Discharge Patient JULY 2019

Mortality Indicators and Inpatient Indicators
Indicator 1
HSMR
Definition
Formula
Inclusion Criteria
Indicator 2
URMP
Definition
Formula
Numerator
Denominator
Denominator
Exclusions:
Indicator 3
Hospitals days per decedent during the the last six months of life
Definition
Formula
Inclusion criteria
Indicator 4
Hospital Readmission percentage
Definition
Formula
Exclusions:
Methodology
Mortality Indicators and Inpatient Indicators
or 1
Hospital Standardized Mortality Ratio
This measure of effectiveness is a ratio of observed deaths to expected deaths in a hospital.By
definition, 100 (in the year 2000 in the United States) is the point where the expected number of
deaths is equal to the number of deaths actually observed
Hospital Standardized Mortality Ratio = (Observed deaths / Expected deaths) * 100
All the deaths happened Inside the hospitals should be entered in the mortality data sheet
or 2
Unadjusted Raw Mortality Percentage
This is a measure of acute care inpatient mortality and provides an organization withan
opportunity to measure effectiveness on a more frequent and timely basis than the HSMR
Unadjusted Raw Mortality Percentage = (Number of in-hospital deaths in acute care
inpatientpopulation / Number of acute care inpatient discharges) * 100
All acute care deaths, including newborns (Acute patients include all the patients who were
admitted in the hospital for 18 days or less)
Number of acute care inpatient discharges
• ED-only patients who are not admitted as inpatients
• Observation and short stay patients who are not admitted as inpatients
• Chronic patients staying more than 18 days at once
• Stillbirths
or 3
ls days per decedent during the the last six months of life
Number of days spent in the hospital as an inpatient in the last six months of life
Hospital Days per Decedent During the Last Six Months of Life = Total per patient days for all
hospitalizations during the last six months of life
Days spend in any hospital as an inpatient can be counted, if data from other hospitals are not
available then only the days spent in the hospital where the patient died should be considered.
or 4
l Readmission percentage
Readmission to the hospital is a measure of both the care received in the hospital and the
coordination of care back to the outpatient setting and within the outpatient setting. The Hospital
Readmission Percentage is defined as the percentage of patients discharged from the hospital
who are readmitted to the hospital within 30 days.
(Number of discharged patients readmitted to the hospital within 30 days of their previous
discharge / Number of patients discharged in the current month) * 100
• Planned readmissions
• False labor patients
• Trauma
Mortality Data for all the deaths to be collected from the Medical record department
Inpatient Data for all the discharges to be collected with the help of Inpatient Department. If
the hospital cannot share the patient with Inpatient details they must fill the inpatient aggregated
sheet attached.
Forms attached To be filled by
MRD/ Inpatient
Mortality data department staff
Inpatient details/ Aggregated Inpatine department
Inpatient sheet staff
Format
Excel
Excel
Mortality dat
Facility Type Facility ID Month Year Total Number of Deaths
Facility Name Auto Fill
Data to be collected from the Medical record department
Facility ID
(Auto-Fill) Patient ID Age Sex Saudi/non Saudi Date of admission
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Mortality data Information She
Mortality data for all the Inpatient deaths ( All the inpatient deaths occurred in the last month has
Total number of Acute Deaths Total per par
Type of Patient Cause of

Length of stay (Acute/chronic) Place of Death Death (ICD
Date of death (Auto-Fill) (Auto-Fill) ( which department) 10)
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ata Information Sheet
urred in the last month has to be recorded - To be collected only from the Hospitals)
Total per partient days in last 6 months of hospitalisation
Diagnosis
(ICD 10)
mation Sheet
ast month has to be recorded - To be collected only from the Hospitals)
Total per partient days in last 6 months of hospitalisation
tp disease category (ICD 10)

Days of previous hospitalization in last 6 months - in this hospital/ or any
other hospital based on patient records
Total number of admissions in last 6 Sum of Length of stay during each

months admission in lat 6 months
Facility Type Facility ID Month Year
Facility Name
AFLAJ JULY 2019
Saudi/Non
Facility ID (Auto-Fill) Patient ID Age Sex Saudi
0 ER#1874 28 Female Saudi
0 ER#1879 0 Male Saudi
0 ER#1882 0 Female Non Saudi
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Inpatient Informa
Inpatient details (List of all the patients d
Date of Dischange ( All the

patients discharged In the
current month should be
recorded, even though
admission was in the Length of stay
Date of Admission previous month) (Auto -Fill) Diagnosis (ICD 10)
6/27/2019 7/1/2019 5 FEVER R/O SRPSIS
7/2/2019 7/3/2019 2 FT, NSVD,GRADE 3 MECONIUM
7/5/2019 7/5/2019 1 FT, NSVD,> 24 HOURS LEAKING
7/4/2019 7/6/2019 3 CONGENITAL PYLORIC STENOS
6/30/2019 7/6/2019 7 FT, ?DOWN SYNDROME
6/20/2019 7/7/2019 18 PRETERM,SVD,WITH RDS
7/6/2019 7/8/2019 3 FT, NSVD,GRADE 3 MECONIUM
7/8/2019 7/11/2019 4 C/S,MACROSOMIA,GDM MOTHE
7/10/2019 7/11/2019 2 FT,NSVD,PROM >13 HOURS
7/12/2019 7/13/2019 2 POST DATE,NSVD,MECONIUM S
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0
npatient Information Sheet
f all the patients discharged in the particular month)
Disease category (ICD 10)

O SRPSIS
GRADE 3 MECONIUM STAINED
> 24 HOURS LEAKING
TAL PYLORIC STENOSIS
N SYNDROME
M,SVD,WITH RDS
GRADE 3 MECONIUM STAINED
ROSOMIA,GDM MOTHER
PROM >13 HOURS
TE,NSVD,MECONIUM STAINED
Admission
through
(OPD/Emergency/
Planned) Type of Patient (Acute/chronic) (Auto Fill)
Emergency Acute
Planned Acute
Planned Acute
Emergency Acute
Emergency Acute
Planned Acute
Planned Acute
Planned Acute
Planned Acute
Planned Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
Acute
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Any Previous admission in last
30 days (check from the records
if this patient has been admitted Reason for
before in last 30 days, previous readmission/ Reason for
month data has to be reviewed current Previous
as well) admission admission
Facility Type Facility ID Month Year
Facility Name Auto Fill
Total number of
Discharges in
Facility ID Last month Number of female discharges Number of male discharges
0
In-patient Details Aggregated values
Number of Saudi Number of non Saudi Total length of stay of all Total number of acute
discharges discharges discharges care discharges
ed values
Number of Number of Number of discharges

Total number of chronic readmissions in discharges Between Between age group 11-
care discharges last 30 days age group 0-10 18
Number of
discharges
Number of discharges Between age
Between age group 19- group 50 and
40 above
Hospital PHC ID
A01 A111 A01
A02 A222 A02
A03 A333 A03
B01 B111 B01
B02 B222 B02
B03 B333 B03
C01 C111 C01
C02 C222 C02
C03 C333 C03
D01 D111 D01
D02 D222 D02
D03 D333 D03
D04 D444 D04
D05 D555 D05
E01 E111 E01
E02 E222 E02
F01 F111 F01
F02 F222 F02
F03 F333 F03
F04 F444 F04
F05 F555 F05
F06 F666 F06
G01 G111 G01
G02 G222 G02
H01 H111 H01
H02 H222 H02
H03 H333 H03
I01 I111 I01
I02 I222 I02
I03 I333 I03
I04 I444 I04
I05 I555 I05
I06 I666 I06
J01 J111 J01
J02 J222 J02
J03 J333 J03
J04 J444 J04
K01 K111 K01
K02 K222 K02
K03 K333 K03
K04 K444 K04
K05 K555 K05
L01 L111 L01
L02 L222 L02
L03 L333 L03
L04 L444 L04
M01 M111 M01
M02 M222 M02
M03 M333 M03
N01 N111 N01
N02 N222 N02
N03 N333 N03
O01 O111 O01
O02 O222 O02
O03 O333 O03
O04 O444 O04
O05 O555 O05
P01 P111 P01
Q01 Q111 Q01
R01 R111 R01
R02 R222 R02
S01 S111 S01
S02 S222 S02
S03 S333 S03
T01 T111 T01
T02 T222 T02
T03 T333 T03
T04 T444 T04
T05 T555 T05
T06 T666 T06
T07 T777 T07
T08 T888 T08
T09 T999 T09
U01 U111 U01
U02 U222 U02
U03 U333 U03
V01 V111 V01
V02 V222 V02
V03 V333 V03
V04 V444 V04
A111
A222
A333
B111
B222
B333
C111
C222
C333
D111
D222
D333
D444
D555
E111
E222
F111
F222
F333
F444
F555
F666
G111
G222
H111
H222
H333
I111
I222
I333
I444
I555
I666
J111
J222
J333
J444
K111
K222
K333
K444
K555
L111
L222
L333
L444
M111
M222
M333
N111
N222
N333
O111
O222
O333
O444
O555
P111
Q111
R111
R222
S111
S222
S333
T111
T222
T333
T444
T555
T666
T777
T888
T999
U111
U222
U333
V111
V222
V333
V444
Hospital Name
King Fahad Hospital Hofuf
Prince Bin Jalawi Hospital Al Ahsa
General Eye City Hospital Al Ahsa
King Fahad Hospital Al Baha
Rehabilitation Hospital & Physiotherapy Center Al Baha
Al Mundiq General Hospital
Prince Muteb bin Abdulaziz Hospital Al Jouf
Dumat Al Jandal General Hospital
King Abdulaziz Hospital Al Jouf
Mahayil General Hospital
Abha General Hospital (Maternity & Children)
Al Mujadarat General Hospital
Belsemr General Hospital
Al Qahmah General Hospital
King Abdullah Hospital Bisha
Al Bashayir Hospital
Dammam Hospital
Qatif Central Hospital
Al Khafji General Hospital
Al Dharan Specialist Eye Hospital
Biqiq General Hospital
Upper Village Hospital
King Khalid Hospital Hafr Al Baten
Al Qaisoomah General Hospital
King Khalid Hospital Hail
Maternity & Children Hospital Hail
Al Salimi General Hospital
King Fahad Central Hospital Jazan
Abu Arish General Hospital
Mental Health Hospital Jazan
Damd General Hospital
Al Tawal General Hospital
Al Rayth Hospital
King Fahad Hospital Jeddah
Jeddah Mental Health Hospital
Al Thaghr General Hospital
Al Layth General Hospital
Al Ansar General Hospital
Mental Health Hospital Madinah
Al Hinakiat General Hospital
Khaybar General Hospital
Al Haso Hospital
King Abdulaziz Hospital Makkah
King Faisal Hospital Makkah
Khulais Hospital
Al Kamil General Hospital
King Khalid Hospital Najran
Sharoura General Hospital
South Badr Hospital
Arar Central Hospital
Abdul Aziz bin Musaed bin Jalawi Hospital
Al Suebah General Hospital
King Fahad Specialist Hospital Buraydah
Maternity & Children Hospital Qassim
Al Bukiriyah General Hospital
Rehabilitation Hospital Onayza
Qasiba General Hospital
Al Qunfudah General Hospital
Qurrayat General Hospital
General Hospital - King Saud Medical City
Maternity Hospital - King Saud Medical City
General Hospital - King Fahad Medical City
Children Hospital – King Fahad Medical City
Prince Mohamad Hospital
Al Dawadmi General Hospital
Al Aflaj General Hospital
Huraymla General Hospital
Al Arawiyah General Hospital
Al Khasirat General Hospital
Tumair General Hospital
Wathilan General Hospital
Darma Hospital
Al Hareeq Hospital
King Khalid Hospital Tabuk
Maternity & Children Hospital Tabuk
Mental Health Hospital Tabuk
King Abdulaziz Specialist Hospital
Al Qureia Hospital
Ranih General Hospital
Al Moaia Hospital
‫السلمانية الجنوبية‬
‫شمال المبرز‬
‫جليجلة‬
‫جــدره‬
‫بالعل‬
‫النصبـاء‬
‫الشمالي‬
‫الملك فهد‬
‫المطار‬
‫قنا‬
‫بني مالك‬
‫ال غيلنا‬
‫خارف‬
‫الحريضة‬
‫ما‪/‬مخطط ‪1‬‬
‫ما‪ /‬شواص‬
‫العدامة‬
‫الرضا‬
‫شمال الخفجي‬
‫القادسية )مخطط ‪(8‬‬
‫الجيشية‬
‫الشيط‬
‫البلدية‬
‫الصداوي‬
‫الوادي‬
‫النقرة‬
‫مرغانا‬
‫المشروع‬
‫الساملة‬
‫المجصص‬
‫ضمد الجنوبي‬
‫وعلنا‬
‫السادة‬
‫العزيزية‬
‫الفيصلية‬
‫الحرازات‬
‫المستنقع‬
‫الوس‬
‫السلما‬
‫المحفر‬
‫الثمد‬
‫المحامة‬
‫الضيافه‬
‫حراض‬
‫النخيل‬
‫القرية‬
‫بئر عسكر‬
‫العزيزية‬
‫القرنا‬
‫الصالحية الشمالي‬
‫المحمدية‬
‫نصاب‬
‫النخيل‬
‫شرق الفايزية‬
‫الشيحية‬
‫الروضة‬
‫يختار المركز الصحي القرب‬
‫خميس حرب‬
‫الناصفة‬
‫حي الملك فهد‬
‫الروضة‬
‫حريملء‬
‫مشرفة‬
‫جنوب الدوادمي‬
‫الشعب‬
‫وثيلنا‬
‫قصور المقبل‬
‫نعاما‬
‫العريجاء الوسط‬
‫سلطانه‬
‫العريجاء الوسط‬
‫التعاونا‬
‫المحمدية‬
‫الخالدية‬
‫المنشية‬
‫روعيات‬
‫الهدا‬
‫بالحليس‬
‫الغافة‬
‫المويه الجديد‬
Certain infectious and parasitic diseases
Neoplasms
Diseases of the blood and blood-forming organs and certain
Endocrine, nutritional and metabolic diseases
Mental and behavioural disorders
Diseases of the nervous system
Diseases of the eye and adnexa
Diseases of the ear and mastoid process
Diseases of the circulatory system
Diseases of the respiratory system
Diseases of the digestive system
Diseases of the skin and subcutaneous tissue
Diseases of the musculoskeletal system and connective tiss
Diseases of the genitourinary system
Pregnancy, childbirth and the puerperium
Certain conditions originating in the perinatal period
Congenital malformations, deformations and chromosomal a
Symptoms, signs and abnormal clinical and laboratory findin
Injury, poisoning and certain other consequences of externa
External causes of morbidity and mortality
Factors influencing health status and contact with health ser
Codes for special purposes
Other
seases
orming organs and certain disorders involving the immune mechanism

lic diseases
neous tissue
system and connective tissue
he perinatal period
mations and chromosomal abnormalities
linical and laboratory findings, not elsewhere classified
r consequences of external causes
mortality
and contact with health services

Discharge Patient JULY 2019

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Discharge Patient JULY 2019

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Mortality Indicators and Inpatient Indicators

Hospital Standardized Mortality Ratio = (Observed deaths / Expected deaths) * 100

Facility Name Auto Fill

Data to be collected from the Medical record department

Type of Patient Cause of

tp disease category (ICD 10)

Total number of admissions in last 6 Sum of Length of stay during each

Date of Dischange ( All the

Disease category (ICD 10)

Facility Name Auto Fill

Number of Number of Number of discharges

orming organs and certain disorders involving the immune mechanism

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