GUIDELINES FOR DOCUMENTING
PERFORMANCE IMPROVEMENT ACTIVITIES
I. GENERAL GUIDELINES
A. ONE YEAR PLAN
A one-year plan outlining your projected Performance Improvement Activities should be
submitted to the QA Department each year with the report for the first quarter of the
year, which is due on April 15. Please note that the Plan has now been incorporated into
the reporting form.
B. QUARTERLY REPORT
Each team and department should submit a
quarterly report to the QA Department. The report should aggregate and analyze the data
collected for each performance measure for that time period. The quarterly reports must be
received in the QA Department by the 15th of the month following the end of the quarter,
April 15 (January - March Report due)
July 15 (April - June Report due)
October 15 (July - September Report due)
January 15 (October - December Report
1. If the report is to be delayed for any
reason, the QA Department must be notified, preferably in writing, of the reason for the
delay, and the expected date of completion.
2. The quarterly reports must be submitted
on designated forms to provide a consistent format. There are no exceptions.
3. Special requests for reporting more
frequently than quarterly may be made by the Utilization Review/Quality Assurance/Risk
Management Committee. In addition, you may be requested to attend the Utilization
Review/Quality Assurance/Risk Management Committee meeting to present your report.
4. The component to be submitted quarterly
is the form titled "Performance Improvement Report Part One: Performance
Measurement Plan and Findings" and "Performance Improvement Report Part
Two: Analysis and Plan for Improvement."
If you also collect performance measures on
the "Additional Performance Improvement Measurements", that should also be
submitted with the quarterly report.
5. Organizational Planning Statistics
If you choose to collect statistical
information for your department or team, it can be recorded on the form called
"Additional Performance Improvement Measurements."
6. Collection of data on a minimum of two
(2) performance measures is required.
The two performance measures, when
possible, should relate to the Priority Functions determined by the Performance
Improvement Task Force.
For 1998, the priority areas are as
a) Patient and family education (Continued
b) Patient restraint/seclusion (Continued
Please note that the Joint Commission on
Accreditation of Healthcare Organizations requires data collection, measurement, and
assessment for restraint and seclusion for all units, all shifts, and all purposes.
7. Submit one report form for each
indicator that is being monitored.
8. If you change your Performance
Improvement Plan, please make the changes directly on the Performance Improvement Report
Part One: Performance Measurement Plan and Findings when your report is submitted.
The findings from ongoing measurement will be updated on this form with each reporting
9. Only two performance measures will be
included on the final report to the Board of Directors. If you submit more than two
performance measures, please indicate which performance measures you want to have included
on the report by checking the appropriate box (Yes or No for Board of Directors) on the
"Performance Improvement Report Part One: Performance Measurement and
10. No more than 5 indicators should be
submitted on the Performance Improvement Report form, however any additional indicators
can be recorded on the form called Additional Performance Improvement Measures.
11. Important Processes or Outcomes
Requiring Data Collection Or Assessment by Joint Commission on Accreditation of Healthcare
The Comprehensive Accreditation Manual for
Hospitals (The JCAHO Standards) specifically indicates processes and outcomes that require
data collection and assessment. They are listed in the Improving Organizational
Performance standards (PI.3.2 4.6) If the standards apply to your area, you must
collect the appropriate data. A list of these processes and outcomes is attached.
The "Additional Performance
Measures" form can be used to document this data. Please note, however that for those
that require analysis, the data must be submitted on the Performance Improvement Report
forms to include the written analysis of the data.
C. ANNUAL APPRAISAL
An Annual Appraisal should be performed at
the end of each calendar year
The Appraisal should be submitted with the
April 15 Quarterly Report
The Annual Appraisal form included in these
Performance Improvement Guidelines should be used for the Annual Appraisal, unless
otherwise indicated by the QA Department.
III. DOCUMENTING PERFORMANCE
A. MISSION AND VISION
The Mission Statement and Vision Statement
for each department or team should be reviewed by the department or team members annually
during the evaluation process, and revised as needed. The revised Mission or Vision
Statement should be submitted annually with the Performance Improvement Plan, utilizing
the Department Mission and Vision Statement Form.
B. SCOPE OF CARE
Each department director and team leader is
responsible for the Performance Improvement activities in his/her department or team.
These Performance Improvement functions may be delegated to others.
2. Delineate Scope of Care
Scope of care should define the types of
services provided, types of patients served, identify the types of care providers, sites
where care is provided, conditions and major diagnoses treated, and times care is
Each department/team must utilize the Scope
of Care Form to define the scope of care/service provided by the department/team, and to
document the assignment of responsibility for identifying indicators, collecting data,
evaluating care and taking actions to improve care
This form should be reviewed and revised
annually and submitted to the QA Department with the first quarter report submitted in
April each year.
C. PERFORMANCE IMPROVEMENT PLAN DEVELOPMENT
Each department must develop a Performance
Improvement Plan, which projects performance measurement activities that are planned for
The plan can be changed at any time
throughout the year with submission of a revised plan.
When the establishing the plan,
consideration should be given to the inclusion of performance measures for those functions
that have been established by the Joint Commission Task Force and Hospital Leaders, as
The Performance Improvement Plan MUST
include those measures that are required by the Joint Commission. (See attached IMPORTANT
PROCESSES OR OUTCOMES REQUIRING DATA COLLECTION OR ASSESSMENT)
Note that if you are involved in
performance measurement activities at the team level, and data collected by that team
directly reflects activities of your department, those activities can account for your
departmental Performance Improvement activities. The Quality Assurance Department must be
notified of your participation in the team Performance Improvement process.
COMPONENTS OF THE PERFORMANCE
All information regarding each performance
measure will be documented on this report form. This form incorporates the plan for
measurement and assessment, and the findings of those activities.
Each quarter, the new information will be
added to this form. Therefore, please keep a copy for your department records so that you
can continue your documentation on this form.
Only two (2) performance measures will be
included on the report to the Board of Directors. Please check the box labeled Board
of Directors to indicate the performance measure you have chosen to be included on
the report. If the boxes are not checked, the Quality Assurance Department will select the
performance measures to be included.
If you are involved in performance
measurement activities at the team level, and data is being collected by that team that
directly reflects activities of your department, those activities will account for your
departmental Performance Improvement activities and you must maintain a copy of those
Performance Improvement records in your department.
Each department manager and team leader
will be required to attend the Utilization Review/Quality Assurance/Risk Management
Committee and present the Performance Improvement report for his or her department. A copy
of the reporting schedule is attached. Updates will be distributed periodically as needed.
If you cannot attend the meeting, please make plans for another representative familiar
with the Performance Improvement for your department to attend and report the information.
Performance Improvement Report
Part One: Performance Measurement Plan and Findings
1. Department or Team Name
Check the applicable box for department or
Indicate the department or name of the team
2. Other Department/s Involved
Indicate any other departments that are
involved in this Performance Improvement activity, or N/A of not applicable
Indicate the calendar year for Performance
4. Submitted by
Indicate who is preparing the report
5. Date Initiated
Indicate the month and year that the data
collection for this indicator began
6. Date Discontinued
When Performance Improvement activities
have been discontinued due to improvement or re-prioritization of your Performance
Improvement activities, indicate the date that the data collection for this indicator was
7. PI Measure #
Each performance measure should be assigned
a number. The number assigned should be entered here.
8. Submit to Board of Directors
Two performance measures from each
department or team will be included in the report to the Board of Directors. Please choose
the performance measures you would like to have included on the report to the Board of
Directors by checking the appropriate (yes or no) box. When possible, the performance
measures selected should reflect the priority functions.
If more than two measures at submitted and
indication has not been made regarding which measures to include, the Quality Assurance
Department will chose the indicators to submit.
Measurements required by Joint Commission
will automatically be included in the report.
The applicable function should be noted for
each performance measure
See the Joint Commission Standards, or the
reference attached for a listing of the Important Hospital Wide Functions
10. Type of Measurement
Indicate whether the performance measure
focuses on the process or outcome
Process A goal-directed,
interrelated series of actions, events, mechanisms, or steps
Outcome The result of the
performance (or nonperformance) of a function or process/es
11. Dimension of Performance
Indicate the Dimension of Performance that
is the focus of the measurement
See the Joint Commission Standards, or the
reference attached for Dimensions of Performance
12. Method of Collection
Indicate how the data will be collected.
A data collection methodology should be
chosen and established. The methodology should consider the following:
Who will collect the data
Data sources that will be utilized
Whether the collection will be concurrent
How often the data will be organized and
compared to a threshold or benchmark
13. Sample Size
Indicate the Sample Size
The sample size to be reviewed should
reflect the volume of cases involved. When the volume is very low, a sample many not be
adequate to reflect a true picture.
Guidelines for Sample Size
*If the average number of cases per quarter
is more than 600, at least 5% of the cases are reviewed
*If the average number of cases per quarter
is less than 600, at least 30 cases are reviewed
14. Age Specific
Indicate whether or not the performance
measurement requires age specific consideration
*Age specific categories include Infants,
Children, Adolescents, Adult, and Geriatric
15. Frequency of Assessment of Data
While the process of data collection is
ongoing, the frequency of assessing the data may vary for each performance measure. The
frequency of assessment should be related to the frequency of the event or activity, the
significance of the event or activity, and the extent to which problem areas are
While some measurements can routinely be
assessed quarterly, others may require assessment of the data more frequently, especially
when problems have been identified that need more intensive investigation.
In determining how often to collect and
assess the data for a given performance measure, consideration should be given to the
Volume of patients that will be affected
Element of risk to the patient
Frequency that the aspect of care is
Extent of previously identified problems in
a particular area
When a problem is identified, the frequency
of measurement may need to be increased, or focused review may be necessary.
16. Rationale For Choice Of
Indicate the rationale for choosing this
indicator for performance measurement efforts.
The rationale is the evidence or reason
that a performance measure is important or useful to measure (how the process or outcome
measured affects patient outcomes).
A rationale could indicate that the
performance measure is of a high-risk nature, high-volume, and/or problem-prone processes.
Performance measurement could also be needed to design or assess new processes, assess the
dimensions of performance relevant to functions, processes and outcomes, measure the level
of performance and stability of important processes, identify areas for possible
improvement of existing processes, determine whether changes have improved the processes,
or because it is an organization-wide priority improvement effort.
17. Goal or Anticipated Outcome
Indicate the expected goal or outcome
desired for this performance measure. The goal or outcome might be the expected standard
of care as it relates to the chosen performance measure.
Outcome - The result of the performance of
a function or process/es
Data Aggregation Findings
18. Performance Measure
Document the performance measure that will
19. Performance Measure Source
Note the source on which the performance is
based (i.e., hospital or departmental policy, standard of care, etc.)
The upper portion of a fraction used to
calculate a rate, proportion, or ratio; the population, or number of patients for whom a
specified event occurs
Example: Number of patients developing a
surgical wound infection
The data should be aggregated quarterly and
the numerator for the performance measure for the quarter documented under the designated
The lower portion of a fraction used to
calculate a rate, proportion, or ratio; the population or number of patients (i.e.,
universe) at risk in the calculation (or who have the specified procedure or condition)
Example: Number of patients having a
The data should be aggregated quarterly and
the denominator for the performance measure for the quarter documented under the
22. Benchmark or Threshold
Indicate the threshold or benchmark that
will be utilized in assessing the data collected for this indicator.
Benchmarks or thresholds can be used to
assess performance. Utilizing thresholds or benchmarks, conclusions can be can be drawn by
analyzing the data collected and comparing the findings to pre-established criteria, a
single sentinel event, or control limits.
Assessing performance can be done using
various frames of reference, including the following:
Internal comparisons over time
Comparison of up-to-date sources of
information, such as accreditation standards, practice guidelines, or practice parameters
Comparison with similar processes and
outcomes in other like facilities, including the use of reference databases
Consideration of legal and regulatory
A means of assessment comparison should be
chosen for each performance measure and should be established by means of a threshold
range or benchmark, which can be documented as a numerator/denominator ,or rate, with a
positive numerical value when possible.
23. Benchmark or Threshold Source
Indicate the reference used to establish
the Benchmark or Threshold (see above Benchmark or Threshold)
Using the numerator and denominator
established for your performance measurement, calculate the rate or each quarter, when
possible in a positive value.
At the end of the calendar year, enter the
total or average for the year, whichever is applicable.
Analysis and Plan for Improvement
Note: The remainder of this report form
only needs to be completed when a problem, or opportunity for improvement is identified.
Upon analysis of the data, when an a
problem or opportunity for improvement has been identified, enter the date of the analysis
27. Summary Of Problem/s Identified
Or Opportunity For Improvement
An analysis is conducted to determine if
the level of performance is acceptable, or if improvement is need. The summary of the
problem or opportunity for improvement is documented here.
In making the assessment, as noted above
under Benchmarks or Thresholds, actual findings should be compared to the benchmark or
threshold. After the comparison is made, if findings are not within the expected range,
the assessment process should continue to determine the cause, decide what needs to be
done, and develop a plan for achieving that goal.
28. Plan of Action
The plan of action is based on the
assessment of the data.
Document the plan that you have developed
to achieve your expected outcome. If you are in a second cycle (or measurement period) of
the improvement process, (you have previously initiated a plan that has not resulted in
improvement) document the new plan or revisions to the previous plan that will be
If the goal of a plan was not achieved,
continue each cycle of the process on the same report form, entering the current date and
modification to the plan in this column.
29. Individual Responsible for
Indicate who is responsible for carrying
out each part of the action plan.
30. Date and Description of
Implementation of Action
Indicate the date, and the action that was
taken with each cycle of the process in this column.
31. Evaluation of Implemented Plan
Evaluate the effectiveness of the action/s
taken, and document whether or not improvement has occurred.
If the action/s taken were not effective in
achieving the expected results, modify the plan and document the new plan of action in the
Plan of Action column.
Repeat this Plan-Do-Check-Act cycle through
subsequent cycles or measurement periods, until the necessary results are achieved.
D. Additional Performance
Performance Improvement Measures should be
limited to 5 indicators. However, if your department collects organizational planning
statistics, quality control data, measurement of functions required by the Joint
Commission, or additional Performance Measurement data, it can be recorded on this form.
No documented analysis is required for
If a performance measure provides an
opportunity for improvement or you detect or suspect significant undesirable variation,
you must promptly initiate intensive assessment to bring the performance to a desired
level. In these instances, a review of the overall department Performance Improvement
activities should be done to re-prioritize your performance improvement efforts.
E. GUIDELINES FOR COMPLETING TEAM
1. Performance Improvement Team
Indicate the team name
2. Date Team Formed
Indicate the date that the team was
3. Completion Date
If the team was formed for a temporary
project, enter the date the project was completed; otherwise leave this area blank
4. Team Type
Check the box for the appropriate team type
Chartered Team An ongoing team
approved and overseen by the Performance Improvement Task Force
Unchartered Team A team that comes
together on the initiative of its members to improve a specific process or problem area
Special Project Team A team assigned
a special project by the performance improvement task force or by a chartered team
5. Team Leader
Indicate who is assigned responsibility of
The Team Leader is responsible for
coordinating team efforts, developing team meeting agendas, providing guidance to the team
members, assigning team functions as appropriate, such as record keeping and time keeping,
scheduling meetings as needed, (at least quarterly), collecting and maintaining all
policies, procedures and minutes of the team, reviewing and approving policies and
procedures that the team is responsible for and determining and obtaining approval from
the necessary individuals, committees or teams, initiating and maintaining a record of and
reporting all performance improvement activities of the as outlined by the Performance
Improvement Plan. (Responsibilities can be assigned to other team members.)
Indicate what individual is assigned the
responsibility of maintaining the focus of the team during team meetings
Indicate which team member is assigned the
responsibility of recording the meeting minutes for each meeting.
It is recommended that one individual
assume the responsibility or be assigned the responsibility for a time period (for example
one year or six months) rather than random assignment to provide continuity. In the event
that the recorder cannot attend the meeting, a temporary recorder should be assigned the
responsibility for documenting the minutes for that particular meeting at the beginning of
8. Time Keeper
Indicate which team member is assigned the
responsibility of TimeKeeper.
The timekeeper should be assigned the
responsibility on a permanent basis, or for a particular time period. Meetings should be
scheduled for now longer than a one hour time period. Every effort should be made to start
the meeting on time in consideration of busy schedules of all team members. The TimeKeeper
should announce to the team when a 30 minutes remain, when 15 minutes remain, and when 5
minutes remain. When complete agendas are developed, the time announcements help to set
the pace for the meeting so that all agenda items can be covered in the time frame.
9. Team Reports To
Indicate the reporting chain of the team.
All teams report progress and activities to
the Performance Improvement Task Force.
Teams that have been established as an ad
hoc team report their findings to the team established to oversee that function. (For
example, the IM.3 Team is an ad hoc team to the Information Management Team, and therefore
reports to the Team Leader of the Information Management Team. The Information Management
Team Leader is then responsible to report the activities of the IM.3 ad hoc team, through
the established channels.)
10. Team Members
List all members of the team.
When possible, teams should be limited to
seven members. Members should be representative of the disciplines involved in the process
or function. Department Managers should be contacted and approve the addition of a staff
member from that area before any new or additional team members are assigned.
11. Team Mission
Indicate the mission statement of the team.
A mission statement should be developed for
each team by the team members. The mission statement should be modeled after the
hospitals mission statement and reflect the activities of the team. The mission
statement should be reviewed each year making any necessary changes.
12. Projected Goals For This Year
List the goals for the team for the coming
During the annual evaluation process, any
changes in regulatory standards should be reviewed and considered in determining items
that need to be accomplished for the year. Priorities should be established based on the
13. Date Met
Indicate the date that the goal was met.
The team updates the list of goals and
accomplishments on an ongoing basis.
14. Special Considerations
A note should be made of any special
considerations of the team (for example, if efforts in a particular area need to be
coordinated with another team or committee).
DIMENSIONS OF PERFORMANCE
I. DOING THE RIGHT THING
The efficacy of the procedure or treatment
in relation to the patients condition
The degree to which the care of the
individual has been shown to accomplish the desired or projected outcome(s)
*The efficacy of a particular treatment
should be supported by scientific literature and research. Efficacy can be determined by
measuring various outcomes of care.
The appropriateness of a specific test,
procedure, or service to meet the patients needs
The degree to which the care and services
provided are relevant to the individuals clinical needs, given the current state of
*Appropriateness pertains to the choices
that practitioners make, whether those choices be medication therapies, diagnostic tests,
noninvasive procedures, or invasive procedures. Even if performed well, an inappropriate
type of care may harm and will not help the patient.
II. DOING THE RIGHT THING WELL
The availability of a needed test,
procedure, treatment, or service t the patient who needs it
The degree to which appropriate care is
available to meet the individuals needs
*Appropriate choices of treatment that are
potentially efficacious for patients are futile unless they are actually available to
patients. Thus an organization needs to ensure that its services meet community needs and
that they be rendered in such way and at such times that the community served can access
The timeliness with which a needed test,
procedure, treatment, or service is provided to the patient
The degree to which the care is provided to
the individual at the most beneficial or necessary time
*Timeliness pertains to the process of care
and can certainly affect the outcome of care. In health care, timing is crucial for
everything from initial assessment to pre-surgical antibiotic administration to patient
The effectiveness with which tests,
procedures, treatments, and services are provided
The degree to which the care is provided in
the correct manner, given the current state of knowledge, to achieve the desired or
projected outcome(s) for the individual
*This dimension of performance also
addresses how care is provided and suggests that an effective process of care increases
the chance of a desirable or expected outcome. Currently, more hospitals are attempting to
standardize care by using such tools as practice guidelines and standards to help ensure
that care reflects the current state of the art.
The continuity of the services provided to
the patient with respect to other services, practitioners, and providers, and over time
The degree to which the are for the patient
is coordinated among practitioners, among organizations, and over time
*Continuity of care has entered the
spotlight with the proliferation of vertically integrated delivery systems. A hallmark of
a truly integrated system is its continuity of careits ability to effectively guide
a patient from acute care to skilled nursing care, or example, or from skilled nursing
care to home care. Continuity within an organization is equally important for good
outcomes. Continuity requires effective communication and planning, or example, discharge
planning that begins early in the care process.
The safety of the patient (and others) to
whom the services are provided
The degree to which the risk of an
intervention (for example, use of a drug or a procedure) and risk in the care environment
are reduced for a patient and others, including the health care practitioners
*Safety management is not an isolated
function. Rather, it permeates the activities in an organization, from managing risk for
patients and practitioners to effectively maintaining equipment, implementing appropriate
fire safety procedures, and monitoring and controlling infection.
The efficiency with which services are
The relationship between the outcomes
(results of care) and the resources used to deliver patient care
*In an era of cost management, efficiency
is the dimension of care that may be receiving the most attention today. Efficiency should
not necessarily be viewed as unfavorable to good patient outcomes. For example, regarding
turnaround times of laboratory tests, increasing efficiency in ordering and performing
tests, thereby potentially improving a patients chance for a good outcome. In
addition, the enhanced understanding of patient care processes, the increased cooperation
among caregivers, and improved practices that arise from multidisciplinary improvement
efforts can improve efficiency while improving efficacy and effectiveness.
Respect and Caring
The respect and caring with which services
The degree to which those providing
services do so with sensitivity and respect for the individuals needs, expectations,
and individual differences, and the degree to which the individual or a designee is
involved in his or her own care decisions
*When seeking to improve the performance of
clinical processes, the focus may be set on a dimension of performance such as efficacy
before any attempt is made to improve the degree of respect and caring. However, patients
treated with respect and caring may be more likely to participate effectively in their
care, for example, to carry out their medication regimens. In addition, patients have the
right to be treated with respect and caring, which makes this dimension of performance a
high priority for improvement. Since patients have choices about who will provide their
care, patient satisfaction, enhanced by respect and caring , will be key to any
Comprehensive Accreditation manual for
Hospitals: The Official Handbook, Joint Commission on Accreditation for Healthcare
Organizations, August 1997 Update, p. PI-4.
*An Integrated Approach to Medical Staff
Performance Improvement, Second Edition, Joint Commission on Accreditation of Healthcare
Organizations, 1996, pp. 5-7.