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Hospital Quality Indicators

Posted on September 1, 2020September 1, 2020 by Healthcare InfoGuide

 

Q.I. No. Responsibility Quality Indicator Formulae Benchmark
1 a (a) Medical Service Department Time for Initial Assessment of Indoor Patients by Doctor Sum of time taken for initial assessment /Total number of patients 12O Minutes
1 a (b) Nursing Service Time for Initial Nursing assessment of Indoor Patients. Sum of time taken for Initial nursing assessment/Total number of patients 30 Minutes
1 a (c) CND Time for Initial Nutritional Assessment by Dietician Sum of time taken for nutritional assessment/Total number of patients 120 Minutes
1 b (a) Medical Service Time for Initial assessment by doctors for Emergency patients. Sum of time taken for initial assessment/Total number of patients 5 Minutes
1 b (b) Nursing Service Time for Initial Nursing assessment Emergency patients. Sum of time taken for Initial nursing Assessment /Total number of patients 5 Minutes
2(a) Medical Service Percentage of cases  (inpatients) wherein care plan with desired outcomes is documented & counter-signed by the clinician (With daycare) (Number of inpatient records where careplan with desired outcomes has been documented/Number of Discharge and Death (Including daycare))*100 100 Percent
3(a) CND Percentage of cases wherein screening for nutritional needs has been done (Number of in-patient case records wherein the nutritional assessment has been documented /Number of Discharge and Death (Including Daycare))*100 75 Percent
3(b) CND Percentage of cases wherein screening for nutritional needs has been done (Number of in-patient case records wherein the nutritional assessment has been documented /Number of Discharge and Death (Patients who have completed 24 hrs of stay))*100 65 Percent
4(a) Nursing Service Percentage of cases (inpatients) wherein the nursing care plan is documented.(With Daycare) (Number of in-patient case records wherein the nursing care plan has been documented /Number of Discharge and Death (Including Daycare))*100 100 Percent
4(b) Nursing Service Percentage of cases (inpatients) wherein the nursing care plan is documented.(Wthout Daycare) (Number of in-patient case records wherein the nursing care plan has been documented /Number of Discharge and Death (Patients who have completed 24 hrs of stay))*100 100 Percent
5 (a) Pathology Number of reproting errors/ 1000 investigations (Number of Reporting Error/Number of Tests Performed)*1000 2
5 (b) Radiology Number of reporting errors/ 1000 investigations (Number of Reporting Error/Number of Tests Performed)*1000 2
5 (c) Radiology (CT + PET CT) Number of reporting errors/ 1000 investigations  – CT & PET CT (Number of Reporting Error/Number of Tests Performed)*1000 2
6 (a) Pathology Percentage of re-dos (Number of Re-Do’s/Number of Tests Performed)*100 3 (Redo’s due to human error)
6 (b) Radiology Percentage of re-dos – Radiology (Number of Re-Do’s/Number of Tests Performed)*100 1
6 (c) Radiology (CT + PET CT) Percentage of re-dos – CT & PET CT (Number of Re-Do’s/Number of Tests Performed)*100 1
7 (a) Pathology Percentage of reports co-relating with clinical diagnosis. (Number of reports correlating with clinical diagnosis /Number of Tests Performed)*100 70%
7 (b) Radiology Percentage of reports co-relating with clinical diagnosis. (Number of reports correlating with clinical diagnosis /Number of Tests Performed)*100 95%
8 (a) Pathology Percentage to adherence to safety precautions by employees working in diagnostics – Pathology (Number of employees adhering to safety precautions/Number of Employees Sampled)*100 95%
8 (b) Radiology Percentage to adherence to safety precautions by employees working in diagnostics – Radiation Area (Number of employees adhering to safety precautions/Number of Employees Sampled)*100 95%
9(a)(a) PTC Incidence of  medication errors (Total Number of Medication Error/Number of Patient Days (With Daycare))*100
9(a)(b) PTC Incidence of  medication errors (Total Number of Medication Error/Number of Patient Days (With out Daycare))*100
9(b)(a) PTC Incidence of prescription error (Total Number of Prescription Error/Number of Patient Days (With Daycare))*100
9(b)(b) PTC Incidence of prescription error (Total Number of Prescription Error/Number of Patient Days (With out Daycare))*100
9(c)(a) PTC Incidence of dispensing error (Total Number of Dispensing Error/Number of Patient Days (With Daycare))*100
9(c)(b) PTC Incidence of dispensing error (Total Number of Dispensing Error/Number of Patient Days (With Daycare))*100
10(a) Medical Service/Nursing Service Percentage of admissions with adverse drug reactions (Number of Adverse Drug Reactions/Number of Discharge & Death (With  Daycare))*100
10(b) Medical Service/Nursing Service Percentage of admissions with adverse drug reactions (Number of Adverse Drug Reactions/Number of Discharge & Death (With out Daycare))*100
11 Medical Service/Nursing Service/Pharmacy/MRD Percentage of medication charts with error prone abbreviations (Number of medication charts with error prone /Number of medication charts reviewed)*100
12 Medical Services/Nursing Services/PTC Percentage of patients receiving high risk medications developing adverse drug event. (Number of patients receiving high risk medication who have an adverse drug event/Number of patients receiving high risk medications)*100
13 OT/Anaesthesia Percentage of modification of anaesthesia plan (Number of patients in whom the anaesthesia plan was modified/Number of patients who underwent anaesthesia)*100
14 OT/Anaesthesia Percentage of unplanned ventilation following anaesthesia (Number of patients requiring unplanned ventilation following anaesthesia/Number of patients who underwent anaesthesia)*100
15 OT/Anaesthesia Percentage of adverse anaesthesia events (Number of patients who developed adverse anaesthesia event/Number of patients who underwent anaesthesia)*100
16 OT/Anaesthesia Anaesthesia related mortality rate (Number of patients who died due to anaesthesia/Number of patients who underwent anaesthesia)*100
17 OT/Anaesthesia Percentage of unplanned return to OT (Number of unplanned return to OT/Number of Patients operated)*100
18 OT/Anaesthesia Percentage of re- scheduling of surgeries (Number of Cases Re-scheduled/Number of Suregeries Performed)*100
19 OT/Anaesthesia Percentage of cases where the organization’s procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to (Number of cases  where the procedure was not followed/Number of Suregeries Performed)*100
20 OT/Anaesthesia/ICN Percentage of cases who received appropriate prophylactic antibiotics within the specified time frame. (Number of  patients who did not receive prophylactic antibiotic(s)/Number of Surgeries Performed)*100
21 g Percentage of cases in which planned surgery changes intra-operatively (No. of cases in which the planned surgery is changed intra-operatively/Total no. of surgeries performed)*100
22 OT Re-exploration rate (No. of re-exploration done during same admission/Total no. of surgeries)*100
23 Blood Bank Transfuion reaction (Number of transfusions/Number of transfusion reaction)*100
24 Blood Bank Percentage of wastage of blood & blood products (Number of blood and blood products issued from the blood bank/Number of blood and blood products used)*100
25 Blood Bank Percentage of blood component usage (Number of blood and blood products used/Number of components used)*100
26 (a) Blood Bank Turnaround time for issue of blood and blood components – Regular Turnaround time for issue of blood and blood components
26 (b) Blood Bank Turnaround time for issue of blood and blood components – Emergency Turnaround time for issue of blood and blood components
27 Infection Control Department Urinary tract infection rate (Number of urinary catheter associated UTIs in a month/Number of urinary catheter days in that month)*1000
28 Infection Control Department Pneumonia rate (Number of pneumonia in a month /Number of ventilator days in that month)*1000
29 Infection Control Department Blood stream infection rate (Number of central line associated blood stream infection in a month/Number of central line days in that month)*1000
30 OT/Infection Control Department Surgical site infection rate (Number of surgical site infection in a given month/Number of Surgeries Performed)*100
31(a) MRD Mortality rate (Number of Death/Number of Discharge & Death (with  Daycare))*100
31(b) MRD Mortality rate (Number of Death/Number of Discharge & Death (without Daycare))*100
32 ICU/Medical service Return to ICU within 48 hours (Number of returns to ICU within 48 hours/Number of discharges, transfers and death in th ICU)*100
33 Emergency Department/Medical Service Return to the emergency department within 72 hours with similar presenting complaints (Number of returns to emergency within 72 hours with similar presenting complaints/Number of patients who have come to the emergency)*100
34 ICU/Medical service Re-intubation rate (Number of  re-intubations within 48 hours of extubation/Number intubations)*100
35 Clinical Research Percentage of research activities approved by ethics committee (Number of research activities approved by ethics committee/Number of research protocols submitted to ethics committee)*100
36 Clinical Research Percentage of patients withdrawing from the study (Number of patients who have withdrawn from all on-going studies/Number of patients enrolled in all on-going studies.)*100
37 Clinical Research Percentage of protocol violations/ deviations reported (Number of protocols violations/deviations reported)*100
38 Clinical Research Percentage of serious adverse events (which have occurred in the organization) reported to the ethics committee within the defined timeframe. (Number of serious adverse events reported/number of serious adverse events reported within and outside the defined timeframe)*100
39 (a) Pharmacy Percentage of drugs and consumables procured by local purchase (Number of items purchased by local purchase/Number of items listed)*100
39 (b) Stores Percentage of items procured by local purchase (Number of items purchased by local purchase/Number of items listed)*100
39 (a+b) Pharmacy + Stores Percentage of drugs and consumables procured by local purchase -Pharmacy + Stores (Number of items purchased by local purchase/Number of drugs, hospital consumables and other items listed)*100
40 (a) Pharmacy Percentage of stock outs including emergency drugs (Number of stock outs/Number of drugs listed in hospital formulary and hospital consumables list)*100
40 (b) Stores Percentage of stock outs (Number of stock outs/Number of items listed in store)*100
40 (a+b) Pharmacy + Stores Percentage of stock out – Pharmacy + Stores (Number stock outs/Number of drugs, hospital consumables and other items listed in store and formulary)*100
41 (a) Pharmacy Percentage of drugs and consumables rejected before preparation of Goods Receipt Note  (Total quantity rejected/Total quantity received before GRN)*100
41 (b) Stores Percentage of consumables rejected before preparation of Goods Receipt Note  (Total quantity rejected/Total quantity received before GRN)*100
41 (a+b) Pharmacy + Stores Percentage of drugs and consumables rejected before preparation of Goods Receipt Note – Pharmacy + Stores ( Total quantity rejected/Total quantity received before GRN)*100
42 (a) Pharmacy Percentage of variations from the procurement process – Pharmacy Total number of variations form the usual (procurement process/Total number of items procured)*100
42 (b) Stores Percentage of variations from the procurement process – Stores (Total number of variations form the usual procurement process/Total number of items procured)*100
42 (a+b) Pharmacy + Stores Percentage of variations from the procurement process – Pharmacy + Stores (Total number of variations form the usual procurement process/Total number of items procured)*100
43 (a) Safety Department Number of variations observed in Mock drills-Safety Number of Variations observed in Mock Drill- Safety
43 (b) Code blue Committee Number of variations observed in Code Blue –  Mock drills Number of Variations observed in Mock Drill- Code Blue
44(a) Safety Department Incidence of falls (Number of Fall/Number of inpatient days (with Daycare))*1000
44(b) Safety Department Incidence of falls (Number of Fall/Number of inpatient days (Without Daycare))*1000
45(a) Nursing Service Incidence of bed sores after admission (Number of patients who develop new/ worsening of pressure ulcer /Number of inpatient days (With Daycare))*1000
45(b) Nursing Service Incidence of bed sores after admission (Number of patients who develop new/ worsening of pressure ulcer /Number of inpatient days (Withot Daycare))*1000
46 Infection Control Department Percentage of employees provided pre-exposure prophylaxis (Number of employees who were provided pre-exposure prophylaxis /Number of employees who were due to be provided pre-exposure prophylaxis)*100
47 a(a) MRD Bed Occupancy rate (Number of Inpatient days in a given month (Including Daycare)/Number of bed days available in that month(Including Daycare))*100
47 a(b) MRD Bed Occupancy rate (Number of Inpatient days in a given month (Excluding Daycare)/Number of bed days available in that month(Excluding Daycare))*100
47(b)(a) MRD Average Length of stay Number of Inpatient days in a given month (Including Daycare)/Number of Discharge & Death (Including Daycare
47 b(b) MRD Average Length of stay Number of Inpatient days in a given month (Excluding Daycare)/Number of Discharge & Death (Excluding Daycare
48 (a) OT OT utilization rate (OT utilisation time in hours/Total Resource hours available)*100
48 (b) ICU ICU utilization rate (Number of bed utlised days/Bed days available)*100
48 (c) ICU ICU Equipment utilization rate (Number of Equipment utilised days/Total Equipment days available)*100
49 Biomedical department Critical equipment down time Critical equipment down time
50 (a) Nursing service/HR Nurse Patient ratio wards (Number of staff/Number of shifts)/Number of Beds
50 (b) Nursing service/HR Nurse Patient ratio for ICUs (Number of staff/Number of shifts)/Number of Beds
50 (c)  Nursing service/HR Nurse Patient ratio for Patient on Ventilator (Number of staff/Number of shifts)/Number of Beds
51 Front Office OPD satisfaction index (Scores Achieved/Maximum Possible Scores)*100
52 Front Office IPD satisfaction index (Scores Achieved/Maximum Possible Scores)*100
53 (a) Radiology (CT + PET CT) Waiting time – PET-CT & CT Sum (Patient-in time  to Radiology – Patient Taken Time in Radiology)/Number of Patients reporting to Radiology
53 (b) Radiology Waiting time – (X Ray, USG & Mammo) Sum (Patient-in time  to Radiology – Patient Taken Time in Radiology)/Number of Patients reporting to Radiology
53 (c) Pathology Waiting time – Lab Sum (patient-in time to Lab –  till the time Test is initiated)/Number of Patients reporting to Lab
53 (d) Front Office Waiting time – OPD Sum of time taken/Number of patients reported in OPD/Diagnostics
54 MRD/Medical service/Nursing service Time taken for Discharge Sum of time taken for discharge/Number of patients discharged
55 HR Employee satisfaction index (Scores Achieved/Maximum Possible Scores)*100
56 HR Employee attrition rate (Number of employees who have left/Number of employees at the beginning of the month + newly joined staff)*100
57 HR Employee absenteeism rate (Total Unauthorised Abseentism/Actual Working Days)*100
58 HR Percentage of employees who are aware of employee rights, responsibilities and welfare schemes (Number of employess who are aware of employee rights, responsibilitites and welfare schemes/Number of employess interviewed)*100
59 Quality Department Number of sentinel events reported, collected and analyzed within the defined timeframe (Number of sentinel events reported, collected and analysed within the defined timeframe/Number of sentinel events reported, collected and analysed)*100
60 Quality Department Percentage of near misses (Number of near misses reported/Number of Incident reports)*100
61(a)(a) Infection Control Department Incidence of blood body fluid exposures (Number of Blood Body Fluid Exposures/Number of in-Patient Days (Including Daycare))*100
61(a)(b) Infection Control Department Incidence of blood body fluid exposures (Number of Blood Body Fluid Exposures/Number of in-Patient Days (Excluding Daycare))*100
61(b) Infection Control Department Incidence of blood body fluid exposures (Number of Blood Body Fluid Exposures/Number of OPD patients visit)*100
62(a) Infection Control Department Incidence of needle stick injuries (Number of Parenteral Exposures/Number of In-patient Days (including daycare))*100
62(b) Infection Control Department Incidence of needle stick injuries (Number of Parenteral Exposures/Number of In-patient Days (excluding daycare))*100
63(c) Infection Control Department Incidence of needle stick injuries (Number of Parenteral Exposures/Number of In-patient Days (OPD))*100
63(a) MRD Percentage of medical records not having discharge summary (Number of Medical Records not having discharge summary/Number of Discharge & Death (Including Daycare))*100
63(b) MRD Percentage of medical records not having discharge summary (Number of Medical Records not having discharge summary/Number of Discharge & Death (Excluding Daycare))*100
64(a) MRD Percentage of medical records not having codification as per International Classification of Diseases (ICD) (Number of medical records not having codifications as per International Classification of Diseases (ICD)/Number of Discharge & Death (with Daycare))*100
64(b) MRD Percentage of medical records not having codification as per International Classification of Diseases (ICD) (Number of medical records not having codifications as per International Classification of Diseases (ICD)/Number of Discharge & Death (with out Daycare))*100
65(a) MRD Percentage of medical records having incomplete and/ or improper consent ((Number of medical records medical records having incomplete and/or improper consent)/Number of Discharge & Death (Including Daycare))*100
65(b) MRD Percentage of medical records having incomplete and/ or improper consent ((Number of medical records medical records having incomplete and/or improper consent)/Number of Discharge & Death (Excluding Daycare))*100
66 MRD Percentage of missing records (Number of missing records/Number of records)*100
67(a)(a)  Medical Service Appropriate handover during shift change                 (With day care) (Total no. of handovers done appropriately/Total no. of handover opportuity)*100
67(a)(b)  Medical Service Appropriate handover during shift change (Without daycare) (Total no. of handovers done appropriately/Total no. of handover opportuity)*100
67(b)(a) Nursing Service Appropriate handover during shift change (With day care) (Total no. of handovers done appropriately/Total no. of handover opportuity)*100
67(b)(b) Nursing service Appropriate handover during shift change (Without daycare) (Total no. of handovers done appropriately/Total no. of handover opportuity)*100
68(a) Medical Services Patient identification errors (No. of patient identification errors/no. of patients)*100
68(b) Nursing Service Patient identification errors (No. of patient identification errors/no. of patients)*100
69(a) Infection Control Department Compliance to hand hygiene practice (Combined) (Total no. of hand hygiene missed opportunitites/Total no. of hand hygiene opportunities)*100
69(b) Infection Control Department/ICU Compliance to hand hygiene practice (ICU) (Total no. of hand hygiene missed opportunitites/Total no. of hand hygiene opportunities)*100
69(c) Infection control department/OT Compliance to hand hygiene practice (OT) (Total no. of hand hygiene missed opportunitites/Total no. of hand hygiene opportunities)*100
70 PTC Compliance rate to medication prescription in capital letters (Compliance to medication prescription in capital letters/Total no. of precription)*100
71(a) Radiology (CT + PET CT) Turn Around Time For PET-CT Sum (Patient-in time to PET-CT – Patient reporting time in PET-CT)/Number of Patients reporting to PET-CT
71(b) Radiology Turn Around Time For CT Sum (Patient-in time to CT – Patient reporting time in CT)/Number of Patients reporting to CT
71(C) Radiology Turn Around Time For X Ray, USG & Mammo Sum (Patient-in time to X Ray, USG & Mammo – Patient reporting time in X Ray, USG & Mammo)/Number of Patients reporting to X Ray, USG & Mammo
71(d)  Maintenance TAT for Complaint Closure – Maintenance Sum of Time taken for closure of Complaints (in Min.)/Total Number of Complaints Receieved
71.(e) Biomedical TAT for Complaint Closure – BME Sum of Time taken for closure of Complaints (in Min.)/Total Number of Complaints Receieved
71(f) Housekeeping TAT for Complaint Closure – Housekeeping Sum of Time taken for closure of Complaints (in Min.)/Total Number of Complaints Receieved
72 Pathology No. of Reports Not informed in Time – Pathology Dept. (Number of investigation not reported within time /Total number of investigations done)*100
73 Radiotherapy Waiting time for Radiotherapy Sum (Patient-in time  to Radiotherapy – Patient Taken Time in Radiotherapy)/Number of Patients reporting to Radiotherapy
74(a) MRD Bed turnover rate (Excluding day care) Number of discharges in the month/Available bed days
74(b) MRD Bed turnover rate (Day care) Number of discharges in the month/Available bed days
75 OPD Avg Outpatient Visits (Per day) Total number of OPD visits/Total number of available days in the month
76 OPD New outpatient visits New outpatient visit
77 PTC Percentage of prescription sheet with error prone abbreviations in OPD (Percentage of prescription sheet with error prone abbreviations in OPD)/No of OPD precription sheet audited)*100
78 PTC Rate of documenting known drug allergies in IPD prescription/transciption (No of occations were Known drug allergies are ascertained/documented in IPD)/No of precription/transciption audited)*100
79 PTC Rate of documenting known drug allergies in OPD prescription/transciption (No of occations were Known drug allergies are ascertained/documented in OPD)/No of precription/transciption audited)*100
80 OT Post operative death rate (Total number of deaths(Within 24 hours after surgery)/Total number of patients who were operated) X 100
81 OT Peri operative death rate (Total number of deaths(Among patient having one or more procedures during the relevant admission)/Total number of patients who were operated) X 100

 

 

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Myself Ashlin Joby Thekkan. Living in a place known as God’s Own Country – Kerala, India.

I have a Masters Degree in Hospital Administration (MHA) and is working in the healthcare industry for the last 10 years.

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