Table 1 Areas of interest related to organizational performance

The percent by which a hospital's total revenue differs from its total expenses, excluding the impact of facility amortization (land, building and building service equipment). (Revenue – Expenses) * 100 / Revenues

Total margin

How much a hospital spends in a given year to operate and maintain its computer systems, x-ray machines, and other capital equipment, compared to its total expenses. Equipment expense * 100 / Expenses

% Equipment expenses

The proportion of full-time patient care personnel hours that were paid sick hours Sick hours * 100 / Full-time earned hours

% Sick time

The proportion of nursing care hours that were provided by registered nurses Acute inpatient registered nursing earned hours * 100 / Acute inpatient nursing earned hours

% Registered nurses

Staff Roles: Which of the following staff roles currently exist in your organization? (Nurse practitioner, Nurse specialist, Nurse educator in ED, Staff for professional practice, Clinical specialist, Hospitalist, Social worker, Case manager, Staff for physician recruitment, Volunteer coordinator, Decision support role, Telehealth coordinator, Utilization review analyst, Risk management analyst, Staff for equity issues, Ombudsperson)

Number of permanent roles

What percentage of physicians with administrative roles participated in continuing education activities (e.g., formal in-service programs, internal/external courses and conferences) supported by your organization

Some or most professionals are educated in quality

What percentage of nursing staff participated in continuing education activities (e.g., formal in-service programs, internal/external courses and conferences) supported by your organization?

What percentage of other patient care staff participated in continuing education activities (e.g., formal in-service programs, internal/external courses and conferences) supported by your organization?

Are electronic records and data currently being used in your organization as a primary source of information? (Patient visit registration information; Diagnostic imaging reports; Electronic medical images; Diagnostic laboratory results; Patient-based pharmacy/drug profiles; Nursing and physician clinical documentation; Clinical documentation by other health professionals)

Number of areas where electronic records and date are used

For each of the following clinical measures, to what extent are these data currently collected, shared and used in your organization? (Unplanned return to the OR; Hospital-acquired infection or sepsis; Adverse drug reaction; Unplanned injury or unplanned repair of organ during surgery; Unplanned transfer to ICU/CCU; In-hospital mortality; Hospital-acquired injury (e.g., falls); Waiting time to gain access from the ED to inpatient bed; Unplanned readmission; Percent of day-surgery patients; Percent procedures completed on scheduled day)

Number of areas where data are collected and shared

Our organization has a policy for hand hygiene.

Yes/No

Our organization has adopted patient safety as a written, strategic priority/goal.

Yes/No

Our organization has implemented a formal policy and process of disclosure of adverse events to patients/families, including support mechanisms for patients, family, and care/service providers.

Yes/No

Patient’s current medications are reconciled against those prescribed in hospital on admission and with the patient’s involvement.

Yes/No

A complete list of the patient's medications is reconciled and communicated to the next provider of health care service when the patient is referred or transferred to another setting, service, practitioner, or level of care within or outside of the hospital.

Yes/No