NURS 522 Week 2 Blog 1 on Choosing Performance Measures Example

Blog 1: Choosing a Performance Measure That Rewards Mobility Instead of Bed Rest

NURS 522 Performance Management in Healthcare, Blog 1

Thread by [Student Name]

The unit example and the classmates replied to are composites written for a model blog.

Last spring my unit celebrated three months without a fall. The banner went up, the manager bought pizza, and nobody asked how we had done it. If we had asked, we would have heard the answer in the hallway: bed alarms on almost everyone, patients told to call before standing, and a quiet reluctance to walk older adults who were unsteady. Our fall count went down. I suspect our patients' strength went down too.

Poister et al. (2015) distinguish outputs, the activities a program carries out, from outcomes, the results for the people it serves, and they caution that measures should be valid, meaning they capture what the organization intends, and resistant to producing perverse incentives. A total fall count fails that second test. It treats a patient who slid gently to the floor during supervised walking the same as a patient who broke a hip climbing over a bed rail, and it can be lowered by the very practice, immobility, that harms patients in other ways.

A 2026 cohort study makes the tradeoff visible. Johnson et al. (2026) reviewed 9,693 adult inpatients at a rural tertiary hospital who were able to walk and compared falls with injury against hospital-acquired pressure ulcers. They framed the question directly: mobility lowers pressure ulcer risk but may raise fall risk. Among these patients, about 1.03% fell without injury and 0.24% fell with injury. A unit that drives its fall count toward zero by keeping patients in bed may be trading a rare injury for losses in strength, skin integrity and independence that never appear on the fall dashboard.

A better approach would pair measures so that one keeps the other honest. My unit could make injurious falls, counted against every thousand days of patient care, its main safety outcome, report total falls as a learning measure rather than a target, and add a mobility measure, such as the percentage of eligible patients walked three times a day. Pressure injury rates would sit beside them. If falls with injury drop while mobility rises, we would know we were improving care rather than restricting it. If falls with injury hold steady while mobility climbs, that would also be a success, because more patients would be leaving the hospital stronger without added harm. The point of pairing is that no single number can be pushed down at the expense of the others without the dashboard showing it. Staff would also need to see the measures explained, so that a rise in total falls during a mobility push is understood as a sign of more walking, not of worse nursing.

There is a biblical principle here too, and it is older than any dashboard. Proverbs 20:23 warns that "unequal weights are an abomination to the Lord, and false scales are not good" (English Standard Version Bible, 2001/2016). A measure that makes a unit look safer than its patients really are is a kind of false scale. Leaders who choose measures are responsible for choosing honest ones, even when an honest measure makes the unit look worse for a while.

Reply to Danielle

Danielle, your point that your hospital uses float nurses to cover gaps and that managers blame them when indicators slip is a good example of a measure being read without enough context. A recent study suggests the blame may be misplaced, at least for some float nurses. Stephens et al. (2026) examined 25 inpatient units in three hospitals over a year and found that float pool nurses were linked to a reduced risk of two harms, pressure injuries and central line infections, while nurses floated from their home unit showed no significant association with nurse-sensitive indicators. The authors concluded that the two kinds of float nurses should be evaluated separately. It is a single study in three hospitals, so it cannot settle the question everywhere, but it does show that "float nurse" is not one category. That finding fits Poister et al.'s (2015) advice that measures must be broken down in ways that reveal what is actually driving performance. If your hospital reports indicators by shift and staffing type, managers may find that a dedicated float pool helps and that the trouble lies elsewhere, perhaps with nurses floated to unfamiliar units without orientation. Scripture warns against judging by appearances (English Standard Version Bible, 2001/2016, John 7:24), and judging float nurses by an unadjusted indicator is judging by appearance. Does your hospital have a dedicated float pool, or are most floats pulled from other units on the day? The answer might change how your managers read the data, and it might also show where orientation for floated nurses would pay off most.

Reply to Marcus

Marcus, I like your idea of a balanced scorecard for your emergency department, because it answers the same problem I described in my post: a single measure can be gamed, while several balanced measures check one another. A recent mixed-methods study offers a practical way to build one around the people who lead units. Mozzarelli et al. (2024) used the balanced scorecard model in an Italian surgical department to map the core competencies of nurse ward managers, combining staff ratings of nine competencies with focus groups, and then identified key performance areas and indicators for the role. Their approach suggests that a scorecard can be built from the bottom up, by asking staff what the leader's work should achieve, rather than imposed from the top. Poister et al. (2015) add that measures earn more trust when the people being measured help define them. For your department, that might mean asking charge nurses which indicators reflect good flow and good care before choosing door-to-provider time as the headline. Paul describes the church as one body with many members, each with a different function (English Standard Version Bible, 2001/2016, 1 Corinthians 12:12), and a scorecard works in a similar way, with each measure doing a different job. Which four perspectives would you choose, and would staff experience be one of them? I ask because in an emergency department, turnover and sick calls can move flow measures more than any process change, so a scorecard without a staff perspective could hide the real cause of delays.

Reply to Priya

Priya, your concern that patient experience scores punish nurses for things they cannot control, such as hospital food or parking, is fair, and I think it raises a deeper measurement question about what the score is meant to capture. Poister et al. (2015) describe validity as the degree to which a measure represents the thing it is intended to measure, and a global satisfaction score blends many things. A recent study suggests that even nursing's own appraisals can miss what patients value. When Kuntarti and Rahmayanto (2026) set the caring inventory scores of 228 hospital nurses beside the same nurses' official appraisal results, the two did not track each other at all, and the authors urged hospitals to write caring into their appraisal forms. The study was done in one public hospital in Jakarta, so the numbers may not transfer, but the pattern is familiar. That suggests a solution for your unit: rather than relying on the overall rating, track the survey items that are specific to nursing, such as whether nurses listened carefully and explained things clearly, and review patients' written comments for examples. Those items are closer to the caring nurses can control. Jesus taught that the one who would be great "must be your servant" (English Standard Version Bible, 2001/2016, Mark 10:43), which reminds me that the goal is serving the patient, not earning the score. Still, a better measure would help leaders see that care. Would your manager be open to reporting the nursing items separately at staff meetings? Sharing two or three patients' comments alongside the numbers might also help staff see what the score is trying to capture.

References

English Standard Version Bible. (2016). Crossway. (Original work published 2001)

Johnson, L., Drabish, K., Ndeh, B., Maduakonam, C., & Samanta, D. (2026). Inpatient mobility and the relative incidence of falls with injury versus hospital-acquired pressure ulcers. Journal of Patient Safety. Advance online publication. https://doi.org/10.1097/PTS.0000000000001530

Kuntarti, K., & Rahmayanto, I. (2026). Do nurse performance appraisals reflect caring behaviors? Evidence from an Indonesian hospital. Frontiers in Health Services, 6, Article 1773688. https://doi.org/10.3389/frhs.2026.1773688

Mozzarelli, F., Catinella, A., & Tuccio, C. (2024). Mapping ward managers' core competencies using the Balanced Scorecard model. Nursing Management, 31(4), 29-34. https://doi.org/10.7748/nm.2024.e2107

Poister, T. H., Aristigueta, M. P., & Hall, J. L. (2015). Managing and measuring performance in public and nonprofit organizations: An integrated approach (2nd ed.). Jossey-Bass.

Stephens, C. P., Norton, J., Walker, D., & Verklan, M. T. (2026). Float nurses' association with nurse-sensitive indicators: A cross-sectional study. Journal of Nursing Care Quality, 41(4), 336-342. https://doi.org/10.1097/NCQ.0000000000000948