SRI VENKATESWARA INSTITUTE OF MEDICAL SCIENCES: TIRUPATI

DEPARTMENT OF MEDICINE

KPI RESULTS FOR THE MONTH SEPTEMBER

S. Standard Indicator Formula SEPTEMBER-2018

no.
1 CQI 3a Time for initial assessment Sum of time taken for the assessment/total no. of patient 9564/517=18.50
in indoor or emergency
2 CQI 3a Treatment plan documentation Number of inpatients records with care plan 517/517*100=100%
documented/total number of patients X 100
3 CQI 3a Nutritional assessment documentation Number of inpatients records with Nutritional assessment 517/517*100=100%
documented/total number of patients X 100
4 CQI 3a Nursing care plan documentation Number of inpatients records with Nursing care plan 517/517*100=100%
documented/total number of patients X 100
5 CQI 3c Medication error: prescription Total no. of prescription errors /number of patient days X 0/2481*100=0
100
6 CQI 3c Medication error: dispensing Total no. of medication dispensing errors /number of 0/2481*100=0
patient days X 100
7 CQI 3c Adverse drug reactions Adverse drug reactions/no. of discharges and deaths X 100 0/354*100=0
8 CQI 3c Error prone abbreviations No. of medications charts with Error prone abbreviations / 24/121*100=19.83
no. of medication charts reviewed X 100
9 CQI 3c High risk medication: adverse event No. of patients receiving high risk medication who have 0/67*100=0
adverse drug event /no of patients receiving high risk
medication X 100
10 CQI 3g UTI (Catheter associated) Number of urinary catheter associated UTI in a month / no. 1/227*1000=0.4
of urinary catheter days x 1000
11 CQI 3g VAP Number of VAP in a month /no. of ventilator days in that 3/162*1000=18.51
month x 1000
12 CQI 3g Central line associated blood stream Number of Central line associated blood stream infections 0/6*100=0
infection rate in a month /no. of central line days in that month x 1000
13 CQI 3h Mortality rate No. of deaths / no. of discharges and deaths x 100 4/354*100=1.12
14 CQI 3h Return to ICU in < 48 hrs No. of returns to ICU in < 48 hrs / no. of discharges or 0/350
 transfers in ICU
15 CQI 3h Readmission in < 72 hrs No. of returns to emergency ICU in < 72 hrs with similar 0
presenting complaints / no. of patients who have come to
emergency
16 CQI 3h Reintubation rate No. of Reintubation within 48 hrs of extubation /no. of 0/16*100=0
intubations x 100
17 CQI 4b Falls No of falls / total no. of patient days x 1000 0/2481*100=0
18 CQI 4b Bed sores No. of patients who develop new or worsening of pressure 0/2481*1000=0
ulcer / total no. of patient days x 1000
19 CQI 4c Bed occupancy rate No. of inpatient days in a given month / total no. of 2481/2970*100=83.54
available beds in that month x 100
20 Length of stay (LOS) No. of inpatient days in a given month / no. of discharges 2481/354=7.00
and deaths in that month
21 CQI 4c ICU equipment utilisation No. of equipment utilised days / equipment days available 294/330*100=89.0%
x 100
22 Bed utilisation No. of bed utilised days / no. of bed days available x 100 2481/2970*100=
23 CQI 4f Sentinel events No. of sentinel events analysed within defined time frame 0
x 100
24 CQI 4f Near misses No. of near misses reported / no. of incidents reported x 0/0
100
25 CQI 4f Body fluid exposures No. of Body fluid exposures / no. of patient days 0/2481
26 CQI 4f Needle stick injury No. of Needle stick injury / no. of patient days 0/2481
27 CQI 3j Appropriate Handovers during shift change Total no. of handovers done appropriately / total no. of 7443/7443*100=100%
handover opportunities x 100 4962/4962*100=100%
28 CQI 3j Patient identification error No. of Patient identification errors / no. of patients x 100 0/517*100=0