PERFORMANCE INDICATOR TEMPLATE

TO THE SECTION SUPERVISOR: ENTER THE REQUIRED INFORMATION

Department / Section (The name of the department or section)

Performance Indicator
(The name of the Performance Indicator being measured)
Rationale of the Performance
Indicator (Reason for monitoring such measure)

Type of Measure (Structure Measure; Outcome Measure; or Process Measure)

Timeline of the measure (May be one or a combination of the following: Monthly; Quarterly.
Depending on the direction of the department)

Data collection methodology Concurrent Collection (As the data arrives)

Retrospective Collection (Historical review of raw data from a specific timeline)

Sources of Data
Logbook / specified forms / other acceptable sources of raw data.
Target sample / population
and Sampling Method (Random Sampling / Convenience Sampling / Trigger Sampling)

Areas of Monitoring
(Identify the areas where monitoring will be performed)
Data Elements
(Data use to come up with the result of the measure)
Measure Target and / or
Threshold (Specify if benchmark from other institution, or regulatory or statutory requirement)
Indicate if measure / audit
tool is attached (The name of the audit / monitoring tool)

Process: Data is collated by (ie. Section staff / monitoring staff) Person(s) Responsible:
Data aggregation and analysis Data is counter – checked by: (Identify the individuals responsible for
process Deficiencies are sent to . . .and collated by . . . .. data collection.

Details of the Analysis

(Define the process of data analysis.)
Please indicate how the data
results will be disseminated
to staff (Thru weekly or monthly meeting; or by any other means)

Reporting time period to

Management
(Indicate on how frequent will the result be reported to management and by what means)

PREPARED BY REVIEWED BY APPROVED BY

Signature above Printed Name Signature above Printed Name Signature above Printed Name
POSITION: POSITION: POSITION:
DATE (MMM/DD/YYYY) DATE (MMM/DD/YYYY) DATE (MMM/DD/YYYY)