Nursing scorecard implementation and metrics

Introduction

Performance scorecards provide a straightforward means of integrating metrics into a healthcare organization’s strategic planning. Scorecards are most effective when they have a clear purpose, identifying specific patient populations and outcome measures. According to Baker (2015), “savvy organizations select the best metrics to track that are appropriate to what the organizational staff members wish to measure,” which could include specific issues like patient vital signs or patient satisfaction survey outcomes (p. 224). Moreover, performance scorecards need to be simple, kept on a manageable scale so that the data gleaned can be readily communicated to inform organizational practices, policies, and procedures (Hansel, n.d.). The following performance scorecard includes three core categories including performance, quality, patient safety, and employee engagement, all while focusing on addressing the needs of a specific patient population: adults over the age of 65 who have been diagnosed with Type II Diabetes.
GOAL
TARGET
KEY STAFF
REVIEW FREQUENCY
JAN 2018
FEB 2018
MAR 2018
APRIL 2018
Performance
Readmission
15%
Monthly
25%
22%
23%
27%
Mortality
10%
Monthly
15%
10%
5%
10%
Quality
Lifestyle counseling
99%
Monthly
80%
82%
79%
82%
Complications
15%
Monthly
18%
22%
23%
19%
At-Home Testing
99%
Monthly
85%
89%
90%
92%
Patient Perceptions
90%
Every three months
90%
85%
89%
90%
Patient Safety
Equipment Failure
5%
Monthly
2%
5%
8%
10%
Voluntary Error Reports
10%
Monthly
5%
2%
6%
10%
Patient Error Reports
5%
Every three months
3%
8%
12%
8%
Employee Engagement
Survey data
90%
Every three months
85%
80%
82%
80%
Outcome Measures

Performance
The outcome measures for performance will include mortality rates within the patient population and readmission rates.

Quality
Performance outcomes for quality include number of patients receiving at-home testing equipment for self-monitoring, number of patients receiving lifestyle counseling and preventative care, complications related to Type II Diabetes, and patient perception of care.

Patient Safety
Patient safety outcomes include number of equipment and/or test failures, voluntary error reporting from staff, and patient-reported errors in care.

Employee Engagement
Employee engagement outcomes include surveys that can be quantified.

Driving Outcomes Measures
Driving outcomes measures requires a combination of leadership best practices and evidence-based practice with the patient population.

Performance

To drive outcomes measures in performance, nurses need to monitor several factors at once, including patient readmission rates and mortality rates within the patient population. An additional indicator that would be important would be one derived from Medicare, such as total cost expenditures per patient. To drive outcome measures, it would be important to pay attention to the other performance metrics including those that address quality of care such as lifestyle counseling and preventative interventions for at-risk patients. The workplace environment, job characteristics, and institutional supports all contribute to measurable performance outcomes.

Quality

Driving outcomes measures to improve quality of care requires a dependence on evidence-based practice, a reinvigoration of nurse training, and additional indicators to monitor outcomes such as patient family surveys to evaluate their perceptions of care quality. Quality of life factors including mental health and social functioning would also be additional indicators nurses could use on a qualitative level, with quantitative indicators including vital signs measurements including BMI/weight-related issues and heart health measures. Another additional indicator would be to quantify numbers of direct patient referrals: the critical word-of-mouth marketing the healthcare organization depends on for its long term success and financial performance. Driving quality of care, nurse leaders can make changes to institutional policies, technologies, and job characteristics.

Patient Safety

Patient safety remains one of the easier outcomes measures to quantify. In addition to core indicators like equipment efficacy and error reporting, nurses can also drive outcomes through the implementation of a no-fault error reporting system, The no-fault error reporting system would encourage nurses to report errors immediately without fear of reprimand, allowing appropriate corrections to be made in a timely and honest fashion. Technology, organizational supports, and leadership drive patient safety outcomes.

Employee Engagement

Employee engagement is known to be a “prerequisite for high performance,” (Lowe, 2012, p. 29). Engaged employees increase overall job satisfaction rates, which means higher morale, commitment, camaraderie, reduced absenteeism, and reduced turnover rates. Therefore, to properly measure employee engagement, it is critical to operationalize the definition and construct different survey instruments and means of measuring engagement outcomes. Having individual interviews with employees is helpful, but primarily yields case-by-case qualitative data that is difficult to input into the balanced scorecard. Preferable for snapshots of performance data and for communicating to hospital administrators would be simpler, more straightforward metrics of assessing employee engagement. Exit interviews, surveys, and online questionnaires that are shorter and which encourage employee responses to be honest and forthcoming would all help administrators measure employee engagement systematically over time.

Scorecard Advantages

Although it includes several more performance outcomes than would be required, this scorecard nevertheless does focus on only four main areas including employee engagement, patient safety, quality of care, and performance measures. Each of these is then broken down into sub-categories with clearly defined measurable outcomes. The benefits of using this particular balanced scorecard include the following.

1. Data-Driven. This scorecard depends on measurable, quantitative outcomes. Even the surveys with patients and employees require measurable data outcomes that can be used to inform company policies and practices. In the evidence-based practice landscape, having data-driven performance outcomes is crucial.
2. Consistent. This scorecard includes multiple elements that all tie together to describe one single patient population: seniors who have been diagnosed with Type II Diabetes. Within this patient population, nurse administrators can then examine specific ways of improving performance outcomes in order to meet the self-defined objectives and goals of the organization.
3. Clear. This scorecard includes several metrics that clearly and accurately encapsulate what they intend to measure. For example, the equipment failures can be tabulated over the course of each month, as can mortality rates. These clearly defined performance indicators are measured using means that have strong internal validity, regardless of whether they can be applied to other patient populations.

Employee Engagement

Employee engagement, while not necessarily linked only to the target population, is nevertheless critical for enhancing performance outcomes. Some of the core elements of employee engagement include allowing pathways for active, earnest, and even anonymous employee feedback, and offering employees the opportunity to receive accurate and supportive feedback in return, overall happiness measures such as workplace satisfaction, relationships with colleagues and managers, and opportunities for personal and professional development. Alignment of professional goals with individual values, mental health and physical wellness, and ambassadorship are also employee engagement practices that can be used to directly improve performance outcomes (Shirar, 2017). Current trends in employee engagement include the standardization and operationalization of terms, altering organizational culture to stimulate employee engagement, and using a variety of tools and surveys for assessing whether employee engagement tactics and techniques are working.

Employee engagement is directly linked to healthcare quality for a number of reasons. First, engaged employees have a personal stake in performance outcomes, taking greater pride in their own performance not just because it reflects well on them but because they genuinely care about both individual patients and the organization as a whole. Second, healthcare quality depends on an engaged employee population because of factors like job satisfaction and low burnout rates. Employees that are working to the point of burnout will not only be less engaged psychologically and physically with their patients, but also more prone to errors, and less willing to communicate their concerns with an unsupportive team. Receiving recognition for good work, maintaining work-life balance, opportunities for job advancements and professional development, and other key trends will help to ultimately drive up patient care outcomes, quality of care, and perceptions of care quality.

Current tools in my organization adequately provide nurse leadership with data regarding employee engagement. For example, my organization uses established digital pulse surveys, which are “a great way to maintain a consistent pulse on the vibe in your office,” (Shirar, 2017, p. 1). Pulse surveys offer nurse managers a distinct advantage over longer format surveys, particularly in that nurses do not need to take much time out of their schedule to perform the pulse survey, and may be far more willing to answer a quick question or two instead of devoting much more time to a more involved instrument. Also, pulse surveys can potentially be more honest because they offer the chance for nurses to give off-the-cuff, instantaneous responses to questions related to leadership, patient safety, performance, and any other meaningful metric.

Another tool my organization uses to assess employee engagement is the scheduled interview and the scheduled performance review. One-on-one interviews provide the opportunity to create dialogue, and should ideally be a bilateral conversation rather than an asymmetrical conversation. Finally, my organization has a policy of providing exit interviews to discover what the organization can do differently to improve retention and to create a more harmonious work environment conducive to employee engagement and job satisfaction.

Plan to Improve Employee Engagement

Goals

The goals of an employee engagement improvement plan include reducing turnover and absenteeism rates, improving all measurable performance outcome goals including those related to readmission rates, cost of care, and patient mortality rates, and finally, improvements in employee job satisfaction.

Strategies

Specific strategies for improving employee engagement include role clarity, a collaborative workplace environment with a transformational leadership model, institutional supports for employee engagement such as opportunities for job advancement and career development, a respectful and non-punitive work environment that encourages error reporting, and a collaborative, team-based decision-making process.

Evaluation

The best means of evaluating employee engagement will include digital metrics that can be accessed on employee mobile phones and personal computers, which they can complete quickly and in their own time. In addition to digital surveys, nurse managers will meet with employees regularly, to discuss their concerns and offer suggestions for improvements.

Timeline

An appropriate timeline for improving employee engagement will roll out over the course of the following year. For the first month, the new techniques and evaluation processes will be planned and implemented. By the three month period, the organization will have collected data on employee engagement measured via the online surveys and face-to-face interviews. After six months, the data will be collected and analyzed to determine overall policy effectiveness, making it easier to identify points of weakness.
Leadership Practices to Improve Employee Engagement

Transformational leadership and servant leadership are the two models that will prove most effective in improving employee engagement. “Vital to the success of an organization's strategic plan are ongoing endorsement, engagement and visibility of senior leaders,” (Jeffs, Merkley, Richardson, et al. 2011, p. 47). Transformational leadership involves empowering each individual on the team to contribute to their own ability, to make decisions according to evidence-based practice, and to offer suggestions and feedback. Similarly, transformational leadership alleviates the burden on nurse leaders to micromanage, instead enabling the cultivation of leadership skills in every member of the healthcare team. Servant leadership always keeps in mind the values, goals, and mission of the organization. Ethical objectives and community outreach and advocacy remain the cornerstones of effective care. When administrators commit to employee engagement and patient safety outcomes simultaneously, the organization is positioned as a financially and ethically successful healthcare institution.

References

Baker, J.D. (2015). Language of improvement. AORN Journal 102(3):223-227.

Hansel, J. (n.d.). Building a powerful hospital scorecard...by keeping it simple! http://www.hfma.org/brg/pdf/MedeAnalytics_Building%20a%20Hospital%20Scorecard_White%20Paper.pdf

Jeffs, L., Merkley, J., Richardson, S., et al. (2011). Using a nursing balanced scorecard approach to measure and optimize nursing performance. Nursing Leadership 24(1): 47-58.

Lowe, G. (2012). How employee engagement matters for hospital performance. Healthcare Quarterly 15(2): 29-39.

Shirar, J. (2017). How to properly measure employee engagement. https://www.officevibe.com/blog/why-employee-engagement-is-hard-to-quantify