Performance Goals and Indicators for the Hospital’s Physical Environment
ACHC Standards are structured to align with a Plan-Do-Study-Act (PDSA) quality improvement framework. Within each chapter, standards identify required policies, the implementation of those policies, evaluation of the results, and communication of changes or corrective actions. The intent across each function is a proactive approach that enhances the quality of the services provided.
Physical environment standards for hospitals (chapter 11 for acute care and chapter 3 for critical access) cover design and construction, plus six areas applicable across the facility:
- Building Safety
- Building Security
- Hazardous Materials and Waste
- Fire Safety Control
- Medical Equipment Management
- Utility Systems Management
For each area, the required elements of ACHC Standard (11.00.02/03.00.02) state that performance goals or indicators are included in the written plan for each area. What exactly does this mean? Are they the same thing? How do you develop and, most importantly, use them for improvement? Goals and indicators are both metrics describing expected results. Getting these right can drive improvement and build team cohesion and collaboration.
Indicators as a Threshold for Action
Indicators are usually a measurement of an existing process that prompts action if a certain threshold is exceeded. For example, an organization may monitor the response time of security officers to panic buttons. Within the building security plan, this indicator could be written as:
We aim to maintain a security officer’s response time of less than two minutes when any panic buttons are activated, as measured by the security lead’s random monthly test. Results will be reported to the Safety Committee monthly.
Other examples of building safety and security performance indicators could include the number of safety violations for defined periods (i.e., monthly, or quarterly), the percentage of staff trained in emergency procedures, or the frequency of safety audits.
At least one indicator per function can be included in a dashboard routed to the Safety and QAPI Committees. Committee minutes should reflect that the measures have been reviewed and any concerns discussed, underscoring the committee’s integral role in the review process.
Goals as Directives for Effort
A performance improvement goal is used when the organization has identified an opportunity for improvement through corrective action, or change. Indicators and goals often work together. Consider the security officer response time example above. If the two-minute indicator was consistently exceeded, an improvement goal could be set and a corrective action identified. Performance improvement requires identification of a corrective action, remeasurement, additional action if needed, and communication to all relevant parties of any new procedures to be followed to maintain the goal (which then becomes an ongoing indicator).
A useful acronym for writing goals is make them SMART:
- Specific
- Measurable
- Attainable
- Realistic
- Timely
A SMART performance improvement goal for hazardous materials and waste might be stated as:
The goal for use of regulated medical waste to 1.8 pounds per adjusted patient day measured by the monthly disposal weight divided by the monthly adjusted patient days (lbs./APD).
Construction Considerations
Construction activities present specific risks to the quality of the physical environment. Proactive plans for measurement bring attention to these risks and support mitigation efforts in the physical environment. Considerations for construction-focused indicators and goals include:
- Building Safety – inspecting and maintaining barriers between the project and adjacent areas. Noise and vibrations are planned, scheduled, and communicated with impacted areas adjacent to and above or below the work site.
- Building Security – inspecting the construction work area to verify inaccessibility during non-work hours.
- Hazardous Materials and Waste – proper use of PPE for all workers and any observers of the construction area (hard hats and eye protection, etc.).
- Fire Safety Control – additional fire drills, use of hot-work permits, proper control of combustibles, and housekeeping practices of the work site.
- Utility Systems – air quality requirements are maintained.
Facilities teams that invest resources in identifying and articulating specific indicators and goals will be compliant with ACHC Standards and in a better position to make improvements that support increased quality of patient care.
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