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					                                                           Table 2              ENVIRONMENTAL DASHBOARD
                                                  Team Name: AMBULATORY SURGERY CENTER               Year:           Coordinator:
                                     INDICATOR                                                   ACTUAL PERFORMANCE
  RESPONSIBLE
                                                                    Jan   Feb     Mar    Apr   May   Jun     Jul   Aug     Sep      Oct   Nov   Dec

LIFE SAFETY
                                Fire drill(s) conducted
                             Fire Extinquisher Inservice
  Data Submitted By           Fire extinguisher inspection
                             Fire extinguisher inspection
                                       MONTHLY
EMERGENCY PREPAREDNESS
                          Participate in Mass Casualty Drill
                                        ANNUAL
                                 Internal Disaster Drill
                                        ANNUAL
                                  Full Evacuation Drill
                                        2X YEAR
                                    Code Blue Drill
                                     QUARTERLY
                             Hurricane Preparedness
SAFETY
                               Environmental Checklist
                                     # deficiencies
                                Leadership Checklist
                                     # deficiencies
                        # of unprotected pipes under sinks
                                # of employee injuries

SECURITY
 Improved Customer
  Data Submitted By
    Data Submitted By
Worker's Compensation    Number ofof Vendors not responses
                           Number unsatisfactory not properly
                             times exterior doors are
                        # of # of times exterior lights receiving
                               # of team members not
                                 wearing name badges
                                # of criteria not met on
                              confidentiality questionaire
HAZARDOUS MATERIALS
  Data Submitted By        HazMat Walk-Through completed
                        # of team members who do not
                               know where spill kits are
                           # of times air quality monitoring
                                      completed
UTILITY
                              # of essential utility failures
  Data Submitted By               # of weekly fuel tank
                                Emergency Generator:
                          # of times monthly runs meet the
                         30/50 rule or annual load bank test
  Data Submitted By
   Data Submitted By
  Data Submitted By      ##of #timesteam member are
                         # of times timesmembers performed
                            of timestelephone Inspection
                                # FireHVAC equipment tested as
                                 ofof semi-annual PMs
                                 # of medicalTransfer
                                    Automatic gases
                                       Marshall system
                                           elevator
INFECTION CONTROL
                             # of criteria not met on the
                                  Infection Checklist
  Data Submitted By
  Data Submitted By           # criteria not met on
                                    Boiler Inspections
                             Surgery Infection Risk
ANNUAL RENEWALS
                               Fire Marshall Facility/Fire
                                Extinguisher Inspection
                                   Boiler Inspections
    Data Submitted By             CLIA License
                                 State Licensure
                                      CLIA Waiver

                                  Pathology License

                             Bio Hazard Mat. Generator
                                    certificate
                                Occupational License

                         A/C Contract maintenance renewal

                                Surgery ASC License
       CATEGORY                        INDICATOR                  GOAL
                                                                                                                 ACTUAL PERFORMANCE
                                                                              Jan      Feb      Mar      Apr     May      Jun      Jul     Aug       Sep       Oct     Nov       Dec

The following are sample formats for different kinds of IMPACT CARE indicators. Just highlight the row
numbers beside the appropriate rows (11, 12, 13 and 14 for example) and "Copy". Then go to the IMPACT
CARE sheet tab and highlight the row number where you want to insert the indicator. Press the right
mouse button and choose "Insert Copied Cells". Then change the wording and numbers to suit your
purpose. If there is not a sample in the format you need, either pick the closest one and change it, or,
create your own.


                                                                   from

                                                                     to
 Sample Department Quality   Number of unsatisfactory responses


Monthly Percentage Indicator
                                                                   from
                                                                               of       of       of       of      of       of       of       of       of        of       of       of
                                                                     to
                                                                               or       or       or       or      or       or       or       or       or        or       or       or
                                                                                -        -        -        -      -         -        -        -        -         -        -        -


Monthly Percentage Indicator (Expense)

                                                                   from      Actual   Actual   Actual   Actual   Actual Actual    Actual   Actual   Actual    Actual   Actual   Actual

                                                                     to      Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
                                                                              Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.
                                                                               -      -      -      -      -      -      -      -      -      -      -      -
                                                                               -      -      -      -      -      -      -      -      -      -      -      -


                                                                   from      Actual   Actual   Actual   Actual   Actual Actual    Actual   Actual   Actual    Actual   Actual   Actual

                                                                     to      Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
                                                                             Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D
                                                                               -      -      -      -      -      -      -      -      -      -      -      -
                                                                               -      -      -      -      -      -      -      -      -      -      -      -


Monthly Percentage Indicator (Revenue)

                                                                   from      Actual   Actual   Actual   Actual   Actual Actual    Actual   Actual   Actual    Actual   Actual   Actual

                                                                     to      Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
                                                                              Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.   Var.
                                                                               -      -      -      -      -      -      -      -      -      -      -      -
                                                                               -      -      -      -      -      -      -      -      -      -      -      -


                                                                   from      Actual   Actual   Actual   Actual   Actual Actual    Actual   Actual   Actual    Actual   Actual   Actual

                                                                     to      Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget Budget
                                                                             Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D Y-T-D
                                                                               -      -      -      -      -      -      -      -      -      -      -      -
                                                                               -      -      -      -      -      -      -      -      -      -      -      -


Regular Quarterly Indicator
                                                                   From

                                                                     to



Quarterly Variance / Percent Indicator (Expense)

                                                                   from                        Actual                    Actual                     Actual                      Actual

                                                                     to                        Budget                   Budget                      Budget                      Budget
                                                                                                Var.                     Var.                        Var.                        Var.
                                                                                                 -                        -                           -                           -
                                                                                                 -                        -                           -                           -


                                                                   Y-T-D                       Actual                    Actual                     Actual                      Actual
                                                                  variance
                                                                    <0%                        Budget                   Budget                      Budget                      Budget
                                                                                               Y-T-D                    Y-T-D                       Y-T-D                       Y-T-D
                                                                                                 -                        -                           -                           -
                                                                                                 -                        -                           -                           -


Quarterly Variance / Percent Indicator (Revenue)

                                                                   from                        Actual                    Actual                     Actual                      Actual

                                                                     to                        Budget                   Budget                      Budget                      Budget
                                                                                                Var.                     Var.                        Var.                        Var.
                                                                                                 -                        -                           -                           -
                                                                                                 -                        -                           -                           -


                                                                   Y-T-D                       Actual                    Actual                     Actual                      Actual
                                                                  variance
                                                                    <0%                        Budget                   Budget                      Budget                      Budget
                                                                                               Y-T-D                     Y-T-D                       Y-T-D                       Y-T-D
                                                                                                 -                         0                           0                           0
                                                                                                 -                      #DIV/0!                     #DIV/0!                     #DIV/0!
 Sample Department Quality   Number of unsatisfactory responses


Monthly Favorable / Unfavorable Indicator


                                                                              Even    Even      Even    Even     Even     Even    Even     Even      Even     Even     Even      Even
       Updated: 7/28/2011                                                                                               Page 2                                                            94603090-014d-4a3b-a480-0d22eb9adac9.xls
   Review of How IMPACT CARE Plans are Developed

A. DEVELOPMENT
    1. Identify the work group whose performance is measured by this plan.
    2. Identify your key customers.
    3. Define the full scope of activities. Ask the following questions
          a. What different functions/tasks are performed (be sure to include your
                  full range of activities).
          b. What areas or places do you perform the functions/tasks?
          c. What ages and sexes of customers (patients) are served?
          d. What team members are required to perform the tasks?
          e. At or during what times are the tasks performed?
    4. Identify the key activities within your scope of activities.
          a. Consider activities which are:
               · High volume - performed frequently or affect large numbers
                     of customers.
               · High risk - expose customers to greater chance of adverse
                    occurrences if not performed correctly.
               · Problem prone - in the past have produced problems for
                   customers or the organization.
    5. Write indicators that measure whether or not customer requirements are
         met. Place your indicators in the appropriate category. User the template
         (disk) for the monitor report format.

           REMEMBER: Only indicators prioritized for improvement should
           have a goal. Whenever possible, goals should be written
           “from ____ to ___”.

    6. Team goals should be written in all caps.
B. IMPLEMENTATION
    1. If ongoing monitoring and progress toward goals is satisfactory, no further
         action is necessary.
    2. If not, the following decisions should be made:
          a. Does the indicator measure what was intended?
          b. Is the goal reasonable?
          c. Is the deviation a negative trend or simply a one time special cause
                variation?
          d. Is there an individual problem?
          e. Is there a process to be improved?
          f. Does a goal need to be set?
                                                                  94603090-014d-4a3b-a480-0d22eb9adac9.xls
    3. Use quality tools such as statistical process control charts, line graphs, bar
          graphs, etc., to help visualize trends within an indicator.
    4. Complete action plans when goals have been established. Determine
          actions that will eliminate root causes(s).
    5. During team meetings, be sure to reward and recognize process
          improvement, both individual and group.
    6. IMPACT CARE reports should be posted on bulletin boards in work areas.
C. RESULTS AND FOLLOW-UP
    1. Monitor and assess the effectiveness of actions taken.
    2. Continue ongoing monitoring and communication of results, using
         Plan - Do - Check - Act (PDCA) cycle of quality improvement.
    3. Regularly review IMPACT CARE indicators to determine whether the
         priorities for ongoing monitoring should be changed, or whether the
         indicators should be revised.
          a. Ongoing appraisal
          b. Annual appraisal




                                                                94603090-014d-4a3b-a480-0d22eb9adac9.xls
                         BEST PRACTICE
                          IMPACT CARE

     All IMPACT CARE Plans that meet the "Best Practice" model will
     include the following standards:



1.   All IMPACT CARE Plans must be written in approved format.

2.   All IMPACT CARE Plans will have a header with "IMPACT CARE" and the team
     name.

3.   All IMPACT CARE Plans will have indicators related to our TEAM GOALS for
     Service, Outcome and Cost.

4.   Team Goals should be written in all CAPS.

5.   All indicators must have at least quarterly data.

6.   75% of all indicators should be written as a negative or error.

7.   75% of all indicators should reflect whole numbers, not percentages.

8.   All IMPACT CARE Plans will have one service indicator related to error reduction
     and show improvement.

9.   Goal statements must be written from ____ to ____.

10. All IMPACT CARE Plans will have an action plan when a goal is established.

11. Team Leaders / Directors will meet with the team to review IMPACT CARE
    Plans monitoring and improvements and document at least ten time a year.




                                                             94603090-014d-4a3b-a480-0d22eb9adac9.xls
                                            IMPACT CARE
                                           SELF ASSESSMENT
         SCORE
     1 = Never
     2 = Sometimes
     3 = Always

                           Do you meet monthly to review IMPACT CARE monitoring and
                           improvements with your team ten times a year?


                           When you prioritize for improvement, do you establish a goal in each
                           area for Service, Outcome and Cost?



                           Are indicators and/or goals written that target the process?



                           Do you have indicators related to our TEAM goals for SOC? Are
                           they capitalized in you IMPACT CARE plan?



                           Do you have action plans when goals are established?


                           Are you using QI tools (i.e.: Process Flows, Control Charts, Bar
                           Graphs) for your indicators with goals to monitor for improvement?
                           Are they available for the team to view?

                           Are data collection tools in an easily accessible area for team
                           member participation?



                           Do ALL team members participate in the IMPACT CARE process?




                           TOTAL SCORE




94603090-014d-4a3b-a480-0d22eb9adac9.xls

				
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Description: Sample Bio Data Forms document sample