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Performance Indicators

We have a comprehensive performance management and measurement system, including regular tracking of performance indicators, which are used to guide our operational and strategic decision making to improve patient and resident care.

Following are some common indicators that we use to measure our performance and inform our improvement activities.

Percentage of elective (non-emergency) surgeries that are completed within the benchmark wait time assigned by a patient’s surgeon.

We measure the percentage of Emergency Department (ED) patients who rate the care they received at the hospital positively. We take the total number of responses that answered “good,” “very good” or “excellent” and divide by the total number of non-blank responses to the overall quality of care questions.

We track the amount of time our employees are away from work due to illness and divide that total by the total number of productive (working) hours.

Number of patients who get sick with the bacterium Clostridium difficilie (C. difficile) as a result of a stay in the hospital. We take the total number of health care-associated C. difficile infection cases identified every three months and divide it by the total number of patient days for the same time period. We multiply that number by 10,000 to arrive at a case rate per 10,000 patient days.

We are measuring the amount of overtime hours our staff work, as an indicator of their workload. We take the total overtime hours and divide by total productive (working) hours.

Rate of nursing sensitive adverse events for all medical and surgical patients aged 55 and older, where a patient is unintentionally harmed as a result of their medical treatment.

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