are taught how their efforts contribute to the realization of organizational goals. Extrinsic engagement approaches, such as monetary rewards, workload balance, pay increases, and promotions, are also used to achieve the same purpose.

The second trend relates to the growing focus on trust-building as the key to greater engagement levels. Hospital managers espouse “respect, fairness, and integrity” in their interaction with staff (Bulkapuram, Wundavalli, Avula & Reddy, 2015, p. 52). They build a culture of professional autonomy and evidence-based practice to build trust, which leads to positive employee experiences. Recent evidence indicates that healthcare institutions are increasingly empowering the middle-level managers to oversee the corporate strategy and promote effective personnel practices (Bulkapuram et al., 2015). The rationale for this trend is that an engaged staff shows trust towards the management and have higher job satisfaction than disengaged ones. To this end, the managers promote an atmosphere of openness and trust.

Employee Engagement and Healthcare Quality

A strong correlation exists between staff engagement levels and retention rates. Lowe (2012) found that, among engaged hospital staff, only 17% indicated the intent to leave their institution compared to 43% of the disengaged ones. Thus, higher engagement levels increase the retention of critical clinical staff that is needed to support quality care delivery. Further, staff engagement contributes to a healthy work environment. According to Roussel (2015), an environment of engagement can be characterized by a mutual reinforcement between “worker health and patient care quality” (p. 67). Therefore, hospitals with engagement (clinical training) programs provide a healthy work environment that supports evidence-based interventions.

Quality care delivery is one that centers on the patient. Providing patient-centered care indicates a hospital’s commitment to quality improvement and patient safety. One study found out that an engaged staff viewed the work environment as being patient-centered while disengaged employees viewed it as being less patient-centric (Lowe, 2012). Therefore, engagement improves the emotional state of the staff, motivating them to utilize personal resources to deliver patient-centered care. Another dimension of quality is patient safety. Employee engagement is associated with skill improvement through training and development. The engagement programs empower the clinical staff to perform better and avoid medication errors. It also builds a culture of collaboration and trust, leading to superior job performance.

Current Tools

Our hospital has adapted the Employee Engagement Survey (EES) tool to capture staff engagement data. The tool is based on the healthcare workplace framework of the Ontario’s Hospital Association (McEwan & Goldner, 2001). It captures engagement drivers as well as staff and institutional outcomes. Data related to workplace conditions, job attributes, and perceived management support are collected to inform the engagement strategy. Additionally, the questionnaire captures nurse outcomes such as employee safety, turnover rates, and performance. Therefore, this tool provides nurse leadership with comprehensive baseline data on several useful engagement drivers.

However, the tool omits data on patient-centered care delivery and safety. Patient-centered care and patient safety are indicators of the quality of care delivered. The exclusion of these two indicators results in insufficient data to evaluate the impact of engagement initiatives. Further, the hospital lacks an assessment tool for each engagement strategy. Consequently, it may be difficult for nurse leadership to determine the most effective approach between intrinsic and extrinsic engagement programs. Moreover, employee demographic characteristics, e.g., age and cultural background, may affect the effectiveness of an engagement strategy. Therefore, a tool that compares the efficacy of different engagement strategies applied to various employee groups would be more appropriate.

Improving Employee Engagement

Communication	Goals	Strategies	Evaluation	Timeline
	Establish employee briefing sessions	Biweekly face-to-face briefing sessions	Number of attendees	Oct. – Dec. 2016
	Build staff feedback mechanisms	Quarterly workshops	Quantity/quality of feedback received	Nov. 2016
	Provide all workers institutional emails/ access to PC	Formal induction Social media use	Number of users per month	Jan. 2017
Performance management	Create clear job descriptions for each position	Unit managers will ensure tasks match the position	Number of workload/burnout complaints	Feb. – Mar. 2017
	Each worker to have a personal development plan (PDP)	Unit managers will help each employee create a PDP	The proportion of employees with PDPs	Mar. – Apr. 2017
	Conduct regular PDP reviews	PDP review training for unit managers	Number of unit managers trained	May 2017
Reward/recognition	Recognition of outstanding staff in the annual event	Employee nomination of excellent performers	Number of employees recognized annually	Dec. 2016
Reward/recognition	Monthly non-monetary rewards	An employee of the month accolades	Number of recipients per annum	Jan. – Dec. 2017
Development opportunities	Talent & succession management	Identify emerging leaders for an annual succession development program	Number of employees trained annually	Jun. 2017
Development opportunities	Multidisciplinary training of staff	Establish multidisciplinary programs	The proportion of the staff trained annually	Nov. 2016 – Nov. 2017

Leadership Best Practices

Effective employee engagement has multiple benefits for the organization. Therefore, best practices in employee engagement are important. The top management should support staff engagement as a strategic priority for the institution. It should be explicitly included in the institution’s strategic plan and adopted at all levels of the organization. Another best practice entails a top-down communication of the organizational mission, objectives, and principles to support engagement initiatives. A shared vision has a unifying effect on the staff, contributing to greater staff participation (Sullivan, 2013). Staff involvement through feedback mechanisms is also considered an engagement best practice. The worker’s voice or input can be sought through surveys, debates, and discussions (Lockwood, 2007). Such approaches empower employees to share their ideas with management about organizational goals and strategies.

Enhanced accountability within the organization is also associated with high engagement levels (Lockwood, 2007). Demanding a high degree of accountability at all managerial levels influences team engagement and performance. In such cases, the line managers apply balanced scorecards to assess performance and “align the systems” with incentive initiatives (Lockwood, 2007, p. 6). The leadership should also implement staff-focused policies to cater for the social and emotional needs of the workers. Caring for workers increases staff motivation and engagement.

References

Bulkapuram, S., Wundavalli, L., Avula, K., & Reddy, K. (2015). Employee Engagement and its Relation to Hospital Performance in a Tertiary Care Teaching Hospital. Journal of Hospital Administration, 4(1), 48-57.

Huang, S., Chen, P., Yang, M., Chang, W., & Lee, H. (2004). Using a Balanced Scorecard to Improve the Performance of an Emergency Department. Nursing Economics, 22(3), 140-148.

Inamdar, S.N., & Kaplan, R.S. (2002). Applying the Balanced Scorecard in Healthcare Provider Organizations. Journal of Healthcare Management, 47(3), 179-196.

Lockwood, R. (2007). Leveraging Employee Engagement for Competitive Advantage: HR’s Strategic Role. SHRM Research Quarterly, 1, 1-12.

Lowe, G. (2012). How Employee Engagement Matters for Hospital Performance. Healthcare Quarterly, 15(2), 29-40.

McEwan, K., & Goldner, E. (2001). Accountability and Performance Indicators for Mental Health Services and Supports: A Resource Kit. Ottawa: Health Canada.

Roussel, L. (2015). Management and leadership for nurse administrators. Burlington: Jones and Bartlett Learning.

Sullivan, E. (2013). Effective leadership and management in nursing. New York: Prentice Hall.

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