Performance Management Plan Proposal

Performance management is, ideally, an ongoing quality-assurance-based process to provide an organization, its employees, regulatory agencies, accreditors, and other stakeholders with a structured means to support and accomplish mutually identified strategic goals and objectives.

Assume the role of a newly-hired risk management officer for a hypothetical new allied health organization in your chosen career field. You and your team will need to develop the organization’s policies.

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The first item you will create will be a performance management plan. Using the resource in HIM Briefings (2019)

( or other qualified framework, craft a proposal (1,250-1,500 words) for a performance management plan for your new organization that includes the following:

Organizational Goals. Provide a statement of your organization’s goals in terms of workplace safety, risk management, or quality improvement. Pick one area, and develop five goals for that one area.
Outline of Organizational Objectives. Outline and provide a brief evaluation of specific objectives that support the organizational goals you previously identified.
Summary of Relevant Performance Measures. Summarize the steps and measures your new organization will adopt to measure performance. Consider: (a) How well measures will align with your stated goals? (b) How do these measures demonstrate a relationship to positive health outcomes? (c) Are the measures you select able to be controlled by your organization (i.e., can your organization effect change in this area?)? (d) Which measures meet criteria related to reliability and validity, and which are standardized?
Performance Baseline. Determine a performance baseline for the measures you have selected. This will enable your organization to conduct comparisons of desired goals versus actual results as time moves on.
Performance Evaluation. Select one of three commonly accepted methods to measure provider quality and summarize the features and why it applies best to your organization. Refer to the assigned reading, “The Measurement of Health Care Performance: A Primer From the Council of Medical Specialty Societies,” by the Council of Medical Specialty Societies (CPSS) (
Definition of Success. Define what success means to the organization. Now that you have chosen measures to assess organizational performance, you need to identify what success means to your organization; otherwise, you are chasing a moving target. Be explicit in the level of performance you see as acceptable. This will change as an organization grows, but you need to start somewhere in order to get anywhere.
You are required to use and cite a minimum of three qualified resources from the readings, qualified websites, or the GCU Library in order to complete this assignment successfully.


Sample Answer


Performance Management Plan Proposal

Organizational Goals

The allied health organization has established five goals for workplace safety. The first goal is that the hospital will ensure that all people working at the organization are provided with appropriate personal protective gear. The hospital will ensure that personnel are supplied with quality and well-maintained personal protective gear to safeguard against infectious material in the workplace (Schnur, 2016). The protective gear creates a physical barrier to prevent the workers from coming into contact with the infectious material. The protective gear includes face shields and masks, respirators, gloves, goggles, aprons, and gowns. For example, the hospital will ensure that all health care personnel who provide care to patients, as well as visitors for the patients, wear personal protective gear.

The second organizational goal is to provide adequate education and training to all hospital workers on safety in the workplace. The goal is to improve workplace safety by enhancing comprehension of appropriate safety measures and standards in the hospital.  All the personnel will receive mandatory training on the importance of safety in the workplace and the measures that the hospital has implemented to ensure safety in the organization (Saleh et al., 2015). The workers will receive education on the workplace safety policy of the hospital. The workers receive training on the correct and effective use of equipment and personal protective gear in the workplace. The training will encompass courses, conferences, demonstrations and assessments.

The third goal is to achieve facility design that promotes workplace safety. The aim is to have a hospital design and layout that minimizes the risk of injury or infection for workers, patients and visitors (TJC, 2012). There should be adequate ventilation throughout all the rooms of the hospital facility. The organization will have sufficient sanitary facilities and changing rooms. The workplace should have appropriate, functioning and readily accessible firefighting equipment. All the rooms in the hospital should have adequate lighting. All surfaces should be dry, unobstructed and clean at all times. The design of the hospital should prevent overcrowding in rooms through a traffic flow system. Finally, the layout of the equipment and furniture should minimize the risk of accidents and exposure.

The fourth goal is to have an effective and reliable waste management system in the hospital (Schnur, 2016). The goal is to minimize the risk of infection or exposure to hospital workers, patients and visitors from the waste generated in the hospital including sharp equipment, pathological waste, infectious waste, chemicals, and radioactive waste. The hospital should have an effective system for collecting, isolating, storing, and disposing of wastes. The hospital will also implement practices that will minimize the volume of infectious and hazardous wastes generated in the hospital.

The fifth goal is to have an accident and incident response and reporting system in the hospital. The goal is to have an effective way of responding to safety incidents in the workplaces and a protocol for reporting such incidents to support preventive actions (Burlison et al., 2016). The hospital records and analyzes all accidents in the workplace. Workers will be required to report all accidents and incidents in the workplace through an established reporting channel. Workers will also report near misses and other safety risks in the workplace environment. The hospital will establish causation and implement preventive measures to prevent recurrence of such incidents.



Outline of Organizational Objectives

The organizational has established a range of objectives to support workplace safety organizational goals. The first organizational objective is to improve the health, safety and wellbeing of all people within the hospital environment. The objective is to guarantee the safety of all people in the hospital facility including health care personnel, other workers, patients and visitors. The organization aims to implement measures and actions that will minimize the risk of injury or infection to all people in the work environment. The hospital aims to have a work environment where employees can work with minimal threat to their wellbeing. Furthermore, the organizational objective is to ensure the safety of all people by reducing accidents and safety incidents in the workplace.

The second organizational objective is to implement a safety culture within the hospital. The organization aims to have a culture around the hospital that promotes values, attitudes, and competencies that promote workplace safety (Saleh et al., 2015). A safety culture is crucial to the effectiveness of the hospital as it allows the organization to maintain safe operations. The safety culture will encourage behaviors and practices that ensure the safety and wellbeing of workers, patients and visitors.  All personnel should take issues of safety seriously. The organizational objective of a safety culture is supported by effective communication between all departments and levels of the organization. Furthermore, the aim is to achieve high employee involvement and engagement in processes of workplace safety.

The third organizational objective is to achieve a high level of patient safety. The objective is to reduce the risk of infection within the hospital facility and thereby improve patient outcomes and improve the quality of care. The hospital aims to have a workplace environment that reduces preventable harm or unnecessary risk to patients. The organization strives for safety improvements across the organization to minimize the risks of patient infection in the facility. The organization seeks to reduce medical errors and injuries to patients. Patient safety is a collaborative undertaking between health care personnel, other staff and patients.

Summary of Relevant Performance Measures

The organization has adopted steps and measures to assess performance against the stated organizational workplace safety goals. The first performance measure for workplace safety is the incident rate. The incident rate measures a hospital’s safety performance based on specific metrics and averages. The incident rate is calculated as the number of safety incidents per 100 workers in the organization. The measure will be founded on the incident reporting processes in the organization (Burlison et al., 2016). A low incident rate indicates high safety performance in the organization.

The second measure for assessing safety performance in the hospital is lost time injury frequency rate. A loss time injury is an injury sustained by an employee in the workplace that forces that individual to miss work. The loss time injury frequency rate is a metric for measuring the number of hours lost injuries that occur in an organization within a specific period. The measure calculates the number of loss time injuries within a particular period divided by total hours worked then multiplied by 1 million. The lost time frequency rate is an effective safety measure that allows an organization to determine disruptions by safety indictments.

The third measure for workplace safety in the organization is hospital-acquired infection (HAI) rate. The HAI rate measures the computes the number of infections that patients and contract while in the hospital facility. The HAI rate is a crucial indicator of patient safety in the organization (Mehta et al., 2014). The measure informs on safety performance by indicating how frequently patients acquire diseases in the clinical environment due to safety conditions as the organization. Finally, the organization will measure the rate of clinical errors in the workplace and the association with patient safety.

Performance Baseline

The performance baselines for the workplace safety performance measures will provide a level of performance that the organization will compare with future performance levels. The first safety measure is the incident rate. For this measure, the performance baseline is 10 incidents per 100 workers in the organization. The performance baseline of the incident rate will show improvements in line with organizational goals if the hospital records a lower incident per 100 workers. The organization targets 3 incidents per 100 workers. The second measure is the lost time injury frequency rate. The performance baseline for this measure is 3 people suffering loss time injuries that keep them away from work and a loss time injury frequency rate of 3.5 per 1,000,000 work hours. The desired goal of the organization is to record one loss time injury and a loss time frequency rate of 2 per 1,000,000 work hours. The third measure is the HAI rate. The performance baseline for the HAI rate is 15 infections per 1000 patients. The organizational goal is to minimize the HAI rate to 5 infections per 1000 patients.

Performance Evaluation

The selected performance measure is structure measures. Structural measures analyze the capacity of a hospital to provide high-quality care. The structural measures the systems in place to facilitate the delivery of health care and demonstrates a link to patient outcomes. Structural measures analyze the health care tools and resources in possession of the organization and the organizational setting where those tools and resources are deployed (CMSS, 2014). Structural measures evaluate whether the organization has the right personnel to provide high-quality care. The structural measures also analyze the level of training and certification with the providers of care.

The structural measures are appropriate and suitable for the organization since the organizational goals aim to improve the capacity of the organization to provide high-quality care through workplace safety improvements. The organization will utilize structural measures to determine whether the hospital has the appropriate tools, infrastructure and systems to achieve workplace safety with the goal of enhancing the quality of care and improving patient outcomes. Structural measures will inform the organization about the capacity of the personnel to attain workplace safety goals based on their certifications, competence and level of training.

Definition of Success

For the organization, the definition of success is achieving all the goals related to workplace safety. The organization hopes to foster a workplace culture that promotes safety behaviors among all the workers. The organization intends to have a clinical environment where staff undertake their duties with due consideration to the safety measures and policies implemented by the organization.  Success to the organization is having a safe workplace that contributes to positive patient outcomes. By achieving high standards of workplace safety, the organization will minimize HAIs and ensure that patients feel safe and comfortable in the hospital.

To the organization, success is minimizing accidents and incidents within the workplace. The organization wants to eliminate workplace injuries suffered by employees and reduce the number of hours missed by employees due to workplace injuries. Success is improving patient safety and reducing the occurrence of errors and mistakes by health care personnel in the clinical setting. The organization hopes to improve patient satisfaction with the quality of care in the hospital. Finally, success to the organization means achieving compliance with health and safety standards as established by relevant authorities.




Burlison, J. D., Quillivan, R. R., Kath, L. M., Zhou, Y., Courtney, S. C., Cheng, C., & Hoffman, J. M. (2016). A multilevel analysis of US hospital patient safety culture relationships with perceptions of voluntary event reporting. Journal of patient safety.

CMSS (2014). The Measurement of Health Care Performance. Council of Medical Specialty Societies. Retrieved from:

Mehta, Y., Gupta, A., Todi, S., Myatra, S. N., Samaddar, D. P., Patil, V., … & Ramasubban, S. (2014). Guidelines for prevention of hospital-acquired infections. Indian journal of critical care medicine: peer-reviewed, official publication of Indian Society of Critical Care Medicine18(3), 149.

Saleh, A. M., Darawad, M. W., & Al‐Hussami, M. (2015). The perception of hospital safety culture and selected outcomes among nurses: an exploratory study. Nursing & health sciences17(3), 339-346.

Schur, M. (2016). Safety in the Healthcare Workplace: How Safe Do You Feel? Retrieved from:

TJC (2020). Improving Patient and Worker Safety. The Joint Commission. Retrieved from:

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