data obtained through performance management and quality improvement to understand the needs of the organization and the patients.7 Performance management is a goal setting and checking process


used in monitoring and achieving established goals. The goals set in performancemanagement help achieve the organization’s goals by ensuring optimization of its performance. Performance management can be used throughout an organization tomeasure numerous functions. Alignment of lower level systems in an organization, such as service lines or patient care units, with the overall goals of the organization result in an improvement of the organization’s total performance.1 Organizations typically set goals at the organizational level


based on areas where they are accountable, and these are translated to goals at the service line, unit and even personnel level. Any goal in the organization should tie to the organiza- tional-level goals for continuity and to help drive organiza- tional goals. For example, an organization may have to meet federally mandated quality goals as an overall organizational goal. Organizational goals tend to be broad, and when one dissects what “federallymandated quality goals” actually means, it becomes evident that this can, and often does, encompass Hospital Core Measures, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores, state and federal requirements, The Joint Commission’s National Patient Safety Goals, and any other goal that the hospital is responsible for meeting.8


Establishing a Score Card Performance management results in a lot of data, and this data must be shared. One of the easiest ways to share information is using a “PerformanceManagement Balanced Score Card.” The data are color-coded, with red for problem areas and green for areas meeting set baselines. Depending on the area of measurement, some scores will need to be higher than the baseline, and some will need to be lower.


HOSPITAL SCORECARD EXAMPLES


Area of Measurement


Number of patients not cor- rectly identified (Joint Commission Core Measures)


Discharge instructions provided (HCAHPS Process of Care Measures)


30-day mortality rate for pneu- monia (shown as survival rate) (HCAHPS outcome measure)


Responsiveness of hospital staff (HCAHPS)


Baseline Quarter 1


Quarter 2


Quarter 3


Quarter 4


0 26 10


As a nurse new to the unit, you notice that there are bulletin boards in the break room that show performance management data for the unit. Each display designates what the data should be versus what they actually are. You notice that the incidence of failure to rescue a pa- tient in acute distress is at five for the year but should be zero. You also notice mortality on the unit is higher than it should be.


1. As a nurse, you know that performance manage- ment is:


a. A process by which organizations monitor import- ant aspects of programs, systems and processes


b. A process by which goals are set and methodolo- gies are used to check the organization’s progress routinely toward these goals


c. The use of Plan-Do-Check-Act (PDCA)


d. A process derived from medical or clinical guide- lines


2. Why is it important that the data is in the break room?


a. To show the unit staff where they are versus where they want to be


b. To demonstrate the financial impact of problems on the unit


c. To demonstrate a management measure for the unit


d. To demonstrate a social determinate of health


3. One of the main ways to determine if something is being done correctly is to:


a. Monitor a process randomly b. Address the problems that arise c. Measure it against preset goals at set intervals d. Listen to staff complaints


4. Failure to meet rescue goals for the floor is a problem because:


a. People may be dying unnecessarily.


b. The unit staff may not be properly trained to assess changes in patient conditions.


c. The unit may be short of staff. d. All of the above


92.09% 80% 88% 95% 90%


88.26% 91.5% 89% 94% 94.8%


85.70% 35% 40% 56.7% 60% 2016 • NURSE.com/Careers 45


Answers


1. B—Performance management is a process by which goals are set and methodologies are used to routinely check an organization’s progress toward these goals.


2. A—It shows the unit staff where they in comparison to the goals they want to reach.


3. C—To determine if something is being done correctly, it can be measured it against preset goals at set intervals.


4. D—All of the above can cause failure to meet rescue goals on a unit.


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