Table 1

Initial measures and improvement Projects*

A: Performance domain
Baseline dataImprovement ProjectAim statement
Discharge timing
(percentage of discharges before 13:00)
9%Early dischargesDischarge 70% of patients before 13:00 by 30 June 2018
Skin injuries
(no of preventable injuries per week)
two per weekSkin injuriesEliminate preventable skin injuries, including phlebitis, by 30 June 2018
Laboratory tests
(no of samples per patient per day)
1.5 samples per patient per dayLaboratory testsReduce the no of laboratory tests by 20% by 30 June 2018
VTE risk assessment*
(percentage of patients undergoing assessment on admission)
5%VTE risk assessmentNot taken for initial aim. Included later
Blood sample rejection*
(total no of samples rejected per week)
2.4%Blood samples rejection rateInterventions included with laboratory tests project. Later incorporated separately on the box score
Nursing satisfaction (Joy in Work)—a balancing measure
(percentage of nurses declaring ‘a good shift’)
60%Nursing Satisfaction (Joy in Work)Balancing measure
B: Capacity domain
Measure (definition—percentage of total nursing hours)Baseline dataImprovement ProjectAim statement
Direct nursing hours
(hours spent in patient facing care)
57%Nursing care hoursIncrease the percentage of time nurses spend in direct patient care by 30% by 30 June 2018
C: Cost domain
Measure (definition—total spend per week)Improvement projectAim statement
ConsumablesConsumables costReduce consumables cost by 20% by 30 June 2018
  • *Not all the initial measures triggered an improvement project at the beginning.

  • VTE, venous thromboembolism.