Hanan Al-Ghammas, , LSSGB, SSYB

Master Degree in Health and Medial Informatics,

King Saud Bin Abdulaziz University for Health Sciences.
Certified as Clinical Research Professional.
Bachelor Degree of Applied Medical Sciences
in Health Education, King Saud University.

King Faisal Specialist Hospital & Research Center

2021 – Present Performance Scorecard Specialist
1. Workshop Introduction, House Rules, and Ice Breaker
2. Pre Assessment Test
3. Key Performance Indicators (KPIs)
3.1 Definition
3.2 Benefits
3.3 Characteristics
3.4 Terminology Standards

4. KPIs Selection
4.1 Purpose
4.2 Value Flow Analysis

5. KPIs Data Collection

6. KPIs Data Analysis and Reporting
7. Interventions and Follow-up
8. Examples
9. Game Time 
10. How to fill out the indicator Definition form?
11. Post Assessment Test
HT TPS://WWW.YOUTUBE.COM/WATCH?V=DXD_N4
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Key Performance Indicators are used to evaluate clinical
performance and compare it with a targeted goal /
benchmark result or standard.
Examples:
 # CLABSI incidents.
 % Hand hygiene compliance.
 # Falls with injuries.
 % Patients who received VTE education.
They are specific performance measurements designed
to monitor one or more processes during a defined
time.
They are useful for evaluating:
◦ Service demands
◦ Production
◦ Adequacy of personnel
◦ Inventory control
◦ Process stability
Managerial Department KPIs 2022
Supply Chain Management 1. % Medical Expired Stock.
2. % Out-Of-Stock Medical Items
3. % Out-Of-Stock Pharmaceutical Items
4. % Pharmaceutical Expired Items
An indicator is
Specific
Measurable
Achievable
Reliable
Timely manner reported

It is a SMART characteristic to show changes or

progress a process is making toward achieving a
specific outcome.
Objective
• Increase Hand Hygiene Compliance

KPI
• % Hand Hygiene Compliance

Target
• 90%

Time
• By end of each quarter

Owner
• Infection Control Manager
1. # Unplanned Downtime for Business Critical Services.

2. % Housing New Arrivals Satisfaction.

3. % Operating Room (OR) Utilization Rate.

4. # Active Clinical Pathways.

5. $ Revenue Generated.
4. KPIs Selection
1. To meet accreditation standards.
2. To monitor stability of the process
3. To prompt actions toward unmet target or triggers.
4. To facilitate leaders decision making.
5. To find opportunity for quality improvement.
6. To improve patient experience in the organization.
OBJECTIVES INPUTS PROCESSES OUTPUTS OUTCOMES

• Ensure • # Population • # Time to • % Vaccinated • % Incidence of

population size. vaccinate population. disease.
immunization. • $ Budget. population. • % Vaccines • % Mortality
• # Physicians. • # Vaccines utilized per rate.
distribution specifications.
time.
Source of Data Collection: ex. Internal Database, ICIS automated
report……
Frequency of Data Assessment / Collection: ex. Weekly, monthly,
quarterly, semi-annually, annually …..
Method of Data Collection: ex. Concurrent, Retrospective
Format of the reported Indicator: ex. Number, Percentage, Average,
Ratio, Rate …
Set a Goal/Target or a Trigger: ex. 100% compliance (Goal), ≥ 80%
(trigger)….
Selection of the Appropriate Graphical Presentation mainly Run
Chart, Bar graph,……..
Identification of the graphical presentation
 Bar Chart
 Pie Chart
 Histogram
 Pareto Diagram
 Run Chart
 Control Chart……
 HITA
Indicator Title Indicator Definition
1. # Unplanned Number of business disruptions caused by (operational) problems.
Downtime for For ICIS, ERP, network link between sites, EC, email, etc. can cause
Business Critical a problem.
Services

# Unplanned Downtime for Business Critical Services

12

10 10 10 10

8 8
7 7
6

0
Q1 2019 Q2 2019 Q3 2019 Q4 2019 Q1 2020

# Unplanned Downtime for Business Critical Services Trigger

Trigger ≤10 Unplanned Downtime.

Data reporting plan:
 Reporting frequency (week, month, quarter, bi-
annual…etc).
 Who will review the reports?
 Who will receive the report?
 1. Excel
reporting

2. Power
Point
presentations

3. Software
solutions
Communication of Indicators
Board of Directors,

Healthcare Executive Leadership Committee,

 Departmental meeting,

 Through hospital official mail,

 Managers/Quality Representatives update,

 Scorecards.
Corrective action plan: An action plan has to be
implemented and put in place any time the indicator is beyond
the set up trigger (red zone).

 Continuous monitoring of the compliance to that action

plan should be followed up in order to get the desired
improvement / outcome.
# Emergency Response Time.
Definition:
The average response time from call received by the
Dispatcher until the crew arrives on scene within a set
period of time.
Rational:
To monitor the efficiency of the Ambulance Service
emergency response for patient safety.
Trigger: Below 10 Minutes
 # Emergency Response Time
12

10
9.14
8.1 7.99
8
7
6.68 6.42
6 5.75

0
Q2-2015 Q3-2015 Q4-2015 Q1-2016 Q2-2016 Q3-2016 Q4-2016
Response time Trigger
% Fill Rate.
Definition:
The percentage of shipped number of Internal
Requisitions within 3 days against the total number of
internal requisitions within a set period of time
Rational:
This indicator shows how responsive is the warehouse to
internal customer requests which has an impact on patient
care.
Target: 95%
 % Fill Rate
100%

95%
94.52% 94.6% 95.0%
93.8%
92.1% 92.4% 92.4% 92.4%
90%

85%

80%
Q1- 2015 Q2- 2015 Q3- 2015 Q4- 2015 Q1- 2016 Q2- 2016 Q3- 2016 Q4- 2016

Fill Rate Target

Remember….
'If You Can't Measure It, ……..
You Can't Manage It'
10. HOW TO FILL OUT THE INDICATOR DEFINITION
FORM?
Indicator Definition Form
Example: Indicator Definition Form
Indicator Definition Example
 Initiating Department:
Quality Management Department

 Initiator's Name:
Hanan AlGhammas

 Initiator's job title:

Performance Scorecard Specialist

 Domain:
☒ Medical
☐ Clinical
☐ Nursing
☐ Patient Services
☒ Quality
☐ Research
☐ Education & Training
☐ Information Technology
☐ Administrative
☐ Human Resources
☐ Supply Chain
☐ Finance
 ASSIGNED DATA STEWARD TO VALIDATE AND MONITOR THIS KPI:
Khaled Alnafee - Infection Control

 OTHER STAKEHOLDERS:
Quality Management Department
 Indicator Category:
☒ Clinical
☐ Non-Clinical

 Indicator Type:
☐ Structure
☒ Process
☐ Outcome

 INDICATOR HISTORY:
☒ New Indicator
☐ Revised Indicator, previous approval date:

 INDICATOR DEFINITION SHARED WITH COUNTERPART IN

RIYADH/JEDDAH (if applicable):
☒ Yes ☒ Not Applicable
☐ No
Indicator Definition Example
Indicator Definition Example
 Indicator Title:
% CLABSI insertion care bundle compliance

 Indicator Definition:
The total number of the complied care bundle over the total
documented care bundle in a specific period of time and
specific unit.

 Rational for Indicator Selection:

Central line insertion care bundle is a group of evidence-based
interventions for patients with intravascular central catheters
that, when implemented together, result in better outcomes
(reduce BSI) than when implemented individually. This indicator
is essential to ensure the risk mitigation to develop CLABSI.

 Inclusion Criteria:
All patients who has central line in inpatient units.

 Exclusion Criteria:
Outpatient unit.

 Formula (BUSINESS):
CLABSI insertion care bundle compliance = (total complied
bundle / total documented bundle) * 100
 Nominator
The number of complied CLABSI insertion bundle.
 Dominator
The number of documented CLABSI insertion bundle.
Indicator Definition Example
Indicator Definition Example
 Indicator Format:
☐ Number
☐ Average
☐ Ratio
☒ Percentage

 Data Source:
CLABSI Bundle in ICIS ERS system.

 Comments:
NA

 Attachment:
Indicator definition (excel sheet).

 ANTICIPATED REPORTING TIME PERIOD

☒ Monthly ☐ Bimonthly ☐ Quarterly
☐ Bi-annually ☐ Annually
Indicator Definition Example
Indicator Definition Example
 FREQUENCY OF ASSESSMENT OF DATA
☐ Daily ☐ Weekly ☒ Monthly ☐ Other, please indicates:
Quarterly (each three months)
 TARGET SAMPLE AND SAMPLE SIZE(N) AND AREA OF MONITORING:
All inpatients who has central line.
 MEASURE (INDICATOR) TARGET AND/OR TRIGGER:
95%
 BENCHMARK VALUE (IF APPLICABLE)
☒ Internal ☐ Regional ☐ National ☒ International
Reference year:
Reference link (if applicable):
 NAME OR FILE NAME FOR THE AUDIT TOOL (IF APPLICABLE):
CLABSI Bundle in ICIS.
 Data collection methodology
☒ Retrospective ☐ Concurrent
 CATEGORY OF THE MEASURE (for example, strategic priority
improvement or individual department/service):
Quality Aim for Zero Harm.
 PLEASE EXPLAIN THE DATA AGGREGATION AND ANALYSIS PLAN:
The data will be extracted from the CLABSI insertion care bundle ERS
report.
 PLEASE INDICATE HOW THE DATA RESULTS WILL BE DISSEMINATED TO
STAFF:
Through Infection control feedback board, dashboard, Zero Harm
Scorecard, CLABSI Quality Aim meetings, PI Council meetings, and Executive
meetings.
 QUALITY DOMAIN:
☒ Safe ☒ Effective ☒ Patient-centered ☐ Timely ☒ Efficient
☐ Equitable
 DEPARTMENT HEAD OR ABOVE APPROVAL
☐ Approved ☐ Disapproved
 INDICATOR DEFINITION COMMITTEE APPROVAL
☐ Approved ☐ Disapproved
 HEALTH INFORMATICS TECHNOLOGIST AFFAIRS
Indicator Number