November 28, 2018 | | Comments 1
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You might have succeeded in changing: Using the annual evaluation to document progress!

I know some folks use the fiscal year (or as one boss a long time ago used to say, the physical year) for managing their annual evaluation process, but I think most lean towards the calendar year. At any rate, I want to urge you (and urge you most sincerely) to think about how you can use the annual evaluation process to demonstrate to leadership that you truly have an effective program: a program that goes beyond the plethora of little missteps of the interaction of humans and their environment. As we continue to paw through the data from various regulatory sources, it continues to be true more often than not that there will be findings in the physical environment during your organization’s next survey. In many ways, there is almost nothing you can do to hold the line at zero findings, so you need to help organizational leadership to understand the value of the process/program as a function of the management of a most imperfect environment.

I think I mentioned this not too long ago: I was probably cursing the notion of a dashboard that is so green that you can’t determine if folks are paying attention to real-life considerations or if they’re just good at cherry-picking measures/metrics that always look good. But as a safety scientist, I don’t want to know what’s going OK, I want to know about what’s not going OK and what steps are being taken to increase the OK-ness of the less than OK (ok?!?). There are no perfect buildings, just as there are no perfect organizations (exalted, maybe, but by no means perfect) and I don’t believe that I have ever encountered a safety officer that was not abundantly aware of the pitfalls/shortcomings/etc. within their organizations, but oh so often, there’s no evidence of that in the evaluation process (or, indeed, in committee minutes). It is the responsibility of organizational leadership to know what’s going on and to be able to allocate resources, etc., in the pursuit of excellence/perfection; if you don’t communicate effectively with leadership, then your program is potentially not as high-powered as it could be.

So, as the year draws to a close, I would encourage you to really start pushing down on your performance measures—look at your thresholds—have you set them at a point for which performance will always be within range. Use the process to drive improvement down to the “street” level of your organization—you’ve got to keep reaching out to the folks at point of care/point of service—in a lot of ways they have the most power to make your job easier (yeah, I know there’s something a little counterintuitive there, but I promise you it can work to your benefit).

At any rate, at the end of the process, you need to be able to speak about what you’ve improved and (perhaps most importantly) what needs to be improved. It’s always nice to be able to pat yourself on the back for good stuff, but you really need to be really clear on where you need to take things moving forward.

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Filed Under: Hospital safetyThe Joint Commission

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Steve MacArthur About the Author: Steve MacArthur is a safety consultant with The Greeley Company in Danvers, Mass. He brings more than 30 years of healthcare management and consulting experience to his work with hospitals, physician offices, and ambulatory care facilities across the country. He is the author of HCPro's Hospital Safety Director's Handbook and is contributing editor for Briefings on Hospital Safety. Contact Steve at stevemacsafetyspace@gmail.com.

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  1. Bravo, Steve!!! A dashboard that’s all (or mostly) green tells me were either not challenging oursleves or not being truthful. And the annual management plan evaluation should not tell the reader how perfect everything is. It’s not! IMHO, the annual evaluation should contain some bragging, but also some opportunities for improvement that were identified and how they were managed.

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