S
Std.
Indicators
Type
Defnition/Interpretation
Source
Initiation/ eneration o data
1
Time or initial assessment o Indoor Patients
Process
1
CQI 3a
Time or initial assessment o ,merency Patients
CQI 3a
Percentae o cases "in*patients& -'erein care plan -it' desired outcomes is documented and counter*sined $y t'e clinician
Percentae o cases "in*patients& -'erein screenin or utritional needs 'as $een done
3
Percentae o cases "in*patients& -'erein t'e ursin care plan is documented
4
Process
Process
Process
Process
The time shall begin begin from the time that the patient has arrived at the bed of the ard till the time #edical that the initial assessment has record been completed b! a doctor" "Reer AA( ) e*.& In case of emergenc! the time shall begin from the time the patient has come to the door of the emergenc! till the time that the initial assessment is completed b! a doctor" 'heel in time in the emergenc! emergenc! 0time the initial assessment as started b! the &#
#edical record
9esired o$tcome incl$des c$rative preventive preventive rehabilitative rehabilitative #edical etc"plan of care ill be ritten b! record the doctor" "Reer AA( ) '*.&
;$tritional assessment can be done b! doctor(n$rse(dietecian" doctor(n$rse(dietecian" It #edical sho$ld be ritten in case sheet" record "Reer AA( ) e*&.
;$rsing care plan shall be the o$tcome of the n$rsing assessment done at the time of #edical admission" It sho$ld be ritten b! record the attendig n$rse" "Reer AA( ) d*e&
2
5
Record s'eet/ orm
Formula
Sample size
Remarks
Patient Assessment
CQI 3a
2
Resp./ monitered $y
time ill be p$t in #% b! &ither 'ard n$rse or attending doctor
QA )ace sheet * Coordinator('a histor! sheet rd Incharge
time ill be p$t in #% b! &ither 'ard n$rse or attending doctor
QA Coordinator
Plan of care to be ritten b! doctor ithin a de:nite time frame
doctor and n$rse ho attends the patient and there after b! dietecian
To To be doc$mented doc$mented b! the ard n$rse in #%"
'heel in register 67ed no" time 8 * initial assessment form 6start time 8
Care Plan QA Coordinator sheet(In0patietn case sheet
;$tritional assessment QA Coordinator form in In0 patient case sheet
;$rsing administrator
;$rsing assessment sheet
S$m of time taen ****************************************** 3011 Total Total no" of patients patients 6sample8
1" )or +ospitals ith , 2- patients(da!. 1--/ 2" )or +ospitals ith 2-05patients(da!. patients (da!. 5-/ 3" )or +ospitals ith 5- patients(da!. 2-/
The average average time sho$ld be revieed b! the hospital to see if this has impacted clinical care o$tcome or has red$ced the ecienc!" T'e outliers+ Those taing more than 2-/ of the average time shall be a$dited"
S$m of time taen ******************************************* 3011 Total Total no" of patients patients 6sample8
1" )or +ospitals ith , 2- patients(da!. 1--/ 2" )or +ospitals ith 2-05patients(da!. patients (da!. 5-/ 3" )or +ospitals ith 5- patients(da!. 2-/
T'e outliers+ Those taing more than 2-/ of the average time shall be a$dited"
;o" of in0patients case records herein the care plan ith desired o$tcome has been doc$mented **************************************** 3011 Total Total no" of patients patients 6sample8
;o" of in0patients case records herein the n$tritional has been doc$mented **************************************** 3011 Total Total no" of patients patients 6sample8
;o" of in0patients case records herein the n$rsing care plan has been doc$mented **************************************** 3011 Total Total no" of patients patients 6sample8
The indicator indicator shall be capt$red capt$red d$ring the sta! of the patient and not from the medical record 1" )or +ospitals ith , 2- admissions(da!. 1--/ department" It shall be collated 2" )or +ospitals ith 2-05on a monthl! basis" The sampling admissions(da!. 5-/ base shall be patients ho have 3" )or +ospitals ith 5- completed 24 ho$rs of sta! in the admissions(da!. 2-/ hospital" +oever immediate correction is to be initiated hen gaps are seen on a real time basis" The indicator indicator shall be capt$red capt$red d$ring the sta! of the patient and not from the medical record department" It shall be collated 1" )or +ospitals ith , 2- admissions(da!. 1--/ on a monthl! basis" The sampling 2" )or +ospitals ith 2-05base shall be patients ho have admissions(da!. admissi ons(da!. 5-/ 3" )or +ospitals completed 24 ho$rs of sta! in the ith 5- admissions(da!. 2-/ hospital" +oever immediate correction is to be initiated hen gaps are seen on a real time basis" The indicator indicator shall be capt$red capt$red d$ring the sta! of the patient and not from the medical record department" It shall be collated 1" )or +ospitals ith , 2- admissions(da!. 1--/ on a monthl! basis" The sampling 2" )or +ospitals ith 2-05base shall be patients ho have admissions(da!. admissions(da!. 5-/ 3" )or +ospitals ith completed 24 ho$rs of sta! in the 5- admissions(da!. 2-/ hospital" +oever immediate correction is to be initiated hen gaps are seen on a real time basis"
Saety/Quality or Dianostics Ser!ices "#a$ % Radioloy&
CQI 3b
um$er o reportin errors/0111 in!estiations
Process
%eporting errors incl$de those piced $p before and after dispatch" It shall incl$de transcription errors" This shall be capt$red in laborator! and radiolog!""Reer AA( 2 &.
It sho$ld be
;o" of reporting errors 6t!ping rong pt" rong test8 **************************************** 30111 Total Total no" of tests performed
not applicable
It is better if the organisation capt$res these errors as errors piced $p before dispatching the reports * after the dispatch of reports" Altho$gh indicator is to be capt$red on a monthl! basis an immediate action shall be initiated hen s$ch instance happen"
%e0dos incl$de tests hich needed to be repeated in vie of poor sample or improper
=
Percentae o Re* do5s
>
Percentae o Co0relation means that the test reports co*relatin res$lts sho$ld match either the $tcome -it' clinical diagnosis or dierential diagnosis dianosis ritten in the reB$isition form"
?
Percentae o ad'erence to saety precautions $y employees -orkin in dianostics
;o" of &mplo!ees adhering to Str$ct$re safet! preca$tions e"g" PP&
Percentae o medication errors 4ADAT6R7 IDI(AT6R 0
A me ication error is an! preventable event that ma! ca$se or lead to inappropriate medication $se or harm to a patient 6ES)9A8" &Famples incl$de b$t are not limited to. G &rrors in the prescribing transcribing dispensing #edical $tcome administering and monitoring of records medicationsH G 'rong dr$g rong strength or rong dose errorsH G 'rong patient errorsH 'rong ro$te of administration errorsH and G Calc$lation or preparation errors"
QA Co ordinator ;$rsing s$perintendent * pharmacologist or ph!sician
Percentae o admissions -it' ad!erse dru reaction"s&
Ad!erse dru reaction+ A response to a dr$g hich is noFio$s and $nintended and hich occ$rs at doses normall! $sed In man for proph!laFis $tcome A9% form diagnosis or therap! of disease or for the modi:cation of ph!siologic f$nction" Therefore ADR 8 adverse event ith a ca$sal lin to a dr$g
QA Co0 ordinator * ;$rsing administrator
Incident %eport(A9% form
Process
Pathologist and
+9 0
Investigation Slip
;o" of re0doDs 6hemol!sed sample rong sample8 **************************************** 3011 Total no" of tests performed in a month
;o" of reports co0relating clinical diagnosis **************************************** 3011 Total no" of tests performed in a month 6sample8
not applicable
1" )or +ospitals ith , 1-- tests(month. 1--/ 2" )or +ospitals ith 1--02-tests(month. 5-/ 3" )or +ospitals ith 2-103-- tests(month. 25/ 4" )or +ospitals ith 3-105-- tests(month. 2-/ 5" )or +ospitals ith 5-- tests(month. 15/
Shall be capt$red in the laborator! 6at least histopatholog!8 and radiolog! 6at least CT and #%I8
Shall be capt$red in the laborator! 6at least histopatholog!8 and radiolog! 6at least CT and #%I8
these areas. 1--/
bservati on report
3
@
1-
11
+9 0
QI %egister
;o" of emplo!ees adhering to safet! preca$tions **************************************** 3011 ;o" of emplo!ees 6sample8
2" )or +ospitals ith , 2=05- emplo!ees oring in these areas. 5-/ 3" )or +ospitals ith 5101-- emplo!ees oring in these areas. 3-/ 4" )or +ospitals ith 1-- emplo!ees oring in these areas. 2-/
&ven if the emplo!ees is not adhering ith an! one of the organisationDs(stat$tor! safet! preca$tions it shall be considered as non0adherence"
4edication 4anaement
Percentae o medication c'arts -it' error prone a$$re!iations
Process
#edication chart ith illegible handriting and $naccepted error #edical prone abbreviations""Reer 464 records )&
QA Co0 ordinator * ;$rsing administrator
#edical records
Total no" of medication errors **************************************** 3011 Total no" of bed da!s
1" )or +ospitals ith average occ$panc! , 5patients(da!. 1-/ of patients(da!" 2" )or +ospitals ith average occ$panc! 5101-- patients(da!. 5/ of patients(da!" 3" )or +ospitals ith average occ$panc! 1-103-patients(da!. 3/ of patients(da!" 4" )or +ospitals ith average occ$panc! 3-105-- patients(da!. 2/ of patients(da!" 5" )or +ospitals ith average occ$panc! 5-10 1--- patients(da!. 1/ of patients(da!" =" )or +ospitals ith average occ$panc! 1--- patients(da!. -"5/ of patients(da!"
Total no" of adverse dr$g reactions **************************************** 3011 Total no" of discharges and deaths
;A
Total no" of medication charts ith error prone abbreviations **************************************** 3011 Total no" of medication charts revieed
" patients(da!. 1-/ of patients(da!" 2" )or +ospitals ith average occ$panc! 5101-- patients(da!. 5/ of patients(da!" 3" )or +ospitals ith average occ$panc! 1-10 3-- patients(da!. 3/ of patients(da!" 4" )or +ospitals ith average occ$panc! 3-105-- patients(da!. 2/ of patients(da!" 5" )or +ospitals ith average occ$panc! 5-101--patients(da!. 1/ of patients(da!" =" )or +ospitals ith average occ$panc! 1--- patients(da!. -"5/
In addition to incident reporting to detect medication errors the organiation shall either adopt medical record revie or direct observation" The sample sie for this shall be as per the preceding col$mn" The average occ$panc! shall be of the preceding 3 months
12
Percentae o patients recei!in 'i' risk Process medications de!elopin ad!erse dru e!ent
+igh ris medications are medications involved in a high percentage of medication errors or sentinel events and #edical medications that carr! a high ris records for ab$se error or other adverse o$tcomes" A good reference for this is the JIS#PKs
QA Co ordinator * n$rsing administrator
#edical records
4
;ot applicable
The denominator can be capt$red from the pharmac! for those patients ho have been dispensed high ris medications"
Anaest'esia
#edical records
+9 anesthesia T Anaesthesia in charge * QA record sheet coordinator
Total no" of patients in hom anaesthesia plan as modi:ed **************************************** 3011 Total no" of patients $nderent Anaesthesia
;ot applicable
#odi:cation in anesthesia plan co$ld be capt$red in a register(s!stem before the patient is shifted o$t of the T"
&ver! anaesthesia plan shall invariabl! mention if there is a #edical possibilit! of the patient reB$iring records ventilation folloing anesthesia"
+9 anesthesia T Anaesthesia in charge * QA record sheet coordinator
Total no" of patients reB$iring $nplanned ventilation folloing anaesthsia **************************************** 3011 Total no" of patients $nderent Anaesthesia
not applicable
&ver! case herein a patient reB$ired ventilation b$t this as not capt$red in the anesthesia plan shall be a part of the n$merator"
+9 anesthesia T In0charge * QA coordinator
Total no" of patients develop adverse anaesthsia event **************************************** 3011 Total no" of patients $nderent Anaesthesia
;ot applicable
Adverse anesthesia events incl$de events hich happen d$ring the proced$re lie h!poFia arrh!thmias cardiac arrest etc"
+9 anesthesia T #edical records In0charge * QA coordinator
;o" of patients ho died d$e to anaesthsia ***************************************** 3011 ;o" of patients ho $nderent anaesthesia
;ot applicable
Self &Fplanator!
;o" of $nplanned ret$rns to T ***************************************** 3011 ;o" of patients operated
;ot applicable
Enplanned ret$rn shall be capt$red onl! d$ring the same admission"
;o" of cases re0sched$led ***************************************** 3011 ;o" of s$rgeries performed
;ot applicable
The anaesthesia plan is the o$tcome of pre0anaesthesia assessment" An! changes done after this shall be considered as modi:cation of anaesthesia plan"
13 CQI 3d
Percentae o modifcation o anaest'esia plan
14
Percentae o unplanned !entilation ollo-in anaest'esia
15
Adverse anaesthesia event is an! $ntoard medical occ$rrence that Percentae o ma! present d$ring treatment #edical ad!erse $tcome ith an anaesthetic prod$ct b$t records anaest'esia e!ents hich does not necessaril! have a ca$sal relationship ith this treatment"
1=
Anaest'esia related mortality rate
Process
Process
An! death here the ca$se is possible probable 6liel!8 or $tcome certain to be d$e to anaesthesia shall be incl$ded"
#edical records
5
Surical Ser!ices #edical records 6T8
T In0charge
%e0sched$ling of patients incl$des cancellation and postponement 6be!ond 4 ho$rs8 of the s$rger! T beca$se of poor comm$nication records inadeB$ate preparation or inecienc! ithin the s!stem"
In0Charge T
1> CQI 3e
Percentae o unplanned return to 6T
1?
Percentae o re* sc'edulin o sureries
1@
Percentae o cases -'ere t'e oranisation5s procedure to pre!ent ad!erse $tcome e!ents like -ron site; -ron patient and -ron surery 'a!e $een ad'ered to
T records
T In0charge
2-
Percentae o It is eB$all! important that the cases -'o recei!ed antibiotic sho$ld have been given appropriate not more than to ho$rs prior to #edical prop'ylactic $tcome the incision" This indicator co$ld %ecords anti$iotics -it'in be capt$red in a register(s!stem t'e specifed time before the patient enters the T" rame
S$rgeon ill order and ard n$rse ill T In0charge administer and rite it in #%"
=
Total no" of patients recieving high ris medications ho have an adverse dr$g event **************************************** 3011 Total no" of patients recieving high ris medications
$tcome
Process
#edical records
;o" of cases here proced$re as folloed ****************************************** 3011 ;o" of s$rgeries performed
;o" of patients ho did not recieve an! proph!lactic antibiotics ****************************************** 3011 ;o" of s$rgeries performed
9se o :lood and :lood products
;ot applicable
This co$ld be checed in the post0 op(recover! room and doc$mented in a register(s!stem"
;ot applicable
This indicator co$ld be capt$red in a register(s!stem before the patient enters the T" Proph!lactic antibiotics sho$ld be administered ideall! ithin 3-0=min$tes b$t certainl! ithin to ho$rs of the time of incision"
21 CQI 3f
Percentae o transusion reactions 4ADAT6R7 IDI(AT6R <
A s!stemic response b! the bod! to the administration of blood incompatible ith that of the recipient" The ca$ses incl$de red blood cell incompatibilit!H allergic #edical $tcome sensitivit! to the le$oc!tes records platelets plasma protein components of the transf$sed bloodH or potassi$m or citrate preservatives in the baned blood
This also incl$des blood prod$cts fo$nd $n:t for $se" In case the organisation does not have a blood ban of its on the denominator shall be the total n$mber of blood and blood prod$cts collected(indented from the blood ban
7lood 7an records
22
Percentae o -astae o $lood Process and $lood products
23
Percentae o $lood component usae
Process
As per ;AC $idelines the $se of blood prod$cts sho$ld be enco$raged rather than hole blood $sage"
7lood 7an records
24
Turnaround time or issue o $lood and $lood components
Process
The time shall begin from the time that the order is raised to blood(blood component reaching the clinical $nit
7lood 7an records
ard sisterard in0charge ( doctor can report to blood ban and ill doc$ment it in #%"
In charge blood ban ill maintain the record of reactions
7lood ban tecnician ill report to the Incharge blood ban
In0Charge 7lood 7an ill
7lood ban tecnician ill report to the Incharge blood ban oo an technician ill p$t don time of reB$isistion * iss$e and ill doc$ment it"
Trasnf$sion reaction form
In0Charge 7lood 7an
In0Charge 7lood 7an
>
;o" of transf$sion reactions ****************************************** 3011 Total no" of $nits transf$sed
;o" of $nits asted ****************************************** 3011 Total no" of $nits iss$ed from the blood ban
;o" of components $sed ***************************************** 3011 Total no" of blood and blood prod$cts iss$ed S$m of time taen *******************************3011 Total no" of blood and components iss$ed
;ot applicable
An! adverse reaction to the transf$sion of blood or blood components shall be considered as transf$sion reaction"It ma! range from an allergic reaction to a life threatening complication lie T%A
not applicable
It is important that the organisation capt$re the n$mber of blood and blood prod$cts $sed and not N$st the n$mber of transf$sions carried o$t" At times more than one blood bag or components ma! have been given in a single transf$sion
not applicable
;A
;ot applicable
This ill incl$de blood o$tso$rced from other blood bans for those organisations not having in ho$se 7lood 7ans"
;ot applicable
+oever ;A7+ no recommends S!mptomatic ETI rate in hich the statement of treating doctor is s$cient"
;ot applicable
In MAP C$lt$re report is m$st to ascertain the case"
not applicable
C
not applicable
SSI is to be monitored for one month in follo $p"
Inection (ontrol
25 CQI 3g
9rinary tract inection rate "9TI/ As per
#edical records
%eporting ill be done b! treating doctor" rder for c$lt$re report"
#icrobiologist * IC;
C$lt$re report
2=
>entilator associated pneumonia rate ">AP& 4ADAT6R7 IDI(AT6R )
#edical records
%eporting ill be done b! treating doctor" rder for c$lt$re report"
#icrobiologist * IC;
C$lt$re report
2>
(entral line associated :loodstream inection rate"(#A:SI& 4ADAT6R7 IDI(AT6R ?
As per
#edical records
%eporting ill be done b! treating doctor" rder for c$lt$re report"
#icrobiologist * IC;
C$lt$re report
2?
Surical site inection rate "SSI& As per
#edical records
%eporting ill be done b! treating doctor(S$rgeon" rder for c$lt$re report"
#icrobiologist * IC;
C$lt$re report
$tcome
$tcome
As per
?
;o" of catheter associated ETIDs in a given month ******************************************** 3011 Total no" of $rinar! catheter da!s in that month ;o" of ventilator associated pne$monia in a given month ******************************************** 3011 Total no" of ventilator da!s in that month ;o" of central line associated blood stream infections in a month ******************************************** 3011 Total no" of central line da!s in that month
;o" of s$rgical site infctions in a given month ******************************************** 3011 Total no" of s$rgeries in that month
4ortality % 4or$idity
2@ CQI 3h
4ortality rate
3-
Percentae o return to I(9 -it'in )@ 'ours
#edical +ospital admission records discharge register Technician
$tcome
+#IS
$tcome
ICE n$rsing sta Admissio ill initiate n(Transfer folloed b! in0 %egister charge ICE"
ICE Incharge
;o" of deaths ******************************************** #edical records 3011 Total no" of discharges and deaths
;ot applicable
;o" of ret$rns to ICE ithin 4? hrs" #edical records ******************************************** 3011 Total no discharges transfers
;ot applicable
+igher val$e ma! repesent a fairl! higher +AI rate in the hospital"
31
32
Rate o return to t'e emerency department -it'in < 'ours -it' similar presentin complaints
Re*intu$ation rate
&mergen c! Patient %ecord %egister
$tcome
Process
This shall incl$de the re0int$bation #edical ithi 4? hrs" of eFt$bation" %ecords
n$rsing in0charge ill report to &# and p$t don in #%"
ard incharge
&% Incharge
;o" of ret$rns to &mergenc! ithin >2 ho$rs ith similar presenting complaints #edical records ******************************************** 3011 Total no" patients ho have come to &mergenc!
;o" of re0int$bations ithin 4? hrs" of eFt$bations ******************************************** 'ard Incharge #edical records 3011 Total no" of eFt$bations
@
;ot applicable
;o" of re0int$bations ithin 4? ho$rs of eFt$bations(;o" of int$bations
To capt$re this indicator it ma! be a good practice to capt$re d$ring the initial assessment itself if the patient had come ithin >2 ho$rs for similar complaints"
;A
(linical Researc'
33 CQI 3i
Percentae o researc' acti!ities (APT9R,D 6 A Q9ART,R#7 $tcome appro!ed $y et'ics :ASIS committee
Clinical %esearch ## of ethics 9epartme committee nt
Clinical %esearch Coordinator
research doc$ments of the hospitals
;o" of research activities approved b! ethics committee ******************************************** 3011 Total no" of research protocols s$bmitted to ethics committee
not applicable
This indicator shall be capt$red on a B$arterl! basis"
34
Percentae o patients -it'dra-in rom t'e study
Clinical %esearch ## of ethics 9epartme committee nt
Clinical %esearch Coordinator
research doc$ments of the hospitals
;o" of patients ho have ithdran from all ongoing activites ******************************************** 3011 Total no" of patients enrolled in all ongoing st$dies"
not applicable
This indicator shall be capt$red on a B$arterl! basis"
not applicable
not applicable
(APT9R,D 6 A Q9ART,R#7 $tcome :ASIS
35
Percentae o protocol !iolations/de!iatio ns reported
(APT9R,D 6 A Q9ART,R#7 :ASIS
Clinical %esearch Clinical %esearch 9epartme Coordinator nt
Clinical %esearch Coordinator
research doc$ments of the hospitals
;o" of protocol violations( deviations ******************************************** 3011 Total no" of patients enrolled in all ongoing st$dies
3=
Percentae o serious ad!erse e!ents "-'ic' 'a!e occurred in t'e (APT9R,D 6 A Q9ART,R#7 oranisation& $tcome :ASIS reported to t'e ,t'ics committee -it'in t'e defned time rame
Clinical %esearch Clinical %esearch 9epartme Coordinator nt
Clinical %esearch Coordinator
research doc$ments of the hospitals
;$mber of serio$s adverse events reported ******************************************** 3011 Total no" of patients enrolled in all ongoing st$dies
$tcome
1-
An! protocol violation(deviation that gets reported based on an internal(eFternal assessment :nding shall be considered as deemed to have happened b$t not reported" +ence even tho$gh it gets reported it shall be incl$ded to onl! calc$late the denominator and shall not be incl$ded in the n$merator"
This indicator shall be capt$red on a B$arterl! basis"
Procurement o medication essential to meet patient needs
3> CQI 4a
Percentae o drus % consuma$les procured $y local purc'ase
Process
3?
Percentae o stock outs includin emerency drus
Process
This incl$des medicines or cons$mables hich ere $sed b! the patients before admission and Pharmac! Incharge Incharge Pharmac! need to contin$e b$t it is not records Pharmac! incl$ded in the hospital list 6generic8"
A stoc o$t is an event hich occ$rs hen an item in a pharmac! or cons$mable store is temporaril! $nable to provide for an intended patient""
Pharmac! Incharge Incharge Pharmac! records Pharmac!
Stoco$t %egister
;o" of items p$rchased b! local p$rchase ******************************************** 3011 no" of dr$gs listed in hospital form$lar! * hospital cons$mables list
;o" of stoc o$ts ******************************************** 3011 no" of dr$gs listed in hospital form$lar! * hospital cons$mables list
not applicable
To capt$re this organiation sho$ld maintain a register in the pharmac! and stores 6and also if necessar! in the ards8 herein all s$ch events are capt$red
not applicable
rganisation sho$ld maintain a register in the pharmac! and stores herein all s$ch events are capt$red"
3@
Percentae o drus % consuma$les Process reected $eore preparation o oods receipt note
All materials received not in conformit! ith the speci:cations Store and reB$irements ordered for in records the p$rchase order shall be reNected"
4-
Percentae o !ariations rom t'e Process procurement process
Mariations from the ritten standardied proc$rement Chief Pharmacist P$rchase process of acB$iring s$pplies from ill notif! the no" records licensed a$thoried agencies of s$ch processes" holesalers( distrib$tors"
In0chrage stores
In0chrage stores
%;
;o" of 9r$gs * cons$mables reNected before the preparation of %; ******************************************** 3011 Total no" of dr$gs * cons$mables received
Store Incharge
P$rchase records
;o" of variatiosn from the proc$rement process ******************************************** not applicable 3011 Total no" of items proc$red
11
Risk 4anaement #oc drill is a sim$lation eFercise of preparedness for an! t!pe of event" It co$ld be event or #oc drill disaster" This is basicall! a dr! r$n QA Coordinator records or preparedness drill" )or eFample :re moc drill disaster drill Code 7l$e 9rill"
um$er o !ariations o$ser!ed in mock drills
Process
42
Incidence o alls 4ADAT6R7 IDI(AT6R
The ES 9epartment of Meteran Aairs ;ational Centre for Patient Safet! de:nes fall as J
43
Incidence o $ed sores ater admission 4ADAT6R7 IDI(AT6R @
A press$re $lcer is localied inN$r! to the sin and(or $nderl!ing tiss$e $s$all! over a bon! ;$rsing $tcome prominence as a res$lt of %ecords press$re or press$re in combination ith shear and(or friction"
44
Percentae o employees pro!ided pre* eposure prop'ylais
Pre0eFpos$re proph!laFis is an! medical or p$blic health proced$re $sed before eFpos$re Personnel ce Str$ct$re to the disease ca$sing agent its records s$perintendent p$rpose is to prevent rather than treat or c$re a disease"
41 CQI 4b
ard n$rse ill report it in #%"
12
Accreditation Coordinator
;$rsing administrator
;$rsing administrator
#oc drill records
Total no" of variations in a moc drill
;o" of )alls Incidence %eport ******************************************** 3011 Total no" of discharges and deaths
Incident %eport
ce Personnel s$perintendent records
;o" of patients ho develop ne(orsening of press$re $lcer after admission ******************************************** 3011 Total no" of discharges and deaths ;$mber of emplo!ees ho ere provided pre0 eFpos$re proph!laFis ******************************************** 3011 ;$mber of emplo!ees ho ere d$e to be provided pre0eFpos$re proph!laFis
not applicable
To capt$re the variation it is s$ggested that ever! organisation develop a checlist to capt$re the events d$ring a moc drill"
not applicable
1" At dierent levels 0 i"e" from one level to gro$nd level" &"g" from beds heelchairs or don stairs" 2" n the same level as a res$lt of slipping tripping or st$mbling from a colllision p$shing or shoving b! or ith another person" 3" 7elo gro$nd level i"e" into a hole or other opening in s$rface" All t!pes of falls are to be incl$ded hether the! res$lt from ph!siological reasons 6fainting8 or environmental reasons"
not applicable
ill be con:rmed b! the attending doctor"
;o" of emplo!ees ho ere provided pre0 eFpos$re proph!laFis (no" of emplo!ees posted in high ris areas lie lab dial!sis ICEs 7lood 7an etc
It shall incl$de at a minim$m proph!laFis against +epatitis 7"
not applicable
Inpatient Days. A patient da! is the $nit of meas$re denoting lodging provided and services rendered to inpatients beteen the cens$s taing ho$rs 6$s$all! at midnight8 of to s$ccessive da!s" A patient formall! admitted ho is discharged or dies on the same da! is co$nted as one patient da! regardless of the n$mber of ho$rs the patient occ$pies a hospital bed" )or patients sitched from observation to inpatient stat$s the patient da! co$nt sho$ld begin on the da! the patient as ociall! admitted as an inpatient"
9tilization o Space; 4anpo-er and ,Buipment
CQI 4c
45
not applicable
9enominator is total B$antit! and not n$mber" )or eg"a single order ma! have 3- items of C3C cons$mable" f the 3- 1- ma! be reNected" In this case the form$la ill be 1-(3-"
The bed occ$panc! rate is the percentage of ocial beds occ$pied b! hospital inpatients for :ed occupancy rate a given period of time")or a bed 4ADAT6R7 $tcome +IS to be incl$ded in the ocial IDI(AT6R E co$nt it m$st be set $p staed eB$ipped and available for patient care"
ard incharge
QA Co0 ordinator * #%9 technician
admission0 discharge register
;o" of inpatient da!s in a given month ******************************************** 3011 ;o" of available bed da!s in that month
A!erae lent' o stay 4ADAT6R7 IDI(AT6R E
4=
6T utilization rate
T $tilisation is de:ned as the B$otient of ho$rs of T time act$all! $sed d$ring elective $tcome +IS reso$rce ho$rs and the total n$mber of elective reso$rce ho$rs available for $se"
I(9 utilization rate $tcome
+IS
An! eB$ipment the fail$re of hich co$ld impede patient care shall be considered critical" e"g" ventilators cardiac monitors p$lse oFimeter etc"
4>
(ritical eBuipment do-n time
4?
The +Cs sho$ld calc$late the stang patterns separatel! for urse*patient ratio ICEs and for the ards" The in Str$ct$re or I(9s % ards charge(s$pervisor of the area shall not be incl$ded for calc$lating the n$mber of sta"
Process
ard incharge
QA Co0 ordinator * #%9 technician
T register
ICE in0charge
QA Co0 ordinator * #%9 technician
+IS(#idnight cens$s register
chief paharmacist
Complaint log
ard incharge
#atron
13
4@ CQI 4d
admission0 discharge register
T incharge( T matron
Complain concerned t log department
%ecords
QA Co0 ordinator * #%9 technician
+ospital Cens$s
;o" of inpatient da!s in a given month ******************************************** 3011 ;o" of discharges and deaths in that month
Act$al no" of s$rgeries performed ******************************************** 3011 #aF" no" of s$rgeries that can be done
Act$al no" of in 0patient bed da!s ******************************************** 3011 #aF" no" of available bed da!s
total no" of ho$rs of dontime ******************************************** 3011 #aF" no" of f$nctional ho$rs of the eB$ipme
;o" of sta per no" of shifts ******************************************** 3011 ;o" of beds
not applicable
A!aila$le $ed days*It is the prod$ct of n$mber of inpatient beds and n$mber of da!s in that month" um$er o inpatient days* It is a s$m of dail! inpatient cens$s" 'hile calc$lating the overall length of sta! and available n$mber of inpatient beds emergenc! rehabilitation and da! care beds sho$ld not be considered"
not applicable
The degree of $tilisation depicts the average $tilisation of beds in per cent" The act$al bed occ$panc! is set in relation to the maFim$m bed occ$panc!" The maFim$m bed capacit! is the res$lt of the prod$ct of installed beds and the n$mber of calendar da!s in the reporting !ear" The act$al bed occ$panc! is the s$m of calc$lation da!s and occ$panc! da!s beca$se ever! patient occ$pies one bed per inpatient da! in the facilit!
Act$al no" of in0patient bed da!s(maF no" of available bed da!s 1--
;A
not applicable
The term dontime is $sed to refer to periods hen a s!stem is $navailable" 9ontime or o$tage d$ration refers to a period of time that a s!stem fails to provide or perform its primar! f$nction
not applicable
)or eFample if in the ICE there are a total of 15 n$rses ho or in 3 shifts the n$merator ill 5 615(38 and if there are 5 beds the ratio is 1.1" Similarl! for ards It is preferable that in case of ICE the organisation capt$re the ratio for ventilated and non0ventilated patients separatel!"
Patient Satisaction
6ut patient satisaction inde
Patient Satisfaction is de:ned in terms of the degree to hich the patientKs eFpectations are $tcome f$l:lled" It is an eFpression of the gap beteen the eFpected and perceived characteristics of a service"
S$rve!
+ospital manager
Accreditaion coordinator
Score Achieved P9 pt ****************************************** satisfaction form 3011 #aFim$m possible score
1" )or +ospitals ith , 2- patients(da!. 1--/ 2" )or +ospitals ith 2105- patients(da!. 5-/ 3" )or +ospitals ith 5101-patients(da!. 2-/ 4" )or +ospitals ith 1-102-- patients(da!. 1-/ 5" )or +ospitals ith 2-104-- patients(da!. 5/ =" )or +ospitals ith 4-- patients(da!. 2/
The sample shall be derived from repeat patients" It is preferable that patients ho are coming to the hospital for the :rst time not be incl$ded as it is possible that the! o$ld not be in a position to give feedbac on some aspects" The organisation co$ld also capt$re satisfaction for vario$s individ$al parameters 6as laid don in its feedbac form8" In case the organisation is not capt$ring an overall feedbac b$t instead onl! for vario$s parameters the indeF shall be calc$lated b! averaging the satisfaction of vario$s parameters"
5-
In patient satisaction inde
atin time or ser!ices out patient consultation
$tcome
Process
S$rve!
A aiting time is a length of time hich one m$st ait in order for a %ecords speci:c action to occ$r after that action is reB$ested or mandated"
1" )or +ospitals ith , 2- discharges(da!. 1--/ 2" )or +ospitals ith 2105discharges(da!. 5-/ 3" )or +ospitals ith 5101-- discharges(da!. 2-/ 4" )or +ospitals ith 1-- discharges(da!. 1-/
Accreditaion coordinator
Score Achieved ******************************************** IP9 pt satisfaction form 3011 #aFim$m possible score
Accreditaion coordinator
%egistration time * Cons$lting time 6shall be noted b! the cons$ltant 8
S$m6 patient in time for cons$ltation0patient reporting time in P9 ******************************************** 3011 ;o" of patients reported in P9
not applicable
;A
+ospital manager
Accreditaion coordinator
%egistration time * Sample collection time6shall be noted b! the technician 8
S$m6 patient in time for cons$ltation0reporting time in diagnostics ******************************************** 3011 ;o" of patients reported in diagnostics
not applicable
aiting time for diagnostics is applicable onl! for o$t0patients"
ard incharge
Accreditaion coordinator
9ischarge note * time on discharge slip or register
S$m of time taen for discharge ******************************************** 3011 ;o" of patients discharge
not applicable
In case patients reB$est additional time to leave the clinical $nit that shall not be added" The discharge is deemed to have been complete hen the formalities for the same have been completed"
+ospital manager
+ospital manager
51
atin time or Process ser!ice dianostics
52
Time taken or disc'are
Process
%ecords
9ischarge is the process b! hich a patient is shifted o$t from the hospital ith all concerned medical s$mmaries after ens$ring stabilit!" The discharge process is %ecords deemed to have started hen the cons$ltant formall! approves discharge and ends ith the patient leaving the clinical $nit"
14
,mployee Satisaction
+ospital manager
Score Achieved ******************************************** &mplo!ee satisfaction form 3011 #aFim$m possible score
+ospital manager
Accreditaion coordinator
+% records
;o" of emplo!ees ho have left ******************************************** 3011 ;o" of emplo!ees at the beginning of the monthRnel! Noined sta
not applicable
Accreditaion coordinator
+% records
;o" of emplo!ees ho are on $n0 a$thorised absence ******************************************** 3011 ;o" of emplo!ees
not applicable
53 CQI 4e
The satisfaction shall be capt$red $tcome from all categories of sta S$rve! (APT9R,D 6(, I 2 46TGS
54
,mployee attrition rate
$tcome
55
,mployee a$senteeism rate
Absenteeism in emplo!ment la is the state of not being present that occ$rs hen an emplo!ee is Personnel ce $tcome absent or not present at or records s$perintendent d$ring a normall! sched$led or period"
5=
Percentae o &mplo!ee aareness is the state employees -'o are or condition of being aareH a-are o employee having noledgeH conscio$sness ri'ts; $tcome S$rve! abo$t emplo!ee rights responsi$ilities responsibilities and elfare and -elare schemes" sc'emes.
Attrition rate is the percentage of people leaving the organisation"
%ecords
+ospital manager
15
5> CQI 4f
5?
1" )or +ospita s it , 1-- sta . 1--/ 2" )or +ospitals ith 1-102-- sta. 5-/ 3" )or +ospitals ith 2-105-- sta. 2-/ 4" )or +ospitals ith 5-101--sta. 15/ 5" )or +ospitals ith 1--- sta. 1-/
Accreditaion coordinator
,mployee Satisaction inde
Accreditaion coordinator
Personnel intervie records
;o" of emplo!ees ho are aare of their rights responsibilities and elfare schemes ******************************************** 3011 ;o" of emplo!ees intervieed
1" )or +ospitals ith , 1-- sta. 3-/ 2" )or +ospitals ith 1-102-- sta. 15/ 3" )or +ospitals ith 2-105-- sta. ?/ 4" )or +ospitals ith 5-10 1--- sta. 15/ 5" )or +ospitals ith 5-10 1--- sta. 4/ =" )or hospitals ith 1--- sta. 2/
Ad!erse e!ents and near misses um$er o sentinel e!ents reported; collected and Process analysed -it'in t'e defned time rame
Percentae o near Process misses
A relativel! infreB$ent $neFpected incident related to s!stem or process de:ciencies 9ata hich leads to death or maNor and end$ring loss of f$nction for a recipient of healthcare services A near miss is an $nplanned event that did not res$lt in inN$r! illness or damage b$t had the potential to do so" &rrors that did not res$lt in patient harm b$t
9ata
ard incharge
Accreditaion coordinator
concerned department
Accreditaion coordinator
;o" of sentinal events reported collected and anal!sed ithin the de:ned time frame ******************************************** 3011 ;o" of sentinal events reported collected and anal!ed ;o" of near misses reported ******************************************** 3011 ;o" of incident reports
not applicable
not applicable
If there is deviation in either reporting(collecting(anal!sis it shall not be incl$ded in the n$merator"
;ear miss reporters can describe hat the! observed of the beginning of the event and the factors that prevented loss from
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Consent is the illingness of a patient to $ndergo eFamination( proced$re( treatment b! a health care provider" Informed consent is a t!pe of consent in hich the health care provider has a d$t! to inform his(her patient abo$t the proced$re its potential ris and bene:ts alternative proced$re ith their ris and bene:ts so as #edical to enable the patient to tae an record informed decision of his(her health care" If an! of the essential element(reB$irement of consent is missing it shall be considered as incomplete" If an! consent obtained is invalid(void 6consent obtained from rong person(consent obtained b! rong person etc"8 it is considered as improper"
=3
Percentae o medical records 'a!in incomplete and/or improper consent
Process
=4
Percentae o missin records
A medical record is considered as missing hen the record co$ld not #edical $tcome be fo$nd o$t from the #%9 after record the >2nd ho$r of the record reB$est"
ote
#%9 Technician
+ospital manager
#%9 chec list
#%9 Technician
+ospital manager
;o" of medical records not having complete consent6s8 ******************************************** 3011 ;o" of discharges * deaths
;o" of missing medical records ******************************************** 3011 ;o" of records
9nless specifed all indicators s'all $e captured on a mont'ly $asis and t'e numerator and denominator s'all $e o t'at mont'.
not applicable
not applicable
%eg$lar checs sho$ld be in place to ens$re that there are no missing medical records or medical records are :led in the rong place"
