| 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 |