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S

Std.

Indicators

Type

Definition/Interpretation

Source

Initiation/
generation of
data

Time for initial


assessment of
Indoor Patients

Formula

Sample size

Remarks

Process

The time shall begin from the


time that the patient has arrived
at the bed of the ward till the time Medical
that the initial assessment has
record
been completed by a doctor.
(Refer AAC 4 e-g.)

time will be put in


QA
MR by Either Ward
Face sheet &
Coordinator/Wa
nurse or attending
history sheet
rd Incharge
doctor

Sum of time taken


-----------------------------------------X100
Total no. of patients (sample)

The average time should be


reviewed by the hospital, to see if
1. For Hospitals with < 20 patients/day: 100%
this has impacted clinical care,
2. For Hospitals with 20-50
outcome, or has reduced the
patients/day: 50%
3. For Hospitals
efficiency. The outliers: Those
with > 50 patients/day: 20%
taking more than 20% of the
average time shall be audited.

Process

In case of emergency the time


shall begin from the time the
patient has come to the door of
the emergency till the time that
the initial assessment is
completed by a doctor. Wheel in
time in the emergency -time the
initial assessment was started by
the EMO

Wheel in register
time will be put in
(Bed no. time )
MR by Either Ward
& initial
QA Coordinator
nurse or attending
assessment
doctor
form (start
time )

Sum of time taken


------------------------------------------X100
Total no. of patients (sample)

1. For Hospitals with < 20 patients/day: 100%


2. For Hospitals with 20-50
patients/day: 50%
3. For Hospitals
with > 50 patients/day: 20%

CQI 3a

Time for initial


assessment of
Emergency
Patients

CQI 3a

Percentage of
cases (in-patients)
wherein care plan
with desired
Process
outcomes is
documented and
counter-signed by
the clinician

Percentage of
cases (in-patients)
wherein screening
Process
for Nutritional
needs has been
done

Percentage of
cases (in-patients)
wherein the
Process
Nursing care plan
is documented

Medical
record

Desired outcome includes


curative, preventive, rehabilitative Medical
etc.plan of care will be written by record
the doctor. (Refer AAC 4 h-j.)

Nutritional assessment can be


done by doctor/nurse/dietecian. It Medical
should be written in case sheet.
record
(Refer AAC 4 e-g).

Nursing care plan shall be the


outcome of the nursing
assessment done at the time of
Medical
admission. It should be written by record
the attendig nurse. (Refer AAC 4
d-e)

Record
sheet/ form

Patient Assessment

CQI 3a

Resp./
monitered
by

Plan of care to be
written by doctor
within a definite
time frame

doctor and nurse


who attends the
patient and there
after by dietecian

To be documented
by the ward nurse
in MR.

Care Plan
QA Coordinator sheet/In-patietn
case sheet

Nutritional
assessment
QA Coordinator form in Inpatient case
sheet

Nursing
administrator

Nursing
assessment
sheet

No. of in-patients case records


wherein the care plan with desired
outcome has been documented
---------------------------------------X100
Total no. of patients (sample)

No. of in-patients case records


wherein the nutritional has been
documented
---------------------------------------X100
Total no. of patients (sample)

No. of in-patients case records


wherein the nursing care plan
has been documented
---------------------------------------X100
Total no. of patients (sample)

The outliers: Those taking more


than 20% of the average time
shall be audited.

The indicator shall be captured


during the stay of the patient and
not from the medical record
1. For Hospitals with < 20 admissions/day: 100% department. It shall be collated
2. For Hospitals with 20-50
on a monthly basis. The sampling
admissions/day: 50%
base shall be patients who have
3. For Hospitals with > 50 completed 24 hours of stay in the
admissions/day: 20%
hospital. However, immediate
correction is to be initiated, when
gaps are seen on a real time
basis.
The indicator shall be captured
during the stay of the patient and
not from the medical record
department. It shall be collated
1. For Hospitals with < 20 admissions/day: 100%
on a monthly basis. The sampling
2. For Hospitals with 20-50
base shall be patients who have
admissions/day: 50%
3. For Hospitals
completed 24 hours of stay in the
with > 50 admissions/day: 20%
hospital. However, immediate
correction is to be initiated, when
gaps are seen on a real time
basis.
The indicator shall be captured
during the stay of the patient and
not from the medical record
department. It shall be collated
1. For Hospitals with < 20 admissions/day: 100%
on a monthly basis. The sampling
2. For Hospitals with 20-50
base shall be patients who have
admissions/day: 50%
3. For Hospitals with
completed 24 hours of stay in the
> 50 admissions/day: 20%
hospital. However, immediate
correction is to be initiated, when
gaps are seen on a real time
basis.

Safety/Quality for Diagnostics Services (Lab & Radiology)

CQI 3b

Number of
reporting
errors/1000
investigations

Process

Reporting errors include those


picked up before and after
dispatch. It shall include
transcription errors. This shall be
captured in laboratory and
radiology.(Refer AAC 6 g).

It should be
Lab/Radio reported by the
logy
Lab technician to
records
the HOD
Lab/Radiology.

Log book/
HOD Register/
Laboratory/Rad
Incident Report
iology
form

No. of reporting errors


(typing, wrong pt., wrong test)
---------------------------------------X1000
Total no. of tests performed

not applicable

It is better if the organisation


captures these errors as errors
picked up before dispatching the
reports & after the dispatch of
reports. Although indicator is to
be captured on a monthly basis,
an immediate action shall be
initiated when such instance
happen.

Re-dos include tests which


needed to be repeated in view of
poor sample or improper
Lab tech will
positioning and in case of
Lab/Radio document if there HOD radiology also includes film
logy
is re-do in any case Laboratory/Rad
wastage.. This shall also include
records
and maintain the
iology
tests repeated before release of
log.
the result (to confirm the finding).
(Refer AAC 6 g).

Percentage of Redo's

Pathologist and
Percentage of
Co-relation means that the test
Lab/Radio radiologist will
reports co-relating
results should match either the
logy
decide whether
Outcome
with clinical
diagnosis or differential diagnosis
records
reports are
diagnosis
written in the requisition form.
corelating

Process

Percentage of
adherence to
No. of Employees adhering to
safety precautions
Structure safety precautions e.g. PPE, Lead
by employees
aprons , TLD Badges, Gloves etc.
working in
diagnostics

Observati
on report

10

11

HOD Lab/Radiology

HOD Lab/Radiology

Log book/
Register/
Incident Report
form

Investigation
Slip

QI Register

No. of re-do's (hemolysed sample,


wrong sample)
---------------------------------------X100
Total no. of tests performed
in a month

No. of reports co-relating


clinical diagnosis
---------------------------------------X100
Total no. of tests performed
in a month (sample)

No. of employees adhering to


safety precautions
---------------------------------------X100
No. of employees (sample)

not applicable

1. For Hospitals with < 100 tests/month: 100%


2. For Hospitals with 100-200
tests/month: 50%
3. For Hospitals
with > 201-300 tests/month: 25%
4. For
Hospitals with > 301-500 tests/month: 20%
5. For Hospitals with > 500 tests/month: 15%
1. For Hospitals with < 25 employees working in
these areas: 100%
2. For
Hospitals with < 26-50 employees working in
these areas: 50%
3. For
Hospitals with > 51-100 employees working in
these areas: 30%
4. For Hospitals with
> 100 employees working in these areas: 20%

Shall be captured in the


laboratory (at least
histopathology) and radiology (at
least CT and MRI)

Shall be captured in the


laboratory (at least
histopathology) and radiology (at
least CT and MRI)

Even if the employees is not


adhering with any one of the
organisation's/statutory safety
precautions it shall be considered
as non-adherence.

Medication Management

Percentage of
medication errors
MANDATORY
INDICATOR 1

A medication error is any


preventable event that may cause
or lead to inappropriate
medication use or harm to a
patient (USFDA). Examples
include, but are not limited to:

Errors in the prescribing,


transcribing, dispensing,
Medical
Outcome
administering, and monitoring of records
medications;
Wrong drug, wrong strength, or
wrong dose errors;

Wrong patient errors; Wrong route


of administration errors; and
Calculation or
preparation errors.

QA Co
ordinator,
Nursing
superintendent
&
pharmacologist
or physician

Log book/
Register/
Incident Report
form

Percentage of
admissions with
adverse drug
reaction(s)

Adverse drug reaction: A


response to a drug which is
noxious and unintended and
which occurs at doses normally
used In man for prophylaxis,
Outcome
ADR form
diagnosis, or therapy of disease or
for the modification of physiologic
function. Therefore ADR
adverse event with a causal link
to a drug

QA Coordinator &
Nursing
administrator

Incident
Report/ADR form

Percentage of
medication charts
with error prone
abbreviations

Process

Medication chart with illegible


handwriting and unaccepted error Medical
prone abbreviations.(Refer MOM records
4g)

QA Coordinator &
Nursing
administrator

Medical records

Total no. of medication errors


---------------------------------------X100
Total no. of bed days

1. For Hospitals with average occupancy < 50


patients/day: 10% of patients/day.
2. For Hospitals with
average occupancy 51-100 patients/day: 5% of
patients/day.
3.
For Hospitals with average occupancy 101-300
patients/day: 3% of patients/day.
4. For Hospitals with average
occupancy 301-500 patients/day: 2% of
patients/day.
5. For Hospitals with average occupancy 5011000 patients/day: 1% of patients/day.
6. For Hospitals with
average occupancy > 1000 patients/day: 0.5%
of patients/day.

Total no. of adverse


drug reactions
---------------------------------------X100
Total no. of discharges
and deaths

NA

Total no. of medication charts


with error prone abbreviations
---------------------------------------X100
Total no. of medication
charts reviewed

1. For Hospitals with average occupancy < 50


patients/day: 10% of patients/day.
2. For Hospitals with average
occupancy 51-100 patients/day: 5% of
patients/day.
3. For Hospitals with average occupancy 101300 patients/day: 3% of patients/day.
4. For Hospitals with
average occupancy 301-500 patients/day: 2% of
patients/day.
5.
For Hospitals with average occupancy 501-1000
patients/day: 1% of patients/day.
6. For Hospitals with
average occupancy > 1000 patients/day: 0.5%
of patients/day.

In addition to incident reporting,


to detect medication errors the
organization shall either adopt
medical record review or direct
observation. The sample size for
this shall be as per the preceding
column. The average occupancy
shall be of the preceding 3
months

12

Percentage of
patients receiving
high risk
Process
medications
developing adverse
drug event

High risk medications are


medications involved in a high
percentage of medication errors
or sentinel events and
Medical
medications that carry a high risk
records
for abuse, error, or other adverse
outcomes. A good reference for
this is the ISMPs List of HighAlert Medications.

QA Co
ordinator &
nursing
administrator

Medical records

Not applicable

The denominator can be


captured from the pharmacy for
those patients who have been
dispensed high risk medications.

Anaesthesia

Process

The anaesthesia plan is the


outcome of pre-anaesthesia
assessment. Any changes done
after this shall be considered as
modification of anaesthesia plan.

Medical
records

HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator

Total no. of patients in whom


anaesthesia plan was modified
---------------------------------------X100
Total no. of patients underwent
Anaesthesia

Not applicable

Modification in anesthesia plan


could be captured in a
register/system before the patient
is shifted out of the OT.

Process

Every anaesthesia plan shall


invariably mention if there is a
Medical
possibility of the patient requiring records
ventilation following anesthesia.

HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator

Total no. of patients requiring


unplanned ventilation
following anaesthsia
---------------------------------------X100
Total no. of patients
underwent Anaesthesia

not applicable

Every case wherein a patient


required ventilation but this was
not captured in the anesthesia
plan shall be a part of the
numerator.

HOD
anesthesia, OT
In-charge & QA
coordinator

Log book/
Register/
Incident Report
form

Total no. of patients develop


adverse anaesthsia event
---------------------------------------X100
Total no. of patients underwent
Anaesthesia

Not applicable

Adverse anesthesia events


include events, which happen
during the procedure like hypoxia,
arrhythmias, cardiac arrest etc.

HOD
anesthesia, OT
Medical records
In-charge & QA
coordinator

No. of patients who died


due to anaesthsia
----------------------------------------X100
No. of patients who underwent
anaesthesia

Not applicable

Self Explanatory

Unplanned return shall be


captured only during the same
admission.

13 CQI 3d

Percentage of
modification of
anaesthesia plan

14

Percentage of
unplanned
ventilation
following
anaesthesia

15

Adverse anaesthesia event is any


untoward medical occurrence that
Percentage of
may present during treatment
Medical
adverse
Outcome with an anaesthetic product but
records
anaesthesia events
which does not necessarily have a
causal relationship with this
treatment.

16

Anaesthesia
related mortality
rate

Any death where the cause is


possible, probable (likely) or
Outcome
certain to be due to anaesthesia
shall be included.

Medical
records

Surgical Services
Medical
records
(OT)

OT In-charge

Log book/
Register/
Incident Report
form

No. of unplanned
returns to OT
----------------------------------------X100
No. of patients operated

Not applicable

Re-scheduling of patients includes


cancellation and postponement
(beyond 4 hours) of the surgery
OT
because of poor communication, records
inadequate preparation or
inefficiency within the system.

In-Charge OT

Log book/Daily
OT Report

No. of cases re-scheduled


----------------------------------------X100
No. of surgeries performed

Not applicable

OT
records

OT In-charge

Log book/
Register/
Incident Report
form

Percentage of
It is equally important that the
cases who received
antibiotic should have been given
appropriate
not more than two hours prior to Medical
prophylactic
Outcome
the incision. This indicator could
Records
antibiotics within
be captured in a register/system
the specified time
before the patient enters the OT.
frame

Surgeon will order


and ward nurse will
OT In-charge
administer and
write it in MR.

17 CQI 3e

Percentage of
unplanned return
to OT

18

Percentage of rescheduling of
surgeries

19

Percentage of
cases where the
organisation's
procedure to
prevent adverse
Outcome
events like wrong
site, wrong patient
and wrong surgery
have been adhered
to

20

Total no. of patients recieving


high risk medications who
have an adverse drug event
---------------------------------------X100
Total no. of patients recieving
high risk medications

Outcome

Process

Medical records

No. of cases where


procedure was followed
-----------------------------------------X100
No. of surgeries performed

No. of patients who did not


recieve any prophylactic
antibiotics
-----------------------------------------X100
No. of surgeries performed

Use of Blood and Blood products

Not applicable

This could be checked in the postop/recovery room and


documented in a register/system.

Not applicable

This indicator could be captured


in a register/system before the
patient enters the OT.
Prophylactic antibiotics should be
administered ideally within 30-60
minutes but certainly within two
hours of the time of incision.

21 CQI 3f

Percentage of
transfusion
reactions
MANDATORY
INDICATOR 2

A systemic response by the body


to the administration of blood
incompatible with that of the
recipient. The causes include red
blood cell incompatibility; allergic Medical
Outcome
sensitivity to the leukocytes,
records
platelets, plasma protein
components of the transfused
blood; or potassium or citrate
preservatives in the banked blood

22

Percentage of
wastage of blood
Process
and blood products

This also includes blood products


found unfit for use. In case the
organisation does not have a
blood bank of its own, the
denominator shall be the total
number of blood and blood
products collected/indented from
the blood bank

23

Percentage of
blood component
usage

Process

As per NACO Guidelines, the use


of blood products should be
encouraged rather than whole
blood usage.

Blood
Bank
records

24

Turnaround time
for issue of blood
and blood
components

Process

The time shall begin from the


time that the order is raised to
blood/blood component reaching
the clinical unit

Blood
Bank
records

Blood
Bank
records

ward sister,ward
in-charge / doctor
can report to blood
bank and will
document it in MR.

In charge
blood bank
will maintain
the record of
reactions

Blood bank
tecnician will
report to the
Incharge blood
bank

In-Charge
Blood Bank will Log Book blood
maintain the
bank
record.

Blood bank
tecnician will
report to the
Incharge blood
bank
blood bank
technician will put
down time of
requisistion & issue
and will document
it.

Trasnfusion
reaction form

In-Charge
Blood Bank

Log Book blood


bank

In-Charge
Blood Bank

Log Book blood


bank

No. of transfusion reactions


-----------------------------------------X100
Total no. of units transfused

No. of units wasted


-----------------------------------------X100
Total no. of units issued
from the blood bank

No. of components used


----------------------------------------X100
Total no. of blood and
blood products issued
Sum of time taken
-------------------------------X100
Total no. of blood and
components issued

Not applicable

Any adverse reaction to the


transfusion of blood or blood
components shall be considered
as transfusion reaction.It may
range from an allergic reaction to
a life threatening complication
like TRALI & Graft Versus Host
Disease.

not applicable

It is important that the


organisation capture the number
of blood and blood products used
and not just the number of
transfusions carried out. At times
more than one blood bag or
components may have been
given in a single transfusion

not applicable

NA

Not applicable

This will include blood outsourced


from other blood banks, for those
organisations not having in house
Blood Banks.

Not applicable

However NABH now recommends


Symptomatic UTI rate in which
the statement of treating doctor
is sufficient.

Not applicable

In VAP Culture report is must to


ascertain the case.

not applicable

CLABSI and transfusion reactions


are to be monitored differently.

not applicable

SSI is to be monitored for one


month in follow up.

Infection Control

25 CQI 3g

Urinary tract
infection rate (UTI/
As per Latest CDC/ NHSN
SUTI)
Outcome
Definition.
MANDATORY
INDICATOR 3

Medical
records

Reporting will be
done by treating
doctor. Order for
culture report.

Microbiologist
& ICN

Culture report

26

Ventilator
associated
pneumonia rate
(VAP)
MANDATORY
INDICATOR 4

Medical
records

Reporting will be
done by treating
doctor. Order for
culture report.

Microbiologist
& ICN

Culture report

27

Central line
associated
Bloodstream
infection
rate(CLABSI)
MANDATORY
INDICATOR 5

As per Latest CDC/ NHSN


Definition.

Medical
records

Reporting will be
done by treating
doctor. Order for
culture report.

Microbiologist
& ICN

28

Surgical site
infection rate (SSI)
As per Latest CDC/ NHSN
Outcome
MANDATORY
Definition.
INDICATOR 6

Medical
records

Reporting will be
done by treating
doctor/Surgeon.
Order for culture
report.

Microbiologist
& ICN

Outcome

Outcome

As per Latest CDC/ NHSN


Definition.

Culture report

Culture report

No. of catheter associated UTI's


in a given month
-------------------------------------------X100
Total no. of urinary catheter days
in that month
No. of ventilator associated
pneumonia in a given month
-------------------------------------------X100
Total no. of ventilator days
in that month
No. of central line associated
blood stream infections in a month
-------------------------------------------X100
Total no. of central line days
in that month

No. of surgical site infctions


in a given month
-------------------------------------------X100
Total no. of surgeries
in that month

Mortality & Morbidity

29 CQI 3h

Mortality rate

30

Percentage of
return to ICU
within 48 hours

Medical
Hospital admission
records
discharge register
Technician

Outcome

HMIS

Outcome

ICU nursing staff


Admissio
will initiate
n/Transfer
followed by inRegister
charge ICU.

ICU Incharge

Medical records

No. of deaths
-------------------------------------------X100
Total no. of discharges
and deaths

Not applicable

Medical records

No. of returns to ICU within


48 hrs.
-------------------------------------------X100
Total no. discharges, transfers
and deaths in the ICU

Not applicable

Higher value may repesent a


fairly higher HAI rate in the
hospital.

31

32

Rate of return to
the emergency
department within
72 hours with
similar presenting
complaints

Re-intubation rate

Emergen
cy Patient
Record
Register

Outcome

Process

This shall include the re-intubation Medical


withi 48 hrs. of extubation.
Records

nursing in-charge
will report to EMO
and put down in
MR.

ward incharge

ER Incharge

Medical records

Ward Incharge Medical records

No. of returns to Emergency within


72 hours with similar presenting
complaints
-------------------------------------------X100
Total no. patients who have
come to Emergency
No. of re-intubations within
48 hrs. of extubations
-------------------------------------------X100
Total no. of extubations

Not applicable

To capture this indicator it may be


a good practice to capture during
the initial assessment itself if the
patient had come within 72 hours
for similar complaints.

No. of re-intubations within 48 hours of


extubations/No. of intubations

NA

Clinical Research

33 CQI 3i

Percentage of
research activities
CAPTURED ON A QUARTERLY
Outcome
approved by ethics
BASIS
committee

Clinical
Research MOM of ethics
Departme committee
nt

Clinical
Research
Coordinator

research
documents of
the hospitals

No. of research activities approved


by ethics committee
-------------------------------------------X100
Total no. of research protocols
submitted to ethics committee

not applicable

This indicator shall be captured


on a quarterly basis.

34

Percentage of
patients
withdrawing from
the study

Clinical
Research MOM of ethics
Departme committee
nt

Clinical
Research
Coordinator

research
documents of
the hospitals

No. of patients who have withdrawn


from all ongoing activites
-------------------------------------------X100
Total no. of patients enrolled
in all ongoing studies.

not applicable

This indicator shall be captured


on a quarterly basis.

not applicable

Any protocol violation/deviation


that gets reported based on an
internal/external assessment
finding shall be considered as
deemed to have happened but
not reported. Hence, even though
it gets reported it shall be
included to only calculate the
denominator and shall not be
included in the numerator.

not applicable

This indicator shall be captured


on a quarterly basis.

not applicable

To capture this, organization


should maintain a register in the
pharmacy and stores (and also if
necessary in the wards) wherein
all such events are captured

not applicable

Organisation should maintain a


register in the pharmacy and
stores wherein all such events are
captured.

Outcome

CAPTURED ON A QUARTERLY
BASIS

35

Percentage of
protocol
violations/deviatio
ns reported

CAPTURED ON A QUARTERLY
BASIS

Clinical
Research Clinical Research
Departme Coordinator
nt

Clinical
Research
Coordinator

research
documents of
the hospitals

No. of protocol violations/


deviations
-------------------------------------------X100
Total no. of patients enrolled
in all ongoing studies

36

Percentage of
serious adverse
events (which have
occurred in the
CAPTURED ON A QUARTERLY
organisation)
Outcome
BASIS
reported to the
Ethics committee
within the defined
time frame

Clinical
Research Clinical Research
Departme Coordinator
nt

Clinical
Research
Coordinator

research
documents of
the hospitals

Number of serious adverse events


reported
-------------------------------------------X100
Total no. of patients enrolled
in all ongoing studies

Outcome

10

Procurement of medication essential to meet patient needs

37 CQI 4a

Percentage of
drugs &
consumables
procured by local
purchase

38

Percentage of
stock outs
including
emergency drugs

Process

This includes medicines or


consumables which were used by
the patients before admission and Pharmacy
Incharge
Incharge Pharmacy
need to continue but it is not
records
Pharmacy
included in the hospital list
(generic).

Local Purchase
register

Process

A stock out is an event which


occurs when an item in a
pharmacy or consumable store is
temporarily unable to provide for
an intended patient..

Stockout
Register

Pharmacy
Incharge
Incharge Pharmacy
records
Pharmacy

No. of items purchased by local


purchase
-------------------------------------------X100
no. of drugs listed in hospital
formulary & hospital consumables list

No. of stock outs


-------------------------------------------X100
no. of drugs listed in hospital
formulary & hospital consumables list

39

Percentage of
drugs &
consumables
Process
rejected before
preparation of
goods receipt note

All materials received not in


conformity with the specifications
Store
and requirements ordered for in
records
the purchase order shall be
rejected.

40

Percentage of
variations from the
Process
procurement
process

Variations from the written


standardized procurement
Chief Pharmacist
Purchase
process of acquiring supplies from
will notify the no.
records
licensed, authorized, agencies,
of such processes.
wholesalers/ distributors.

In-chrage stores

In-chrage
stores

Purchase
Store Incharge
records

11

not applicable

Denominator is total quantity and


not number. For eg.a single order
may have 30 items of "X"
consumable. Of the 30, 10 may
be rejected. In this case the
formula will be 10/30.

No. of variatiosn from the procurement


process
-------------------------------------------not applicable
X100
Total no. of items procured

Risk Management
Mock drill is a simulation exercise
of preparedness for any type of
event. It could be event or
Mock drill
disaster. This is basically a dry run
QA Coordinator
records
or preparedness drill. For
example, fire mock drill, disaster
drill, Code Blue Drill.

Number of
variations
observed in mock
drills

Process

42

Incidence of falls
MANDATORY
INDICATOR 7

The US Department of Veteran


Affairs National Centre for Patient
Safety defines fall as Loss of
upright position that results in
landing on the floor, ground or an
object or furniture or a sudden,
uncontrolled, unintentional, nonIncidence ward nurse/ward
Outcome purposeful, downward
Report
boy/aya
displacement of the body to the
floor/ground or hitting another
object like a chair or stair. It is an
event that results in a person
coming to rest inadvertently on
the ground or floor or other lower
level.

43

Incidence of bed
sores after
admission
MANDATORY
INDICATOR 8

A pressure ulcer is localized injury


to the skin and/or underlying
tissue usually over a bony
Nursing
Outcome prominence, as a result of
Records
pressure, or pressure in
combination with shear and/or
friction.

44

Percentage of
employees
provided preexposure
prophylaxis

Pre-exposure prophylaxis is any


medical or public health
procedure used before exposure
Personnel Office
Structure
to the disease causing agent, its
records
superintendent
purpose is to prevent, rather than
treat or cure a disease.

41 CQI 4b

ward nurse will


report it in MR.

12

Accreditation
Coordinator

Nursing
administrator

Nursing
administrator

Mock drill
records

not applicable

To capture the variation it is


suggested that every
organisation develop a checklist
to capture the events during a
mock drill.

not applicable

1. At different levels - i.e. from


one level to ground level. E.g.
from beds, wheelchairs or down
stairs.
2. On the same level
as a result of slipping, tripping or
stumbling from a colllision,
pushing or shoving by or with
another person.
3. Below
ground level i.e. into a hole or
other opening in surface. All
types of falls are to be included
whether they result from
physiological reasons (fainting) or
environmental reasons.

No. of patients who develop


new/worsening of pressure
ulcer after admission
-------------------------------------------X100
Total no. of discharges
and deaths

not applicable

will be confirmed by the


attending doctor.

Number of employees who


were provided preexposure prophylaxis
-------------------------------------------X100
Number of employees who
were due to be provided
pre-exposure prophylaxis

No. of employees who were provided preexposure prophylaxis /no. of employees posted
in high risk areas like lab ,dialysis, ICUs, Blood
Bank etc

It shall include at a minimum


prophylaxis against Hepatitis B.

not applicable

Inpatient Days: A patient day is


the unit of measure denoting
lodging provided and services
rendered to inpatients between
the census taking hours (usually
at midnight) of two successive
days. A patient formally admitted
who is discharged or dies on the
same day is counted as one
patient day, regardless of the
number of hours the patient
occupies a hospital bed. For
patients switched from
observation to inpatient status,
the patient day count should
begin on the day the patient was
officially admitted as an inpatient.

Total no. of variations in a mock drill

No. of Falls
Incidence Report -------------------------------------------X100
Total no. of discharges
and deaths

Incident Report

Office
Personnel
superintendent records

Utilization of Space, Manpower and Equipment

CQI 4c

45

GRN

No. of Drugs & consumables rejected


before the preparation of GRN
-------------------------------------------X100
Total no. of drugs & consumables
received

The bed occupancy rate is the


percentage of official beds
occupied by hospital inpatients for
Bed occupancy rate
a given period of time.For a bed
MANDATORY
Outcome
HIS
to be included in the official
INDICATOR 9
count, it must be set up, staffed,
equipped and available for patient
care.

ward incharge

QA Coordinator &
MRD
technician

admissiondischarge
register

No. of inpatient days in a


given month
-------------------------------------------X100
No. of available bed days in
that month

45

Average length of
stay MANDATORY
INDICATOR 9

46

OT utilization rate

Length of stay (LOS) is a term


used to measure the duration of a
single episode of hospitalization.
Inpatient days are calculated by
Outcome subtracting day of admission from HIS
day of discharge. However,
persons entering and leaving a
hospital on the same day have a
length of stay of one

OT utilisation is defined as the


quotient of hours of OT time
actually used during elective
Outcome
HIS
resource hours and the total
number of elective resource hours
available for use.

ICU utilization rate Outcome

HIS

Any equipment the failure of


which could impede patient care
shall be considered critical. e.g.
ventilators, cardiac monitors,
pulse oximeter etc.

47

Critical equipment
down time

48

The HCOs should calculate the


staffing patterns separately for
Nurse-patient ratio
ICUs and for the wards. The in
Structure
for ICUs & Wards
charge/supervisor of the area
shall not be included for
calculating the number of staff.

Process

ward incharge

QA Coordinator &
MRD
technician

OT register

ICU in-charge

QA Coordinator &
MRD
technician

HIS/Midnight
census register

ward incharge

chief
paharmacist

Matron

13

49 CQI 4d

admissiondischarge
register

OT incharge/ OT
matron

Complain concerned
t log
department

Records

QA Coordinator &
MRD
technician

Complaint log

Hospital Census

No. of inpatient days in a


given month
-------------------------------------------X100
No. of discharges and deaths in
that month

Actual no. of surgeries performed


-------------------------------------------X100
Max. no. of surgeries that
can be done

Actual no. of in -patient bed days


-------------------------------------------X100
Max. no. of available bed days

total no. of hours of downtime


-------------------------------------------X100
Max. no. of functional hours
of the equipme

No. of staff per no. of shifts


-------------------------------------------X100
No. of beds

not applicable

Available bed days-It is the


product of number of inpatient
beds and number of days in that
month.
Number of inpatient daysIt is a sum of daily inpatient
census. While calculating the
overall length of stay and
available number of inpatient
beds, emergency, rehabilitation
and day care beds should not be
considered.

not applicable

The degree of utilisation depicts


the average utilisation of beds in
per cent. The actual bed
occupancy is set in relation to the
maximum bed occupancy. The
maximum bed capacity is the
result of the product of installed
beds and the number of calendar
days in the reporting year. The
actual bed occupancy is the sum
of calculation days and
occupancy days, because every
patient occupies one bed per
inpatient day in the facility

Actual no. of in-patient bed days/max no. of


available bed days X 100

NA

not applicable

The term downtime is used to


refer to periods when a system is
unavailable. Downtime or outage
duration refers to a period of time
that a system fails to provide or
perform its primary function

not applicable

For example, if in the ICU there


are a total of 15 nurses who work
in 3 shifts the numerator will 5
(15/3) and if there are 5 beds the
ratio is 1:1. Similarly for wards It
is preferable that in case of ICU
the organisation capture the ratio
for ventilated and non-ventilated
patients separately.

1. For Hospitals with < 20 patients/day: 100%


2. For Hospitals with 21-50 patients/day:
50%
3. For Hospitals with 51-100
patients/day: 20%
4. For Hospitals with
101-200 patients/day: 10%
5. For Hospitals
with 201-400 patients/day: 5%
6. For
Hospitals with > 400 patients/day: 2%

The sample shall be derived from


repeat patients. It is preferable
that patients who are coming to
the hospital for the first time not
be included as it is possible that
they would not be in a position to
give feedback on some aspects.
The organisation could also
capture satisfaction for various
individual parameters (as laid
down in its feedback form). In
case the organisation is not
capturing an overall feedback but
instead only for various
parameters, the index shall be
calculated by averaging the
satisfaction of various
parameters.

Patient Satisfaction

Out patient
satisfaction index

Patient Satisfaction is defined in


terms of the degree to which the
patients expectations are
Outcome fulfilled. It is an expression of the
gap between the expected and
perceived characteristics of a
service.

Survey

Hospital manager

Accreditaion
coordinator

Score Achieved
OPD pt
-----------------------------------------satisfaction form
X100
Maximum possible score

50

In patient
satisfaction index

Wating time for


services out
patient
consultation

Outcome

Process

Survey

A waiting time is a length of time


which one must wait in order for a
Records
specific action to occur, after that
action is requested or mandated.

Hospital manager

Hospital manager

1. For Hospitals with < 20 discharges/day: 100%


2. For Hospitals with 21-50
discharges/day: 50%
3. For Hospitals with
51-100 discharges/day: 20%
4. For Hospitals
with > 100 discharges/day: 10%

Accreditaion
coordinator

Score Achieved
-------------------------------------------IPD pt
satisfaction form X100
Maximum possible score

Accreditaion
coordinator

Registration
time &
Consulting time
(shall be noted
by the
consultant )

Sum( patient in time for


consultation-patient reporting
time in OPD
-------------------------------------------X100
No. of patients reported
in OPD

not applicable

NA

Accreditaion
coordinator

Registration
time & Sample
collection
time(shall be
noted by the
technician )

Sum( patient in time for


consultation-reporting
time in diagnostics
-------------------------------------------X100
No. of patients reported
in diagnostics

not applicable

waiting time for diagnostics is


applicable only for out-patients.

Accreditaion
coordinator

Discharge note
& time on
discharge slip or
register

Sum of time taken for discharge


-------------------------------------------X100
No. of patients discharge

not applicable

In case patients request


additional time to leave the
clinical unit that shall not be
added. The discharge is deemed
to have been complete when the
formalities for the same have
been completed.

51

Wating time for


Process
service diagnostics

52

Time taken for


discharge

Process

Records

Discharge is the process by which


a patient is shifted out from the
hospital with all concerned
medical summaries after ensuring
stability. The discharge process is Records
deemed to have started when the
consultant formally approves
discharge and ends with the
patient leaving the clinical unit.

Hospital manager

ward incharge

14

Employee Satisfaction

Hospital manager

Score Achieved
-------------------------------------------Employee
satisfaction form X100
Maximum possible score

Hospital manager

Accreditaion
coordinator

HR records

No. of employees who have left


-------------------------------------------X100
No. of employees at the beginning
of the month+newly joined staff

not applicable

HR records

No. of employees who are on unauthorised absence


-------------------------------------------X100
No. of employees

not applicable

53 CQI 4e

The satisfaction shall be captured


Outcome from all categories of staff
Survey
CAPTURED ONCE IN 6 MONTHS

54

Employee attrition
rate

Outcome

55

Employee
absenteeism rate

Absenteeism in employment law


is the state of not being present
that occurs when an employee is Personnel Office
Outcome
absent or not present at work
records
superintendent
during a normally scheduled work
period.

56

Percentage of
Employee awareness is the state
employees who are
or condition of being aware;
aware of employee
having knowledge; consciousness
rights,
Outcome
Survey
about employee rights,
responsibilities
responsibilities and welfare
and welfare
schemes.
schemes.

Attrition rate is the percentage of


people leaving the organisation.

Records

Hospital manager

15

57 CQI 4f

58

1. For Hospitals with < 100 staff: 100%


2. For Hospitals with 101-200 staff: 50%
3. For Hospitals with 201-500 staff:
20%
4. For Hospitals with 501-1000
staff: 15%
5. For Hospitals with >
1000 staff: 10%

Accreditaion
coordinator

Employee
Satisfaction index

Accreditaion
coordinator

Accreditaion
coordinator

Personnel
interview
records

No. of employees who are aware


of their rights, responsibilities and
welfare schemes
-------------------------------------------X100
No. of employees interviewed

1. For Hospitals with < 100 staff: 30%


2. For Hospitals with 101-200 staff: 15%
3. For Hospitals with 201-500 staff:
8%
4. For Hospitals with 5011000 staff: 15%
5. For Hospitals with
501- 1000 staff: 4%
6. For hospitals
with > 1000 staff: 2%

Adverse events and near misses


Number of sentinel
events reported,
collected and
Process
analysed within
the defined time
frame

A relatively infrequent,
unexpected incident, related to
system or process deficiencies,
Data
which leads to death or major and
enduring loss of function for a
recipient of healthcare services

ward incharge

Accreditaion
coordinator

Log book/
Register/
Incident Report
form

Percentage of near
Process
misses

A near miss is an unplanned


event that did not result in injury,
illness, or damage but had the
potential to do so. Errors that did Data
not result in patient harm, but
could have, can be categorized as
near misses.

concerned
department

Accreditaion
coordinator

Log book/
Register/
Incident Report
form

No. of sentinal events reported,


collected and analysed within
the defined time frame
-------------------------------------------X100
No. of sentinal events reported
collected and analyzed
No. of near misses reported
-------------------------------------------X100
No. of incident reports

not applicable

If there is deviation in either


reporting/collecting/analysis it
shall not be included in the
numerator.

not applicable

Near miss reporters can describe


what they observed of the
beginning of the event, and the
factors that prevented loss from
occuring.

59

60

Incidence of blood
body fluid
exposures

Process

An exposure is when blood, blood


components or other potentially
infectious materials come in
Data
contact with a staffs eyes,
mucous membranes, non-intact
skin or mouth.

Needle stick injury is a


penetrating stab wound from a
Incidence of needle
needle (or other sharp object) that
stick injuries
may result in exposure to blood or
Outcome
Data
MANDATORY
other body fluids. Needle stick
INDICATOR 10
injuries are wounds caused by
needles that accidentally
puncture in the skin

ward incharge

ward incharge

Accreditaion
coordinator

Matron

16

61 CQI 4g

62

Log book/
Register/
Incident Report
form

Needle stick
injury form/
Incident Report
form

Number of blood body fluid exposures


in the given period

Incidence of needle stick injuries


reported during the given period

not applicable

not applicable

Parenteral exposure means injury


due to any sharp. All incidences
of needle stick injuries should be
assessed on a case-by-case basis.
Analyze needle stick and other
sharps related injuries in the
workplace to identify hazards and
injury trends. Data from injury
reporting should be compiled and
assessed to identify: (1) where,
how, with what devices, and
when injuries are occurring and
(2) the groups of health care
workers being injured.

not applicable

Every medical record that comes


to the MRD from the clinical unit
following the discharge of a
patient shall be immediately
checked for the presence of
discharge summary. If this is not
present at this stage it shall be
captured as a part of the
numerator.

1. For Hospitals with < 20 discharges/day: 100%


2. For Hospitals with 21-50
discharges/day: 50%
3. For Hospitals with
51-100 discharges/day: 20% 4. For Hospitals
with > 100 discharges/day: 10%

ICD codification shall be done by


the concerned staff within the
specified period following
discharge. After completion of
this specified period an audit
shall be done (using sample size
mentioned in the previous
column) by an independent
person to capture this

Medical Records

Percentage of
medical records
Process
not having
discharge summary

A discharge summary is the part


of a patient record that
summarizes the reasons for
admission, significant clinical
findings, procedures performed,
treatment rendered, patients
condition on discharge and any
specific instructions given to the
patient or family (for example
follow-up medications). It is a
summary of the patients stay in
hospital written by the attending
doctor.

Percentage of
medical records
not having
codification as per
International
Classification of
Diseases (ICD)

The ICD is the international


standard diagnostic classification
for all general epidemiological,
many health management
purposes and clinical use. These
include the analysis of the general
health situation of population
groups and monitoring of the
Medical
incidence and prevalence of
record
diseases and other health
problems in relation to other
variables such as the
characteristics and circumstances
of the individuals affected,
reimbursement, resource
allocation, quality and guidelines
(WHO).

Process

Medical
record

MRD Technician

MRD Technician

Hospital
manager

Hospital
manager

MRD check list

MRD check list

No. of medical records not having


discharge summary
-------------------------------------------X100
No. of discharges & deaths

No. of medical records not having


codification as per ICD
-------------------------------------------X100
No. of discharges & deaths

Consent is the willingness of a


patient to undergo examination/
procedure/ treatment by a health
care provider. Informed consent is
a type of consent in which the
health care provider has a duty to
inform his/her patient about the
procedure, its potential risk and
benefits, alternative procedure
with their risk and benefits so as
Medical
to enable the patient to take an
record
informed decision of his/her
health care. If any of the essential
element/requirement of consent is
missing it shall be considered as
incomplete. If any consent
obtained is invalid/void (consent
obtained from wrong
person/consent obtained by
wrong person etc.) it is considered
as improper.

63

Percentage of
medical records
having incomplete
and/or improper
consent

Process

64

Percentage of
missing records

A medical record is considered as


missing when the record could not
Medical
Outcome be found out from the MRD after
record
the 72nd hour of the record
request.

Note

MRD Technician

Hospital
manager

MRD check list

MRD Technician

Hospital
manager

Log book/
Register/
Incident Report
form

No. of medical records not having


complete consent(s)
-------------------------------------------X100
No. of discharges & deaths

No. of missing medical records


-------------------------------------------X100
No. of records

Unless specified all indicators shall be captured on a monthly basis and the numerator and denominator shall be of that month.

not applicable

not applicable

Regular checks should be in place


to ensure that there are no
missing medical records or
medical records are filed in the
wrong place.