HospiTEL Nursing Leadership Dashboard
"The Main Thing Is to Keep the Main Thing the Main Thing" — The patient, their safety, their medication, their family, and the story they tell about Oasis Point.
As you complete this dashboard, remember: Patient → Team → Self in every narrative. You are the calmest leader in the room. Every hint of distress is a service-recovery opportunity. Documentation is not loop closing—fixing systems is loop closing.
In the HospiTEL model, the Director of Nursing is a guardian of hospitality, safety, and emotional healing — measuring both hard metrics (clinical, regulatory, financial) and soft metrics (human experience, culture, and empathy). This dashboard reflects the eight pillars of H.O.S.P.I.T.E.L. that define who we are and how we deliver 5-star IRF care.
Our operating system: measuring both clinical excellence and cultural excellence across the eight pillars.
Create an environment that heals emotionally as well as physically
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
First-Impression Readiness Score(Facility) | Spot-check of arrival zones (entry, lobby, hall scent/lighting, front-desk presence, wayfinding). HSO 10-point checklist, twice daily; score = points met ÷ points possible. | ≥95% | ||
Suite Presentation & Turnover Readiness(Facility) | Room 'hotel-grade' readiness at admission and post-discharge turnover time. % suites passing a 15-point presentation checklist before occupancy; median turnover minutes from discharge to 'ready.' | ≥98% pass; ≤60 min | ||
Quiet-at-Night Compliance(Facility) | Nighttime serenity (noise, light, interruptions). Random HSO sound/light rounds + patient spot surveys; % shifts with zero noise alerts; ≤1 non-clinical interruption per patient between 10p–6a. | ≥90% | ||
Concierge Response Time & Resolution(Facility) | Speed and completeness of non-clinical service requests (linens, tech help, amenities). Median minutes from ticket open→first touch; % resolved within SLA (15 min easy, 60 min complex). | ≤5 min; ≥95% | ||
Dining Experience On-Time & Delight Score(Facility) | Punctuality and guest-rated quality of chef-curated meals. % trays delivered within ±10 minutes of scheduled time; CSAT 1–5 after meals; 'delight' = % 5/5 ratings. | ≥97% on-time; ≥85% delight | ||
Family Engagement Index(Facility) | Family participation in rounds, education, and amenities (wellness center, movie night, chapel). % patients with ≥1 family-involved education event/week + % attending family rounds + amenity utilization rate. | ≥80% | ||
Service-Recovery Half-Life(Facility) | How fast we turn a service miss into a 'win.' Median hours from complaint → documented resolution with close-the-loop follow-up; % issues resolved in first contact. | ≤4 hrs; ≥70% | ||
Staff Warmth & Greeting Compliance(Facility) | Observed courtesy behaviors ('on-stage' posture, name use, eye contact, HEAT/AIDET-style openers). Secret-shopper/HSO audits; % encounters meeting all greeting elements. | ≥95% | ||
Wayfinding & Wait Transparency(Facility) | Guests' ease of navigation and clarity about waits. % guests who reach destination without asking twice; % waits with posted ETA and updates every 10 minutes. | ≥90%; ≥95% | ||
'This Felt Like a Healing Place' Score(Facility) | Sentiment that blends environment + empathy. Discharge micro-survey ('Strongly agree' to the statement) plus open-text sentiment analysis; report top drivers by unit. | ≥90% |
Ensure consistency of care and service at every touchpoint
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
% staff trained on HospiTEL standards(HR/Training) | Percentage of all staff (clinical + non-clinical) who have completed HospiTEL cultural training and competency validation. Tracks completion of initial orientation plus annual refreshers. | 100% | ||
Handoff communication compliance (SBAR)(Nursing Quality) | Adherence to SBAR (Situation, Background, Assessment, Recommendation) structured communication during shift changes, transfers, and interdisciplinary handoffs. Measured via direct observation audits. | 100% | ||
Medication reconciliation accuracy(Pharmacy) | Accuracy of medication lists reconciled at admission, transfer, and discharge. Compares documented medications against actual home medications and physician orders. Critical safety metric. | ≥98% | ||
Discharge planning initiated within 24 hrs of admission(Case Management) | Percentage of patients with documented discharge planning assessment and initial plan within 24 hours of admission. IRF CoP requirement and best practice for optimal outcomes. | ≥95% | ||
Standardized care plan adherence(Nursing Quality) | Compliance with evidence-based care protocols and standardized care plans for common IRF diagnoses (stroke, joint replacement, spinal cord injury, etc.). Measured via chart audits. | ≥95% |
Build a just culture where safety is everyone's responsibility
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
HAI(Facility Surveillance) | Healthcare-Associated Infections - Any infection acquired during hospital stay that was not present at admission. Zero tolerance target reflects commitment to infection prevention protocols. | 0 | ||
CAUTI Rate (per 100 fds)(Facility Tracking / NHSN Reporting) | Catheter-Associated Urinary Tract Infections per 100 facility days. Preventable infection tracked via NHSN (National Healthcare Safety Network). Critical CMS quality measure. | 0 | ||
# Patient Days w/ Catheter(Facility Surveillance) | Total patient days with indwelling urinary catheter. Tracking metric to monitor catheter utilization and support CAUTI rate denominator calculations. | Track | ||
# Patient Days w/ Central Line(Facility Surveillance) | Total patient days with central venous catheter. Tracking metric for CLABSI rate calculations and device utilization monitoring. | Track | ||
C-Diff Rate (per 100pds)(eRehabdata) | Clostridioides difficile infection rate per 100 patient days. Hospital-onset C. diff is a key quality and safety indicator requiring aggressive prevention protocols. | 0 | ||
Hand Hygiene Compliance(Pharmacy Tracking) | Percentage of observed hand hygiene opportunities where proper technique was performed. Foundation of infection prevention; measured via direct observation audits. | 100% | ||
Infection control bundle compliance(Nursing Quality / Facility Tracking) | Adherence to evidence-based infection prevention bundles (CAUTI bundle, CLABSI bundle, VAP bundle, etc.). All-or-nothing measurement of bundle element completion. | 100% | ||
Falls Since Admission(Facility Tracking) | Total number of patient falls during current reporting period. Zero harm goal requires proactive fall prevention strategies and environmental safety. | 0 | ||
Falls Since Admission Percentage(Facility Tracking) | Percentage of patients who experienced a fall during admission. Tracks prevalence of fall events across patient population. | 0% | ||
Fall rate / 1,000 pt-days(Nursing Quality / Facility Tracking) | Falls per 1,000 patient days - standardized rate allowing comparison across facilities and time periods. IRF benchmark typically 3.0-4.0; excellence target ≤3.0. | ≤3.0 | ||
# Medication doses(Facility Tracking) | Total medication doses administered during reporting period. Denominator for medication error rate calculations. | Track | ||
# Medication Errors(Facility Tracking) | Total medication errors (wrong drug, dose, time, route, patient). Zero tolerance reflects high-reliability medication safety culture. | 0 | ||
Medication Error Rate (per 1000 doses)(Facility Tracking) | Medication errors per 1,000 doses administered. Industry benchmark <1.0; excellence facilities achieve <0.5. Includes all error types regardless of patient harm. | <1 | ||
# Transcription Errors(Facility Tracking) | Errors occurring when transferring medication orders from one format to another (verbal to written, written to MAR, etc.). Preventable through EHR and verification protocols. | 0 | ||
# Documentation Errors(Facility Tracking) | Medication administration documentation errors (missing signature, wrong time documented, etc.). Critical for audit trail and regulatory compliance. | 0 | ||
# Dispensing Errors(eRehabdata) | Pharmacy dispensing errors (wrong medication, strength, or quantity dispensed). Requires pharmacy-nursing partnership and barcode verification. | 0 | ||
# Administration Errors(QMIRF) | Errors during medication administration (wrong patient, time, route, technique). Most common error type; prevented through 5 Rights verification. | 0 | ||
# Omissions(QMIRF) | Scheduled medications not administered without documented clinical reason. Omissions can compromise patient outcomes and indicate workflow issues. | 0 | ||
Adverse Drug Events(Facility Tracking) | Harm to patient caused by medication use (adverse reactions, interactions, errors causing harm). Subset of medication errors that reach the patient and cause injury. | 0 | ||
Med error severity index(Facility Tracking) | Average severity of medication errors using NCC MERP index (0=no error, 9=death). Target ≤2 indicates errors caught before reaching patient or causing minimal harm. | ≤2 | ||
Medication Refrigerator Temperature Checks(Facility Tracking) | Compliance with required refrigerator temperature monitoring (2-8°C) for temperature-sensitive medications. Regulatory requirement and medication integrity safeguard. | 100% | ||
Drug Regime review conducted with follow-up for ID'd issues(Facility Tracking) | Percentage of patients receiving comprehensive medication regimen review by pharmacist with documented follow-up on identified issues. IRF CoP requirement. | 100% | ||
#New Pressure Ulcers (not identified in admit assessment)(Facility Tracking) | Hospital-acquired pressure injuries (HAPI) - pressure ulcers developed after admission. Zero tolerance for preventable harm; requires skin assessment and prevention protocols. | 0 | ||
#Worsened Pressure Ulcers(Facility Tracking) | Pressure ulcers present on admission that progressed to higher stage during stay. Indicates inadequate wound care or prevention strategies. | 0 | ||
HAPI rate (new pressure injuries)(Nursing Quality / Facility Tracking) | Hospital-Acquired Pressure Injury rate - percentage of patients developing new pressure ulcers during admission. CMS never event; zero tolerance standard. | 0 | ||
Crossmatch Transfusion Ratios(Facility Tracking) | Ratio of blood units crossmatched to units actually transfused. Efficiency metric; high ratios indicate over-ordering and blood product waste. | Track | ||
# Blood Transfusion Reactions(Facility Tracking) | Adverse reactions to blood product transfusions (hemolytic, allergic, febrile, etc.). Zero tolerance; requires rigorous verification and monitoring protocols. | 0 | ||
Mortality Reviews Completed(Facility Tracking) | Percentage of patient deaths receiving comprehensive mortality review by interdisciplinary team. Quality improvement and learning opportunity; regulatory expectation. | 100% | ||
Deaths within 48 hours of admission(Facility Tracking) | Patient deaths occurring within 48 hours of IRF admission. Sentinel event requiring immediate review; may indicate inappropriate admission or acute decompensation. | 0 | ||
# Restraint Days(Facility Tracking) | Total patient days with physical or chemical restraints. Tracking metric to monitor restraint utilization and support restraint-free care initiatives. | Track | ||
% Restraint charts compliant with policy(Facility Tracking) | Compliance with restraint documentation requirements (physician order, time-limited, monitoring, alternatives attempted). CMS CoP requirement; subject to survey. | 100% | ||
# CPR Resuscitation(Facility Tracking) | Number of cardiopulmonary resuscitation events (code blue). Tracking metric for emergency preparedness and code team performance review. | Track | ||
% CPR Resuscitation successful(Facility Tracking) | Percentage of CPR events resulting in return of spontaneous circulation (ROSC). Quality metric for code team effectiveness and patient selection for resuscitation. | Track | ||
Near-miss reporting frequency (↑ = open culture)(Facility Tracking) | Number of near-miss safety events reported weekly. Higher reporting indicates open safety culture where staff feel safe reporting errors without fear of punishment. | ≥10/week | ||
% incidents closed with RCA within 72h(Facility Tracking) | Percentage of safety incidents receiving Root Cause Analysis and closure within 72 hours. Rapid investigation prevents recurrence and demonstrates accountability. | 100% |
Integrate therapy, nursing, and emotional well-being for each patient
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
% care plans personalized with therapy + psychosocial goals(Nursing Quality / Facility Tracking) | Percentage of care plans that include individualized therapy goals AND psychosocial/emotional well-being goals. Reflects whole-person care approach beyond physical rehabilitation. | 100% | ||
Daily therapy readiness checklist completion(Facility Tracking) | Nursing completion of daily therapy readiness assessment (pain controlled, vitals stable, patient rested, etc.). Ensures patients are medically and emotionally prepared for therapy sessions. | 100% | ||
% nurses documenting patient preferences (music, routine, etc.)(Facility Tracking) | Percentage of nurses documenting patient personal preferences (wake time, music, food, routine, etc.) in care plan. Demonstrates commitment to individualized, patient-centered care. | ≥90% | ||
Family engagement in discharge teaching(Facility Tracking) | Percentage of discharges where family/caregiver participated in discharge teaching sessions. Critical for successful home transitions and caregiver preparedness. | ≥95% | ||
Observed nurse-patient rapport (H.E.A.R.T. rounds)(Facility Tracking) | Average score from H.E.A.R.T. (Hear, Empathize, Apologize, Respond, Thank) rounding observations of nurse-patient interactions. Measures relationship quality and therapeutic communication. | ≥4/5 | ||
Acute Care Discharge Reviews completed(eRehabdata) | Percentage of patients discharged to acute care who receive comprehensive discharge review within 72 hours. Identifies opportunities to prevent future acute transfers. | 100% | ||
Against Medical Advice (AMA)(eRehabdata) | Number of patients who left against medical advice. Zero tolerance; AMA discharges indicate dissatisfaction, communication breakdown, or unmet needs requiring investigation. | 0 |
"Therapists Train, Nurses Teach" — Mission-driven accountability: Structure is non-negotiable, culture is not optional. Metrics measure both clinical excellence AND alignment with Mission → Team → Individual framework.
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
Pre-Session Checklist Completion Rate(Facility Tracking) | CULTURE SIGNAL: Structure is non-negotiable. % of robotics sessions where nursing pre-session checklist is completed in full. No shortcuts, even when 'I know better.' Partial completion = operating outside the structure. | 100% | ||
Contraindication Screening Documentation(Nursing Documentation) | CULTURE SIGNAL: No exceptions. % of robotics sessions with documented contraindication screening before every session. Even if 'we've done this patient 20 times before,' the checklist is completed. This is discipline. | 100% | ||
Adverse Event Documentation Within 2 Hours(Incident Tracking) | CULTURE SIGNAL: Accountability is not optional. % of robotics adverse events where nursing documentation is complete within 2 hours. When something goes wrong, we document immediately and transparently. | 100% | ||
Nursing Staff Trained for Robotics (All 6 Devices)(DON Office) | CULTURE SIGNAL: You cannot teach what you have not learned. % of nursing staff trained in robotics patient education for all 6 devices (Lokomat, Ekso, Bioness Vector, ROBERT, HydroWorx, Bemo). Training is not a suggestion. | 100% | ||
Pre-Session Preparation Completed On Time(Facility Tracking) | CULTURE SIGNAL: Therapists cannot train if nurses have not prepared. % of robotics sessions where nursing pre-session preparation is completed on time (patient toileted, skin assessed, medical clearance verified). This measures whether nursing owns their role in the structure. | ≥95% | ||
Therapy Hold Rate Due to Nursing Causes(Therapy Department) | CULTURE SIGNAL: When therapy is held because nursing did not fulfill their role (patient not ready, contraindication not screened), it reflects misalignment with the mission. Mission → Team → Individual. | ≤2% | ||
Pre-Session Nursing Education Completion(Nursing Documentation) | CULTURE SIGNAL: This is the nursing role in 'Therapists train, Nurses teach.' % of patients scheduled for robotics who receive pre-session nursing education. If this is not 100%, nurses are not fulfilling the mission. | 100% | ||
Family Confidence in Nursing Safety Monitoring(Patient Satisfaction Survey) | CULTURE SIGNAL: Families must trust that nurses are competent guardians of safety. % of families who report confidence in nursing robotics safety monitoring. This is not optional. | ≥95% | ||
Vital Sign Monitoring Documentation(Nursing Documentation) | CULTURE SIGNAL: No shortcuts. % of robotics sessions with documented nursing vital sign monitoring (pre/during/post). Even if 'the patient looks fine,' vitals are documented. This is discipline. | 100% | ||
Skin Integrity Checks Documentation(Nursing Documentation) | CULTURE SIGNAL: Skin breakdown is preventable. % of robotics sessions with documented skin integrity checks at harness/device contact sites. If it happens, it reflects failure to follow structure. | 100% | ||
Adverse Events Requiring Nursing Intervention(Incident Tracking) | CULTURE SIGNAL: Low rate = proactive monitoring. High rate = reactive monitoring (failure to screen contraindications or prepare properly). % of robotics sessions requiring nursing intervention for vital sign changes, orthostatic responses, skin breakdown, patient distress. | ≤2% | ||
HospiTEL Environment Optimization Compliance(DON Office) | CULTURE SIGNAL: These are not 'nice-to-haves.' They are the framework that amplifies robotics effectiveness. % compliance with HospiTEL robotics environment optimization (quiet recovery suites, warm towel/heat therapy pre-session, private changing areas, coordinated scheduling). Culture is not optional. | 100% | ||
Same-Day Documentation Completion(Nursing Documentation) | CULTURE SIGNAL: Accountability means documenting in real-time, not when it's convenient. % of robotics documentation completed same-day (no retrospective charting). | 100% | ||
Root Cause Analysis Completion Within 72h(DON Office) | CULTURE SIGNAL: We do not distance ourselves when problems arise. % of robotics adverse events closed with root cause analysis within 72 hours. We analyze, learn, and improve. | 100% |
Shared accountability across all disciplines
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
Attendance at daily rehab readiness huddles(Facility Tracking) | Percentage of nursing staff attending daily interdisciplinary rehab readiness huddles. 100% attendance demonstrates commitment to team communication and shared accountability. | 100% | ||
Therapy hold rate due to nursing causes(Therapy Department) | Percentage of scheduled therapy sessions held/canceled due to nursing-related causes (patient not ready, pain not managed, contraindication not screened). Low rate reflects strong nursing-therapy collaboration. | ≤2% | ||
Cross-department handoff compliance(Nursing Quality) | Compliance with structured handoff communication (SBAR) during interdisciplinary transitions (nursing to therapy, nursing to case management, etc.). Critical for patient safety and continuity. | 100% | ||
IDT members' satisfaction with nursing communication(IDT Survey) | Interdisciplinary team members' satisfaction rating of nursing communication quality, timeliness, and collaboration. Measured via quarterly IDT survey. | ≥4.5/5 | ||
"No-blame" feedback examples logged weekly(Facility Tracking) | Number of constructive, no-blame feedback exchanges logged weekly between nursing and other disciplines. Higher numbers indicate psychological safety and open communication culture. | ≥3 |
Nurture a healing environment grounded in compassion
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
% nurses completing Empathy/H.E.A.R.T. training(HR/Training) | Percentage of nursing staff who have completed H.E.A.R.T. (Hear, Empathize, Apologize, Respond, Thank) empathy training. Foundation for compassionate communication and therapeutic relationships. | 100% | ||
Empathy index (patient-reported)(Patient Satisfaction Survey) | Percentage of patients who report feeling heard, understood, and cared for by nursing staff. Measured via validated empathy scale questions on patient satisfaction surveys. | ≥90% | ||
Rounding notes reflecting psychosocial attention(Nursing Documentation) | Percentage of nursing rounding documentation that includes psychosocial observations (emotional state, coping, family concerns, fears, goals). Reflects whole-person care approach. | ≥95% | ||
Emotional tone observed in patient interactions(Leadership Rounding) | Average rating of nursing staff's emotional tone during patient interactions (warmth, patience, active listening). Measured via leadership rounding observations and patient feedback. | ≥4.5/5 | ||
Peer recognition for compassionate care(Facility Tracking) | Number of peer-to-peer recognitions for compassionate care examples per week. High frequency indicates culture where empathy is valued and celebrated. | ≥10/week |
Every nurse leads by example; the DON leads through visibility
| Metric | Target | Actual | Culture Signal / Notes | |
|---|---|---|---|---|
DON leadership rounding frequency(DON Office) | Frequency of DON leadership rounding (visible presence on units, staff engagement, patient interaction). Daily rounding demonstrates servant leadership and accessibility. | Daily | ||
% shift huddles attended by charge RNs(Facility Tracking) | Percentage of shift huddles where charge RN is present and actively leading. Charge RNs model leadership through consistent presence and engagement. | 100% | ||
Nurse leader-to-staff ratio(HR/Staffing) | Ratio of nurse leaders (charge RNs, supervisors) to staff nurses. Optimal ratio ensures adequate coaching, mentorship, and support. Target 1:15 or better. | 1:15 | ||
% completed coaching conversations(DON Office) | Percentage of planned coaching conversations completed by nurse leaders. Reflects commitment to staff development and accountability. Measured via coaching logs. | ≥90% | ||
Staff morale rating (pulse survey)(HR Pulse Survey) | Average staff morale rating from monthly pulse surveys. High morale reflects effective servant leadership, psychological safety, and supportive culture. | ≥4/5 | ||
Retention of top performers(HR) | Retention rate of top-performing nurses (identified via performance reviews and peer recognition). High retention indicates effective leadership and career development support. | ≥95% |
Regulatory requirements and clinical performance indicators
| IRF Metric | Requirement | This Week | YTD | Comments |
|---|---|---|---|---|
| PAPE (24h post-admit) completed | 100% | |||
| IOPOC (≤4 days) completed | 100% | |||
| Weekly IDT attendance | 100% | |||
| Section GG accuracy | ≥95% | |||
| GG Audit Completion | 100% | |||
| IRF Documentation Compliance | 100% | |||
| Care Plans Updated | 100% | |||
| Shift Assessments Completed | 100% |
| Category | Target | Actual | Variance |
|---|---|---|---|
| RN Hrs per Pt Day (HPPD) | |||
| LPN HPPD | |||
| PCT HPPD | |||
| Overtime % | |||
| Agency Hours % | |||
| Call-ins / Absences |
| Indicator | This Week | Prior Week | Trend |
|---|---|---|---|
| Patient Falls | |||
| HAPIs (New) | |||
| Med Errors (Severe) | |||
| Infection Events | |||
| Readmissions (within 7 days) |
| Metric | Target | Actual | Comments |
|---|---|---|---|
| Physician orders taken off within 1 hour of receipt | 100% | ||
| STAT orders executed within 15 minutes | 100% | ||
| Routine orders executed within 4 hours | ≥95% | ||
| Lab results reported to physician within 1 hour | 100% | ||
| Diagnostic results reported to physician within 2 hours | 100% | ||
| Critical values reported to physician immediately | 100% |
| COP Standard | Requirement | Compliance % | Deficiencies / Action Plan |
|---|---|---|---|
| Patient Rights (42 CFR 482.13) | 100% | ||
| Nursing Services (42 CFR 482.23) | 100% | ||
| Medical Record Services (42 CFR 482.24) | 100% | ||
| Infection Prevention & Control (42 CFR 482.42) | 100% | ||
| Quality Assessment & Performance Improvement (42 CFR 482.21) | 100% | ||
| State Licensure Requirements (Nursing Standards) | 100% | ||
| State Licensure Requirements (Staffing Ratios) | 100% | ||
| Medicare IRF-PAI Compliance | 100% |
Cross-cutting measures that reflect culture and operational excellence
| Metric | Target | Actual | Notes |
|---|---|---|---|
| % patients ready on time for therapy sessions | ≥95% | ||
| Night-to-morning delays due to vitals/labs | ≤2 | ||
| H.E.A.R.T. Audit Score (composite hospitality) | ≥3.5/4.0 | ||
| Staff engagement pulse survey | ≥4/5 | ||
| Promise Board completion (% staff) | ≥90% | ||
| "Wow" moments captured | ≥5 | ||
| Missed hospitality opportunities (service recoveries) | ≤3 | ||
| Leadership rounds completed by DON | 100% |
Executive-level metrics: Financial stewardship, workforce development, regulatory readiness, and organizational leadership
Nursing department financial performance and resource optimization
| Metric | Target | Actual | Variance Notes | |
|---|---|---|---|---|
Labor Cost Per Patient Day (RPPD)(Finance/Payroll) | ≤$550 | |||
Overtime Percentage(Payroll) | ≤5% | |||
Agency/Contract Staffing Usage(Payroll) | ≤2% | |||
Nursing Supply Cost Variance(Finance) | ±3% of budget | |||
Budget Variance (Nursing Dept)(Finance) | ±5% of budget | |||
Productivity (Hours per Patient Day)(Payroll/Census) | 8.5-9.5 hrs/pt/day |
Talent acquisition, retention, and professional growth
| Metric | Target | Actual | Action Plan | |
|---|---|---|---|---|
RN Turnover Rate (Annualized)(HR) | ≤15% | |||
RN Vacancy Rate(HR) | ≤8% | |||
Time-to-Fill Critical Positions (Days)(HR) | ≤45 days | |||
90-Day New Hire Retention(HR) | ≥85% | |||
Training Hours Per FTE (Monthly)(Education) | ≥4 hrs/FTE | |||
HospiTEL Training Completion Rate(Education) | 100% | |||
Staff Certifications Earned (This Week)(Education) | Track |
CMS compliance, survey preparedness, and quality assurance
| Metric | Target | Actual | Corrective Action | |
|---|---|---|---|---|
Open Survey Deficiencies(QAPI) | 0 | |||
Plan of Correction Completion Rate(QAPI) | 100% | |||
Mock Survey Score (Last Month)(QAPI) | ≥95% | |||
CMS Star Rating Trajectory(CMS) | Improving | |||
Policy Review Completion (Annual)(QAPI) | 100% | |||
Nursing Documentation Audit Score(QAPI) | ≥95% |
42 CFR 412.622-412.638: IRF-unique regulatory requirements and state licensure compliance
| IRF-Specific Regulatory Requirement | Target | Actual | Compliance Notes | |
|---|---|---|---|---|
Nursing Services 24/7 RN Availability(42 CFR 412.622(b)) | 100% | |||
Preadmission Nursing Assessment (<48hrs)(42 CFR 412.622(a)(4)(i)) | 100% | |||
Post-Admission Physician Orders Executed (<24hrs)(42 CFR 412.622(a)(4)(ii)) | 100% | |||
IRF-PAI Section GG (Self-Care) Accuracy(42 CFR 412.606) | 100% | |||
Nursing Care Plan Documentation(42 CFR 412.622(b)) | 100% | |||
Medication Reconciliation (Admission/Transfer/DC)(42 CFR 482.24) | 100% | |||
Nursing Documentation Timeliness(42 CFR 482.24) | 100% | |||
Patient/Family Education (Nursing Component)(42 CFR 412.622(a)(7)) | 100% | |||
Nursing Participation in IDT Meetings(42 CFR 412.622(a)(3)(v)) | 100% | |||
State Nursing Licensure Requirements(State Regs) | 100% |
Clinical outcomes, discharge performance, and value-based care metrics
| Metric | Target | Actual | Improvement Strategy | |
|---|---|---|---|---|
CMG (Case Mix Group) Performance vs Benchmark(eRehabdata) | ≥National Avg | |||
Discharge to Community Rate(Facility Tracking) | ≥75% | |||
30-Day Readmission Rate(Facility Tracking) | ≤12% | |||
Average Length of Stay vs Target(Facility Tracking) | Within 1 day | |||
Functional Gain (FIM/GG Improvement)(eRehabdata) | ≥National Avg | |||
Patient Satisfaction (HCAHPS Top Box)(HCAHPS) | ≥85% |
Critical strategic priorities: Robotics program, HospiTEL implementation, and organizational innovation
| Metric | Target | Actual | Progress Update | |
|---|---|---|---|---|
Robotics Utilization Rate (% Eligible Patients)(Therapy/Facility) | ≥60% | |||
HospiTEL Training Completion (All Nursing Staff)(Education) | 100% | |||
Innovation Projects Launched (This Quarter)(DON Office) | ≥2 | |||
Community Partnership Events (Monthly)(Marketing) | ≥1 | |||
Press/Media Mentions (Robotics Program)(Marketing) | Track | |||
Staff Innovation Ideas Submitted(DON Office) | Track |
Team coordination, physician relations, and cross-functional effectiveness
| Metric | Target | Actual | Collaboration Notes | |
|---|---|---|---|---|
IDT Meeting Attendance (Nursing)(Facility Tracking) | 100% | |||
Physician Satisfaction Score (Nursing Support)(Survey) | ≥4.5/5 | |||
Therapy Collaboration Rating(Survey) | ≥4.5/5 | |||
Case Management Efficiency (Discharge Planning)(Case Management) | ≥95% on-time | |||
Pharmacy Collaboration (Medication Reconciliation)(Pharmacy) | ≥98% |
Leadership development, succession readiness, and DON visibility
| Metric | Target | Actual | Development Plan | |
|---|---|---|---|---|
Leadership Development Program Participation(Education/HR) | ≥3 staff/quarter | |||
Succession Plan Completion (Key Roles)(HR) | 100% | |||
DON Visibility Hours (Rounding/Staff Engagement)(DON Office) | ≥10 hrs/week | |||
Staff 1:1 Meetings Completed (Direct Reports)(DON Office) | 100% monthly | |||
External Speaking/Thought Leadership Events(DON Office) | ≥1/quarter |
Qualitative insights: What we're celebrating, where we're growing, and who's leading the way
Report Name: HospiTEL Nursing Dashboard – Week Ending [Date]
Due: Every Monday by 12:00 PM
Format: PDF + Excel (for trend data)
Recipients: CEO, CMO, Compliance Officer, QAPI Committee
Presenter: DON during weekly Executive Leadership Meeting
This dashboard reflects our commitment to measuring both clinical excellence and cultural excellence. It demonstrates how the HospiTEL operating system drives superior outcomes through hospitality, safety, and emotional healing.