Every Hospital Environment of Care/Safety Program is required to produce annual reviews, both for individual programs within the Safety Committee and for the Committee itself.  We've seen hundreds of these over the years from dozens of facilities, in addition to the ones they themselves have created.   We are providing a summary of what we learned here in our blog.

For any given program (e.g. Security), the Management Plan and the Annual Review should be synchronized with each other, the latter being used to measure the effectiveness of the former.  Think of the management plan as a ship complete with a rudder and wheel, and the annual review as the navigation system that determines whether or not the ship is on course. 

The annual review should have an overall structure that shadows that of the management plan and that allows for thoughtful consideration of both.  BPM has had considerable success using the following Annual Review outline.

* Review of Management Plan Scope
* Review of Management Plan Objectives
* Last Year's Accomplishments
* Performance and Effectiveness Discussion (centered around measurable indicators)
* Next Year's Initiatives (will hopefully be last year's accomplishments next year)

A good rule of thumb is to write the plan as you would hold a conversatoin with someone to convey the same information.   For example a concise summary might go something like this. 

"Last year we set about to accomplish several objectives.  We bought this and installed that, hired two people and began using new forms.  It turned out that after doing all these things we achieved most of our objectives but fell short on these two fronts (see graphs).  Given all of this we're going to try something different next year to address the shortcomings and do a few more things to maintain our gains.  Here are the initiatives we've thought of thus far."

Let's consider each section of the annual review in turn.

Review of Management Plan Scope

The Scope statement should be concise as it is simply designed to convey the extents of the program.  Include a list of buildings, systems or people.  It may even be possible to reference exceptions to the scope by name, whichever is simpler and helps best convey the limits of the program. 

A good example of something that may or may not be in a program is Patient Beds, which might be maintained by Facilities Management but might also be maintained by Biomedical Engineering, or the two might both play a role. 

We recommend copying and pasting the scope statement from the management plan into the annual review.  Just below it should be a statement describing any changes including the rationale for each.  If there have been changes, we recommend writing the scope verbatim below the discussion.  The updated scope statement should then be copied and pasted into the next iteration of the management plan.

Review of Management Plan Objectives

We recommend following the same procedure for updating the Objective statment as for the Scope statement. 

Objectives should be larger in scope and not small and discreet.  Small and discrete items should be reserved for initiatives that help achieve objectives and that will change from year to year.    

For example.  A program objective might be to increase improve the knowledge of personnel.  This might include the creation of several training programs and increasing the numbers of rounds, but the latter will change over time. 

A good way to review objectives is to put them into the first column of a 4-column table, with the remaining columns being "Met" "Not-Met" and "Adjusted Objective."  In the management plan they can also be in a table but it is more common to show them in a bulleted list.  

Note:  If an objective is "Not-Met" this does not mean that the objective has to be changes, nor does a "Met" mean it does not.  The idea is to continue to improve and refine both the document and its content.

Last Year Accomplishments

This should be an overview, not much more than a list of things you did.  These can be one-time events or they could be the beginnings of ongoing endeavors.  In short, anything you did to try to achieve your outcomes. 


Discussion of Performance and Effectiveness

Although this is just an extension of the previous section we recommend breaking it out in this manner.  Here you can discuss what worked and what might not have worked in your list of initiatives.  Don't worry if you wind up restating what you just stated here.  This is actually in line with the teaching axiom of "Tell them what you're going to teach them, tell them, then tell them what you taught them and will only aid the reader in understanding.

At the end of this discussion, which needn't be more than a few sentences or paragraphs, you should make some overall declaration of the program's effectiveness.  This is really the point in the review where you decide whether or not you're going to change or stay the course next year, based on how well your measurable indicators performed.  What you really want to avoid is saying "We were thoroughlly effective" when your key indicators are showing that you failed miserably.

We recommend self-grading yourself on an effectiveness range, for example:

Very effective
Effective
Not very effective


Don't be be afraid to call it like you see it.  If the indicators didn't go in the direction you wanted, simply state this and tell what you're going to do differently next year to make it right. Inspectors are more concerned that you interpret the information correctly than the fact that your program may have been less than effective.

Next Year's Initiatives

As with last year's accomplishments, this should be short and concise and ideally not much more than a bulleted list or a few sentences.  "Based on this year's performance, we're going to do keep doing A-C, stop doing D and add E, F and G."  As with the Performance and Effectiveness discussion, don't worry if you seem to be repeating something you just said.  Again, this will only increase the reader's understanding.

Welcome to the Balon Process Management Blog. 

It is our hope that this forum will allow you to interact with us and allow us to hopefully provide you with timely, useful advice, tools and techniques.

On behalf of Brad and the entire team, we look forward to working with all of you.