2b. Measurement The capability of an organization to A. obtain and execute on the skills and competencies required to undertake improvement throughout the organization; and, B. to establish, manage, and analyze data for improvement in a timely and routine manner to meet the objectives and expected results of organization’s improvement plan. (from Framework: Improving work processes and patient outcomes using standard improvement tools including measurements over time.) The organization uses data to measure performance, but only a few places use data to support and inform activities designed to improve safe and reliable care. There is limited ability to communicate information across systems. The organization uses data to measure performance and to support many improvement projects designed to improve safe and reliable care. The organization has established a number of data systems to allow for some cross-organizational measures. The organization uses data to measure performance and to support almost all projects designed to improve safe and reliable care. The organization has established a number of data systems which it uses routinely to share performance information across key partners and stakeholders in the organization. The organization uses data to drive all improvement measures at both the whole system (across the continuum) and sub-system level. Data systems allow for highly effective communication within and across all continuum partners and with key stakeholders in a manner that informs the knowledge and actions required to meet the shared objectives. Just beginning Making progress Significant impact Exemplary Please provide a brief description of the type of data or other evidence you used to inform your choice:
3. Transparency Operational transparency exists when leaders, patients and their families, organizations and the community are able to visibly see the activities involved in the learning process. It provides clarity over decision making and monitoring of performance. Transparent organizations openly share data and other information concerning safe, respectful and reliable care with staff and partners and families and encourage a dialogue regarding shared information. The organization meets its legal or minimum requirements in terms of publishing data or communicating with a patient or family following an adverse event. Data or information shared is high level and not used for learning or improvement. Leaders rarely time visiting the ‘shop floor’. Data is not typically displayed around the organization, where it is it tends to be high level or may be out of date. Patients and families are not involved in investigations. A proportion of leaders visit the ‘shop floor’ at least twice a year. Learning boards may be in use in a couple of but they are not regularly updated so the information may not be current. Learning boards are updated in preparation for a visit from a leader or visitor but are not used routinely by staff. Patients and families have some involvement in some investigations or improvement activities but this is relatively superficial. Leaders spend time on the ‘shop floor’ at least every month and review local data with teams. Some managers are use learning boards and encourage to participate in the process of populating the learning boards. Patients and families are deeply involved in all investigations of adverse events and are Patient and families are routinely involved in improvement activities although this involvement may be quite limited at times. Leaders create the expectation that all are using learning boards to share the process of learning and improvement. Senior leaders spend a significant proportion of time reviewing learning boards and highlighting learning. Managers are adept at using learning boards to share the improvement journey. Patients and families are actively engaged in the improvement functions of the organization and feel that they can the communication they receive. Just beginning Making progress Significant impact Exemplary Please provide a brief description of the type of data or other evidence you used to inform your choice: 4. Teamwork & Communication
Few if any are able to use effective negotiations tactics to engage others in change. Differences are expressed in methods that result in poor teamwork and lack of agreement. Some staff are skilled in and able to successfully negotiate with peers. Conflicts continue to lead to poor behavior and are seldom resolved in the interest of the patient. Many of the differences in the approach to the improvement work and process changes needed are negotiated with the team. Resolution to conflicts is achieved in a way that all parties benefit and patient care is improved. All are able to negotiate through differences. Collaborative Staff differentiate Position from Interests. Use appreciative inquiry. Staff report a high level of respect and minimal disruptive behaviors due to the ability to reach agreement. Just beginning Making progress Significant impact Exemplary Please provide a description of the type of data or other evidence you used to inform your choice: 7. Accountability Being held to act in a safe and respectful manner given the training and support to do so. This framework component underscores the importance of holding people to account for their actions, but not for flaws in processes or systems. Each individual is accountable to others for acting in ways that embody organizational values, and each individual is accountable as a team member to be committed, self-managing, competent, and courageous