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Board Reporting of Core Quality KPIs – Hospital Acquired Complications and Patient Experience


Jeffrey Woods

Healthscope, Melbourne, VIC, Australia; Frankfurt School of Finance & Management, Frankfurt, , Germany;, AU
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Introduction & Aim:

This paper describes how aligning two innovative core quality indicators with values and objectives drives improvements in patient safety and quality of care.


In 2017, Healthscope selected two new measures for Executive and Board quality Key Performance Indicator reporting for each of their 43 hospitals:

•             Quality Clinical Outcomes – measured by Hospital Acquired Complication (HAC) rate

•             Patient Experience – measured by overall rating of the quality of treatment and care using the Australian Hospital Patient Experience Question Set (AHPEQS)

The focus on two core measures was a new innovation aimed at simplifying and aligning core Board and Executive strategies, values and company purpose. Selection of the measures was a collaborative top down and bottom up approach, with direct care staff, managers, executive and board involvement in selecting the measures to align with the core values of the company – Quality Clinical Outcomes and Exceptional Patient Care. Over 100 clinical quality indicators are measured and reported by Healthscope, however streamlining the measures and focusing on priorities was a key.

Neither of these measures had previously been used in the industry, however HAC rate was foreshadowed by the Independent Hospital Pricing Authority as a penalty measure in their commonwealth public hospital funding model.

Outcomes & Lessons Learnt:

As both measures were new in the industry, implementation was a major change management project. Frequency of monitoring was increased to monthly, with real-time dashboards at ward level.

Focus and simplification of core quality indicators, with alignment to objectives was a major catalyst for change and continuous improvement in quality and patient safety. Both core measures showed significant improvement in year 1, with a continued positive trend in year 2.

Hospital acquired complication rate in year 1 was initially a pure rate, with hospital targets focused on improvement over time, as well as a focus on data quality. In year 2, risk adjusted methodology allowed hospitals to compare specific complication types with peer hospitals, public and private, with monitoring of HACs in real time.

The focus for the AHPEQS patient experience measure in year 1 was at hospital level, with ward-level real-time reporting and a person-centred care strategy in year 2 driving further improvements.


Aligning innovative core quality measures with organisation purpose and goals, coupled with monthly reporting to Board and Executive, has driven significant change and improvement.

How to Cite: Woods J. Board Reporting of Core Quality KPIs – Hospital Acquired Complications and Patient Experience. International Journal of Integrated Care. 2021;20(S1):49. DOI:
Published on 26 Feb 2021.


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