Implementing Key Performance IndicatorsThe Nursing Contribution

Implementing

Key Performance IndicatorsThe Nursing Contribution

Mary Duff, Director of Nursing, Adjunct Associate Professor of Nursing, UCD.

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.

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

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

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 MeetingsHeads of Departments MeetingsSpecialty Specific Admission Group MeetingsStaff Briefings Newsround – in HandoutMonthly Monitoring Meetings with the HSE Network Manager

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

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

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

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

Implementing Key Performance IndicatorsThe Nursing Contribution

Current Nursing KPIs - 2011

Heights, Weights and MUST

640846510085

Implementing Key Performance IndicatorsThe Nursing Contribution

Heights, Weights and MUST

Pressure Ulcers

43210

Implementing Key Performance IndicatorsThe Nursing Contribution

Pressure Ulcers

Falls

848377

760

Implementing Key Performance IndicatorsThe Nursing Contribution

Falls

Implementing Key Performance IndicatorsThe Nursing Contribution

Falls

Falls

Pain Assessment

5009951100

Pain Assessment

Implementing Key Performance IndicatorsThe Nursing Contribution

Hygiene Services

Implementing Key Performance IndicatorsThe Nursing Contribution

Infection Prevention & Control

Day Services (St Marks Ward)

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 !

Implementing Key Performance IndicatorsThe Nursing Contribution

Clinical Information Management System

(CIMS)

SVUH Current Position

Thank You !

Implementing Key Performance IndicatorsThe Nursing Contribution