KPI Analysis and Action Plan

Subject: Nursing
Pages: 4
Words: 882
Reading time:
4 min
Study level: Master


Key Performance Indicator (KPI) is a reliable tool for assessing how well a facility meets its goals. Calculating KPI is especially relevant for medical practices since accountability has become one of the important concepts of modern healthcare. For this assignment, KPI analysis was conducted at Temple University Hospital, Pennsylvania. This paper provides an in-depth KPI dashboard analysis and offers an action plan that aims to tackle such issues as the turnover rate, low patient satisfaction, and finance management.

KPI Dashboard Analysis

The strategic pillar dashboard analysis provided essential data to evaluate Temple University Hospital against four criteria – quality, people, service, and finance. The gathered evidence has demonstrated that quality-wise, the facility seems to be succeeding in meeting its goals. Namely, the survival rate has risen to 98.7%, which is slightly higher than the required 97.54%. Further, the readmission rate has plunged to 12.25%, therefore, meeting and even surpassing the required =<13.61%. Healthcare-associated infections (HAI) are also on the decline: the hospital has solved the issues of Clostridium difficile, central-line associated blood infections, and methicillin-resistant Staphylococcus aureus. However, Temple University Hospital has yet to improve the CAUTI (catheter-associated urinary tract infection) rate. Lastly, the Mental Health of America (MHAC) indicators are also showing signs of improvement.

As for the hospital staff, the Engagement Survey Score and Participation have shown that the employees are slightly less involved in the work process than expected (50% vs. the required =>60%). The overall turnover rate has gone all the way down to 22%; however, this is somewhat far from the norm of >=16%. The turnover rate for registered nurses is currently at 14%, which meets the requirement of =<19%. Nevertheless, after one year of employment, more nurses than expected quit their job – 5% vs. the expected 3%. When it comes to customer service, Temple University hospital demonstrates many weaknesses. First, according to the HCAHPS overall hospital rating, the facility only scored 66.1% as opposed to the desired >=70.23%. The ED CAHPS ranking puts Temple University hospital in the 11th percentile whereas the initial goal was to make it to the 50th percentile. The same goes for the OAS CAHPS ranking: Temple University hospital has yet to end up in the required 75th percentile. As for the rising tide domains, communication with nurses and staff responsiveness were evaluated positively by patients.

On the other hand, they were not as satisfied with pain management and communication about medication. Lastly, Temple University hospital has shown outstanding results in improving the cash flow margin that is not at 11.4%. However, the other indicators are not as optimistic: the program increment (PI) is down to $3.5 million as opposed to the norm of >=$4.3 million. The GBR volume variance (6.9%) is also somewhat outside the allowed range from 0 to 5.5%.

Action Plan

The necessary changes have to comply with the so-called PDSA model, which stands for Plan, Do, Study, Act. As Donnelly and Kirk (2015) put it, the cycle starts with making predictions based on reliable data. Further, health workers implement the plan on a small scale to test it, which constitutes the second phase. After that, the team gathers data once again for further analysis and making a more comprehensive plan with a greater impact. Only after these steps are complete, can the health workers take action.

In accordance with the KPI analysis and PDSA model, the following recommendations can be given. First, Temple University hospital can prevent nurse turnover by enhancing working conditions and making them more comfortable psychologically. Two ideas are up for consideration: checking staffing ratios, distributing shifts to allow for proper night sleep, and introducing mentorship programs (Dawson, Stasa, Roche, Homer, & Duffield, 2014). The lack of communication about medication can be tackled by implementing translation aids in case of a language discordance and holding training sessions in communication for nurses (O’Hagan et al., 2014).

Improving pain management is a complex task that requires ongoing communication and both health workers’ and patients’ genuine engagement (Riley, 2017). Nurses need to be more considerate about patients’ experiences and be more responsive when they express distress and discomfort. To promote safe health practices after discharge, patients need to be counseled on pain management strategies so that they could be self-sustainable (Goh & Corke, 2014). If Temple University hospital reaches the customer satisfaction goals, it is likely to move up the ranks and score better at different ratings. Lastly, a better, more sound budget is likely to tackle the issues of the underwhelming PI and excessive volume variance (Kuhlmann, Blank, Bourgeault, & Wendt, 2016). These are general recommendations that may be subject to readjustment if they prove to be faulty during the third phase, Study.


Accountability is understood as the ability of a medical facility to ensure that the direction that the organization has chosen is aligned with its health objectives. KPI analysis provides actual, measurable data that allows for troubleshooting, highlighting growth areas, and putting together a comprehensive action plan. The KPI dashboard analysis has shown that Temple University hospital is meeting its goals when it comes to quality. However, there needs to be something done about people, service, and finance. A comprehensive action plan should be based on the PDSA model within which health workers would make predictions, implement changes, and study the outcomes.


Dawson, A. J., Stasa, H., Roche, M. A., Homer, C. S., & Duffield, C. (2014). Nursing churn and turnover in Australian hospitals: Nurses perceptions and suggestions for supportive strategies. BMC Nursing, 13(1), 11.

Donnelly, P., & Kirk, P. (2015). Use the PDSA model for effective change management. Education for Primary Care, 26(4), 279-281.

Goh, S., & Corke, P. (2014). Postoperative pain management. Australian Prescriber, 37(3), 76-78.

Kuhlmann, E., Blank, R., Bourgeault, I., & Wendt, C. (Eds.). (2016). The Palgrave international handbook of healthcare policy and governance. Berlin, Germany: Springer.

O’Hagan, S., Manias, E., Elder, C., Pill, J., Woodward-Kron, R., McNamara, T.,… McColl, G. (2014). What counts as effective communication in nursing? Evidence from nurse educators’ and clinicians’ feedback on nurse interactions with simulated patients. Journal of Advanced Nursing, 70(6), 1344-1355.

Riley, J. B. (2017). Communication in nursing (8th ed.). Amsterdam, Netherlands: Elsevier Health Sciences.