Quality Indicators

(Performance of Hospital Processes)

1
 Patient Assessment related quality
indicators
• Time for initial assessment of indoor and
emergency patients
• Percentage of cases (in-patients) wherein care
plan with desired outcomes is documented
and counter-signed by the clinician.
• Percentage of cases (in- patients) wherein
screening for nutritional needs has been done.
• Percentage of cases (in- patients) wherein the
nursing care plan is documented.
 Lab related quality indicators
• Number of reporting errors/1000
investigations
• Percentage of re-dos
• Percentage of reports co-relating with clinical
diagnosis
• Percentage of adherence to safety precautions
by employees working in diagnostics
 Medication related quality indicators
• Incidence of medication errors
• Percentage of admissions with adverse drug
reaction (s)
• Percentage of medication charts with error
prone abbreviations
• Percentage of patients receiving high risk
medications developing adverse drug event
Anaesthesia related quality indicators
• Percentage of modification of anaesthesia
plan
• Percentage of unplanned ventilation following
anaesthesia
• Percentage of adverse anaesthesia events
• Anaesthesia related mortality rate
 OT related quality indicators (1)
• Percentage of unplanned return to OT
• Percentage of re-scheduling of surgeries
• Percentage of cases where the MPUH's procedure to prevent
adverse events like wrong site, wrong patient and wrong
surgery have been adhered to
• Percentage of cases who received appropriate prophylactic
antibiotics within the specified time frame
• Percentage of transfusion reactions
• Percentage of wastage of blood and blood products
• Percentage of blood component usage
• Turnaround time for issue of blood and blood components
 OT related quality indicators (2)
• Urinary tract infection rate
• Pneumonia rate
• Bloodstream infection rate
• Surgical site infection rate
• Mortality rate
• Return to ICU within 48 hours
• Return to Emergency department within 72 hours with similar
presenting complaints
• Re-intubation rate
Research related quality indicators
• Percentage of research activities approved by
Ethics committee
• Percentage of patients withdrawing from the
study
• Percentage of protocol violations/ deviations
reported
• Percentage of serious adverse events (which have
occurred in the organisation) reported to the
ethics committee within the defined timeframe.
Purchase related quality indicators
• Percentage of drugs and consumables
procured by local purchase
• Percentage of stock outs including emergency
drugs
• Percentage of drugs and consumables rejected
before preparation of Goods Receipt Note
• Percentage of variations from the
procurement process
 Safety related quality indicators
• Number of variations observed in mock drills
 Patient Safety related quality
indicators
• Incidence of falls
• Incidence of bed sores after admission
• Percentage of employees provided pre-exposure
prophylaxis
• Number of sentinel events reported, collected
and analysed within the defined timeframe
• Percentage of near misses
• Incidence of blood/body fluid exposures
• Incidence of needle stick injuries
 Patient Satisfaction related Quality
Indicators
• Nurse-patient ratio for ICUs and wards
• Out patient satisfaction index
• In patient satisfaction index
• Waiting time for services including diagnostics
and out- patient consultation
• Time taken for discharge
Utilization and Services related quality
indicators
• Bed occupancy rate
• Average length of stay
• OT Utilisation rate
• ICU Equipment Utilisation
• ICU Bed Utilisation rate
• Critical equipment down time
 Medical Records related Quality
Indicators
• Percentage of medical records not having
discharge summary
• Percentage of medical records not having
codification as per International Classification
of Diseases (ICD)
• Percentage of medical records having
incomplete and/or improper consent
• Percentage of missing records
 HR related Quality Indicators
• Employee satisfaction index
• Employee attrition rate
• Employee absenteeism rate
• Percentage of employees who are aware of
employee rights, responsibilities and welfare
schemes