Nethera Kiza S.

Imperial - Balanced Score Card

Target

Initiative

Actual

>NALS training completed and % staff

passing

>every staff pass NALS

>Attend NALS training and be a certified

provider

>91% of the staff in the unit are NALS

provider

>Institute regular continuing education for

the whole team

>attendance for each topic >Schedule and assign different topic and
covered
updates to be discussed among colleagues
>Search for updates among chosen topics
for additional knowledge

1. Learning and Growth

>Conduct CME lectures

>Be active in professional organization

(e.g. MCNAP)

>Establish Mother-Baby Friendly Hospital

Program

>Facilitate lectures
assigned by the nursing
service
>every staff become
members of the
organization
>Promote breastfeeding
and rooming-in policies
>Conduct lactation

>Prepare syllabus, invitation and invite

pediatricians as speakers and nurses from
other departments as participants
>Register as members of the organization
>Attend annual seminars conducted by the
organization
>Promote breastfeeding to mothers
>Milk formulas will not be allowed in the
facility
>Immediately room-in well babies

>Monthly discussion together with a

pediatrician are held during scheduled
dates

>CME lectures are conducted on dates

assigned by the office with the
pediatrician as speaker with the
attendance from other staff nurses
>All staff members of the department
are members of the organization
>85% of the team were able to attend
the seminar conducted
>Breastfeeding is promoted in the
facility
>Milk formulas and feeding bottles are

management seminars to
all personnel

strictly prohibited
>Rooming-in of babies are implemented
for well babies

2. Internal Process
>Establish safe environment

>Reduce HAI

>Hand hygiene compliance

>Conduct environmental culture twice a
year
>Follow infection control protocols

>5 moments of and proper hand hygiene

are strictly followed
>Environmental culture is done twice a
year
>Audit committee passed the unit in
following infection control protocols

>Increase clinical research

>Increase research
projects initiated and
completed by the end of
2015

>Research grants renewed; alternative

research effort initiated

>Research projects initiated and

completed by 10% by the end of 2015

>Improve parent satisfaction

>Improve survey
response rate

>Random discharge patient satisfaction

survey
>Increase parent participation in patient
care
>Reviewing suggestion box concerns

>Obtained >80% very good and

outstanding levels in 1 year
>Recommendation to other families
>Positive feedback are reviewed from
the customers

>Instigate impressive staff satisfaction

>Obtain above average

and excellent ratings in 1
year

>Hospital-wide staff education and

incentive programs

>Obtained >86% above average and

excellent ratings in 1 year
>Recommendation from employees to

3. Customer Satisfaction

others
4. Financial Performance
>Reduce supplies expense
>Improve cost of NICU care

>10% reduction in
quarterly expenses from
2014 baseline

>Implement clinical pathway; review of

alternative supplies

>Benchmark quarterly budget from

2014, highlight variance for supplies

>Utilize all services to increase income of

the unit

>Increased productivity of the services