National Accreditation Board For Hospitals and Health Care Pr

Quarterly Mandatory Data Information Sheet Health

INSTRUCTIONS
1 All fields marked under "DATA FIELD" with yellow background should be filled by the HCO
2 No row or column should be deleted or modified
3 Use only same excel sheet file sent to you. Do not retype or make new sheet.
4 Do not enter indicators's calculated Value. Enter only discrete data in each cell (Enter each va
5 automatically done
Duly filled excel by may
sheet sheetbe
itself.
send back by email.

Data period
Start Date
End Date

S. General Information
No.
1 Name of the Hospital
2 Total number of hospital operational beds
3 Total number of ICU beds
4 Total number of non-ICU beds
5 Average number of Doctors on hospital rolls at
specified period of time
6 Average number of Nurses on hospital rolls at any
point of time
7 Total number of operation theatre tables
8 Average number of admissions/day(excluding day
care)
9 Average number of patients visiting OPD/day
10 Average number of patients visiting Emergency/day

11 Average number of elective surgeries/day

12 Average number of emergency surgeries/day
13 Average number of day care surgeries/day
14 Average units of water consumed/month(KL)
15 Average units of electricity consumed/month(UNITS)
16

Average length of stay

Number of inpatient days in a given period

Number of discharges and deaths in that period
16.1 Average length of stay (excluding day care and
obstetric cases

Number of inpatient days in a given period

(excluding day care and obstetric)
number of discharges and deaths in that period
(excluding day care and obstetric)
17 Bed occupancy rate

Number of inpatients days in a given period

Number of available bed days in that period

S. Indicator Name
No.

1 Percentage of medication errors

1.1 Incidence of Medication errors

1.2 Prescription error

1.3 Dispensing error

2 Percentage of cases who received appropriate

prophylactic antibiotics within specified time
frame
2 Percentage of cases who received appropriate
prophylactic antibiotics within specified time frame
3 Percentage of transfusion reactions
2 Transfusion reaction(percentage)

4 Catheter Associated Urinary tract infection rate

(CAUTI)
4 catheter Urinary tract infection rate (CAUTI)

5 Ventilator associated pneumonia (VAP)

5 Ventilator associated pneumonia (VAP)

6 Central Line Associated Blood Stream Infection (CLABSI)

6 Central Line Associated Blood Stream Infection

(CLABSI)

7 Surgical site infection rate (SSI)

7.1 Surgical site infection rate (SSI)

7.2 inguinal herniorraphy with mesh

7.3 Caesarean section

7.4 Laproscopic cholecystectomy

7.5 Coronary artery bypass grafting(CABG)

8 Total mortality rate

8.1 Total mortality rate

8.2 Proportional infant mortality rate

8.3 Proportional maternal mortality rate

9 Compliance to hand hygiene

9 Compliance to hand hygiene

10 Incidence of fall
10 Incidence of fall

11 Incidence of bed sores after admission

11 Bed Sore

12 Incidence of sharps/needle stick injuries

12.1 in IPD areas

12.2 in OPD areas

Board For Hospitals and Health Care Providers . Quality Council Of India

ndatory Data Information Sheet Health Care Quality Indicators

th yellow background should be filled by the HCO

modified
u. Do not retype or make new sheet.
e. Enter only discrete data in each cell (Enter each value separately). Indicators's calulation will be
by email.

DD/MM/YYYY

DATA FIELD
(To
be filled by hospital)

`
 #DIV/0!

#REF!

#DIV/0!

Data Description Tracability to NABH DATA FIELD

Standards (To be
filled by hospital)

Total number of medication errors. CQI 3 (c)

Number of in patient days. CQI 3 (c)

total number of prescription errors. CQI 3 (c)

Number of in patient days. CQI 3 (c)

total number of medication CQI 3 (c)

dispensing errors.
Number of in patient days. CQI 3 (c)

Number of patients who did receive

appropriate prophylactic antibiotic CQI 3e
within specified time
 Total number surgeries performed
CQI 3e
within specified time

Number of transfusion reaction CQI 3f

Number of units transfused CQI 3f

Number of urinary catheter HIC 4(a),CQI 3 (g)

assosciated UTIs in a month
number of urinary catheter days in HIC 4(a),CQI 3 (g)
that month

number of "ventilator associated HIC 4(b),CQI (3g)

Pneumonia" in a month
Number of Ventilator days in that HIC 4(b),CQI (3g)
month
fection (CLABSI)

number of central line associated HIC 4(c), CQI 3(g)

blood stream infections in a month
number of central line days in that HIC 4(c), CQI 3(g)
month

Number of surgical site infections in HIC 4(d), CQI 3(g)

a given month
Number of surgeries performed in HIC 4(d), CQI 3(g)
that month

Number of surgical site infections HIC 4(d), CQI 3(g)

(among patients undergone
inguinal herniorraphy with a mesh)
in a given period
Number of inguinal herniorraphies HIC 4(d), CQI 3(g)
performed in that period
Number of surgical site infections HIC 4(d), CQI 3(g)
(among caesarean sections) in a
given period
Number of caesarean sections HIC 4(d), CQI 3(g)
performed in that period

Number of surgical site HIC 4(d), CQI 3(g)

infections(among laproscopic
cholecystectomy) in a given period

Number of laproscopic HIC 4(d), CQI 3(g)

cholecystectomies performed in
that period

Number of surgical site infections HIC 4(d), CQI 3(g)

(among coronary artery bypass
grafting(CABG)) in a given period

Number of CABGs performed in HIC 4(d), CQI 3(g)

that period

Total number of deaths in a given CQI 3h

period
Total number of discharges and CQI 3h
deaths in that period

Total number of infant deaths in a CQI 3h

given period
Total number of deaths in that CQI 3h
period

Total number of maternal deaths in CQI 3h

a given period
Total number of deaths in that CQI 3h
period

Total number of missed CQI 3j

opportunities for hand hygiene
Total number of hand hygiene CQI 3j
opportunities

Number of falls CQI4(b)

Total number of patient days CQI4(b)
Number of patients who develop CQI 4(b)
new or worsening of pressure
ulcer
Total number of patient days CQI 4(b)

Number of parentral exposures in CQI 4 (f)

IPD
Number of in-patient days CQI 4 (f)

Number of parentral exposures in CQI 4 (f)

OPD
Number of OPD patient visits CQI 4 (f)
uncil Of India

rs

's calulation will be

Calculated Values
Hand hygiene compliance can be monitored as per WHO guidelines. Tools for monitoring
accessed at: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/
Average length of stay (all admissions excluding day care patients) is defined as ratio of number of
inpatient days in a given period (all patients excluding day care patients) and number of discharges and
deaths in that month (excluding day care and obstetric cases). For this data submission this period is
defined as one quarter. Please do not calculate the ratio. You need to put values for numerator and
denominator only.

Average length of stay (excluding day care and obstetric cases) is defined as ratio of number of inpatient
days in a given period (excluding day care and obstetric cases) and number of discharges and deaths in
that month (excluding day care and obstetric cases). For this data submission this period is defined as one
quarter. Please do not calculate the ratio. You need to put values for numerator and denominator only.

Bed occupany rate is ratio of number of inpatients days in a given period and number of available bed day
in that period. For this data submission this period is defined as one quarter. Please do not calculate the
ratio. You need to put values for numerator and denominator only.

Remarks

In addition to incident reporting, to detect medication errors the organisation shall either adopt medical record review or direct
observation. 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, administering, and
monitoring of medications; Wrong drug, wrong strength, or wrong dose errors; Wrong patient errors; Wrong route of
administration errors; and Calculation or preparation errors.
 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 and Graft Versus Host Reaction

As per the latest CDC/NHSN definition

As per the latest CDC/NHSN definition

As per the latest CDC/NHSN definition

As per the latest CDC/NHSN definition

Hand hygiene compliance can be monitored as per WHO guidelines. Tools for monitoring and providing feedback can b
accessed at: http://www.who.int/gpsc/5may/tools/evaluation_feedback/en/

The US Department of Veteran Affairs National Centre for Patient Safety defines fall as “Loss of upright position that results
landing on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, nonpurposeful, downwa
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. Falls may be:
• At different levels – i.e., from one level to ground level e.g. from beds, wheelchairs or down stairs
• On the same level as a result of slipping, tripping, or stumbling, or from a collision, pushing, or shoving, by or with anoth
person
• 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. Assiste
falls (when another person attempts to minimize the impact of the fall by assisting the patient’s descent to the
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. Falls may be:
• At different levels – i.e., from one level to ground level e.g. from beds, wheelchairs or down stairs
• On the same level as a result of slipping, tripping, or stumbling, or from a collision, pushing, or shoving, by or with anoth
person
• below ground level, i.e. into a hole or other opening in surface
• A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressur
All types of falls are to be included whether they result from physiological reasons (fainting) or environmental reasons. Assiste
or pressure in combination with shear and/or friction.
falls (when another person attempts to minimize the impact of the fall by assisting the patient’s descent to the
• The organisation shall use The European and US National Pressure Ulcer Advisory panels (EPUAP and NPUAP) stagin
floor) should be included. (NDNQI, 2005)
system to look for worsening pressure ulcers.
• Needle stick injuries or sharp injuries is a penetrating stab wound from a needle (or other sharp object) that may result
exposure to blood or other body fluids.
• Needle stick injuries are wounds caused by needles that accidentally puncture the skin.
• Needle stick injuries are a hazard for people who work with hypodermic syringes and other needle equipment. These injuri
can occur at any time when people use, disassemble, or dispose of needles.
• When not disposed of properly, needles can become concealed in linen or garbage and injure other workers who encount
them unexpectedly.(Canadian Centre for Occupational Health and Safety)
• 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.
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