NURS 6231: Community General Hospital Case Study

Based on the case study, identify 6–8 measures for inclusion in a dashboard for the Community General Hospital Board. What organizational, national, and regulatory factors contributed to your decision to focus on these areas? Describe what you would expect to learn from the measurement and evaluation of your identified priority areas. Be specific and provide examples.

case study file

Community General Hospital Case Study

Creating a Quality and Safety Dashboard

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It’s your first week on the job—your dream job, actually. You are thrilled to be working as the Assistant Director of Clinical Quality Improvement at Community General Hospital (CGH). For your first project, Dr. Schenk, your boss, and mentor, asks you to create a quality and safety dashboard for her monthly report to the Board. You are eager to show off the skills you’ve gained from your master’s program. If this goes well, you might be the one presenting to the Board in a few months.


Dr. Schenk gives you tips on where to start. She shows you some previous dashboards and says that they were not particularly helpful to the Board members, who really want information that allows comparisons to other hospitals.


You wonder aloud whether there are national standards that would be useful because you have read in the literature that active hospital board reviews of quality and safety using dashboards are associated with better performance (Denham, 2006; Kroch et al., 2006; Jha & Epstein, 2010).


Dr. Schenk agrees, “Yes, you should search the relevant sites for current information. Look at the Joint Commission, CMS Hospital Compare, and the Institute for Healthcare Improvement.” She continues, “Of course, we should have measures that are relevant to our quality and safety issues here at CGH. We need to highlight our current QI projects to show that we are making improvements, but we also want to identify some of the gaps where we could do better. Right now, we are working on reducing surgical site infections, reducing readmissions, and reducing wait times in the Emergency Department.”

Dr. Schenk outlines a few additional instructions:

  • Try to kill two birds with one stone—start with measures that the hospital is required to report.
  • Present clear metrics that reflect the current status of the hospital.
  • Don’t get too bogged down in detail because it will only overwhelm the Board.

Dr. Schenk then leaves you to your research. You look at the websites she has recommended for current reporting requirements and measures.

Centers for Medicare and Medicaid Services. (n.d.). Hospital Compare. Retrieved December 5, 2019, from

Joint Commission. (2019). Performance measurement. Retrieved from

Institute for Healthcare Improvement. (n.d.). Measures. Retrieved from

The websites include so many measures, too many for one dashboard. Clearly, you will need to focus the CGH Quality and Safety Dashboard on a subset or aggregation of the many possible measures that you could include.

Next, you remember Dr. Schenk’s advice to keep it relevant. You think about what you know about the hospital. Not everything that you found in your research would be relevant. On the other hand, you didn’t find measures for some things that are relevant for CGH. This hospital is such a vital part of the community. How do you capture that on a dashboard? People love working here. The turnover rate for nurses is low. Physicians move here to practice medicine because this is such a great hospital, in a family-oriented community. And the best part, in your opinion, is that physicians and staff are truly engaged in making things better—probably because everyone from the cleaning staff to the CEO is required to take the CGH Performance Improvement course. It’s hard to put numbers on those indicators.

Some other facts are easier to put numbers on. CGH is a nonprofit, 200-bed, non-teaching hospital. In 2019, CGH recorded the following data:

Number of admissions: 11,986

Number of patients over the age of 65: 2,637

Percent of patients over the age of 65: 22%

Percent of patients who identify as a race other than White: 38%

Percent of patients who are female: 59%

Mean length of stay for all patients (days): 3

Percent of patients readmitted within 30 days: 1.4

After completing your research, you now have enough details to select measures and draft the CGH Quality and Safety Dashboard.


Denham, C. R. (2006). Leaders need dashboards, dashboards need leaders. Journal of Patient Safety, 2(1), 45–53.

Jha, A., & Epstein, A. (2010). Hospital governance and the quality of care. Health Affairs, 29(1), 182–187. doi:10.1377/hlthaff.2009.0297

Kroch, E., Vaughn, T., Koepke, M., Roman, S., Foster, D., Sinha, S., & Levey, S. (2006). Hospital boards and quality dashboards. Journal of Patient Safety, 2(1), 10–19.\

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Discussion: Community Hospital Case Study

            A medical director must prepare a quality and safety dashboard to enable the key stakeholders to assess the quality and safety of patient care. Additionally, the dashboard allows board members to identify an area in the clinical practice that requires improvement. This discussion presents measures for inclusion in a dashboard, associated organizational, national, and regulatory variables contributing to the decision, and what is expected to be learned.

The case study indicates various measures to be included in the dashboard presented to the Community General Hospital (CGH) board members. These measures include the hospital’s bed capacity, recent quality improvement (QI) projects, high rate of surgical site infections, high rate of readmissions, long wait times in the Emergency Department, and availability of CGH Performance Improvement course. The decision to focus on the selected areas was impacted by organizational, national, and regulatory variables. First, corporate culture and values to meet the healthcare needs of the community members informed the decision to include hospital’s bed capacity and recent quality improvement (QI) projects in the dashboard. A medical facility should aim at meeting the health care needs of its patients (WHO, 2018). Additionally, regulatory authorities that require healthcare organizations to provide quality and safe patient care led to the inclusion of high rate of surgical site infections, high rate of readmissions, and long wait times in the Emergency Department in the dashboard. These measures enable the regulatory authorities to determine the quality of patient care based on the outcomes. Finally, national factors, particularly the federal government, influenced the decision to include the CGH Performance Improvement course since it emphasizes continuous training for medical practitioners. According to Song and Tucker (2016), performance improvement enables healthcare professionals to provide quality and safe patient care. I anticipate learning about various factors that determine the quality and safety of patient care from measurement and evaluation of the prioritized healthcare organization’s areas. For instance, I will learn that QI projects play a significant role in addressing quality and safety issues in a healthcare organization (Cantiello et al., 2016).

Overall, various measures enable the board to assess the performance of a healthcare organization. Thus, a director should carefully select measures to include in the director’s dashboard. The chosen measures based on the case study include the hospital’s bed capacity, recent quality improvement (QI) projects, high rate of surgical site infections, high rate of readmissions, long wait times in the Emergency Department, and availability of CGH Performance Improvement course.




Cantiello, J., Kitsantas, P., Moncada, S., & Abdul, S. (2016). The evolution of quality improvement in healthcare: patient-centered care and health information technology applications. J Hosp Admin5(2), 62-8.

Song, H., & Tucker, A. (2016). Performance improvement in health care organizations. Foundations and Trends® in Technology, Information and Operations Management9(3–4), 153-309.

World Health Organization (WHO) (2018). Delivering quality health services. WHO.