S Std. Indicators Type Initiation/ Resp.

/ Sample size Remarks

Record
1
Definition/Interpretation Source generation of monitered Formula
sheet/ form
data by
Patient Assessment
The time shall begin from the The average time should be
time that the patient has arrived Sum of time taken 1. For Hospitals with < 20 patients/day: 100% reviewed by the hospital, to see
at the bed of the ward till the time will be put in ------------------------------------------ 2. For Hospitals with 20-50 if this has impacted clinical care,
Time for initial QA
time that the initial assessment X100 patients/day: 50% 3. For Hospitals outcome, or has reduced the
Medical MR by Either Ward Total no. of patients (sample) efficiency. The outliers: Those
CQI 3a assessment of Process has been completed by a doctor. Face sheet & with > 50 patients/day: 20%
(Refer AAC 4 e-g.) record nurse or attending taking more than 20% of the
Indoor Patients Coordinator/Wa history sheet average time shall be audited.
In case of emergency the time doctor
shall begin from the time the rd Incharge
1
Wheel in register
patient has come to the door of
Time for initial (Bed no. time ) Sum of time taken 1. For Hospitals with < 20 patients/day: 100%
the emergency till the time that time will be put in & initial The outliers: Those taking
assessment of QA Coordinator ------------------------------------------- 2. For Hospitals with 20-50
CQI 3a Process the initial assessment is more than 20% of the average
Emergency assessment X100 patients/day: 50% 3. For Hospitals
completed by a doctor. Wheel in Medical MR by Either Ward time shall be audited.
Patients form (start Total no. of patients (sample) with > 50 patients/day: 20%
time in the emergency -time the time )
record nurse or attending
initial assessment was started
by the EMO doctor
The indicator shall be captured
Percentage of No. of in-patients case records during the stay of the patient
wherein the care plan with desired and not from the medical record
cases (in-patients)
outcome has been documented 1. For Hospitals with < 20 admissions/day: 100% department. It shall be collated
wherein care plan Desired outcome includes curative,
Care Plan ---------------------------------------- 2. For Hospitals with 20-50 on a monthly basis. The
with desired preventive, rehabilitative etc.plan of
2 CQI 3a Process QA Coordinator sheet/In-patietn X100 admissions/day: 50% sampling base shall be patients
outcomes is care will be written by the doctor. 3. For Hospitals with > 50 who have completed 24 hours
Plan of care to be case sheet Total no. of patients (sample)
documented and (Refer AAC 4 h-j.) admissions/day: 20% of stay in the hospital. However,
counter-signed by Medical written by doctor immediate correction is to be
the clinician
record within a definite initiated, when gaps are seen on
a real time basis.
time frame
The indicator shall be captured
No. of in-patients case records during the stay of the patient
wherein the nutritional has and not from the medical record
Percentage of
Nutritional assessment can be done Nutritional been documented department. It shall be collated
cases (in- 1. For Hospitals with < 20 admissions/day: 100%
by doctor/nurse/dietecian. It should assessment ---------------------------------------- on a monthly basis. The
patients) wherein 2. For Hospitals with 20-50
3 Process
be written in case sheet. QA Coordinator form in In- X100 sampling base shall be patients
screening for admissions/day: 50% 3. For Hospitals
patient case Total no. of patients (sample) who have completed 24 hours
Nutritional needs (Refer AAC 4 e-g). with > 50 admissions/day: 20%
sheet of stay in the hospital. However,
has been done doctor and nurse immediate correction is to be
initiated, when gaps are seen on
Medical who attends the a real time basis.
record patient and there

after by dietecian
The indicator shall be captured
during the stay of the patient
and not from the medical record
Percentage of Nursing care plan shall be the No. of in-patients case records department. It shall be collated
1. For Hospitals with < 20 admissions/day: 100%
cases (in-patients) on a monthly basis. The
outcome of the nursing wherein the nursing care plan 2. For Hospitals with 20-50
4 wherein the Process sampling base shall be patients
admissions/day: 50% 3. For Hospitals with
Nursing care plan assessment done at the time of Medical To be documented Nursing Nursing has been documented > 50 admissions/day: 20% who have completed 24 hours
is documented of stay in the hospital. However,
admission. It should be written by record by the ward nurse administrator assessment ---------------------------------------- immediate correction is to be
initiated, when gaps are seen
the attendig nurse. (Refer AAC 4 in MR. sheet X100
on a real time basis.
d-e) Total no. of patients (sample)

2 Safety/Quality for Diagnostics Services (Lab & Radiology)

 No. of reporting errors
It is better if the organisation
Reporting errors include those captures these errors as errors
picked up before dispatching the
It should be (typing, wrong pt., wrong test)
reports & after the dispatch of
Number of picked up before and after Lab/Radio reported by the HOD - Log book/ ---------------------------------------- not applicable reports. Although indicator is to
be captured on a monthly basis,
5 CQI 3b reporting Process dispatch. It shall include logy Lab technician to Laboratory/Rad Register/ X1000 an immediate action shall be
initiated when such instance
errors/1000 transcription errors. This shall be records the HOD iology Incident Report Total no. of tests performed happen.
investigations captured in laboratory and form

Lab/Radiology.

radiology.(Refer AAC 6 g).

Re-dos include tests which needed
to be repeated in view of poor No. of re-do's (hemolysed
sample or improper positioning and sample, wrong sample)
Lab tech will ---------------------------------------- Shall be captured in the
in case of radiology also includes Log book/
Percentage of X100 laboratory (at least
6 Process film wastage.. This shall also not applicable
Re-do's Lab/Radio document if there Total no. of tests histopathology) and radiology
include tests repeated before HOD -
release of the result (to confirm the logy is re-do in any case performed in a month (at least CT and MRI)
finding). Laboratory/Rad Register/
(Refer AAC 6 g). records and maintain the
Incident Report
log.
iology No. of reports co-relating 1. For Hospitals with < 100 tests/month: 100%
clinical diagnosis 2. For Hospitals with 100-200
Percentage of Co-relation means that the test form ---------------------------------------- Shall be captured in the
tests/month: 50% 3. For Hospitals
reports co- results should match either the X100 laboratory (at least
7 Outcome with > 201-300 tests/month: 25% 4. For
relating with diagnosis or differential diagnosis Total no. of tests performed Hospitals with > 301-500 tests/month: 20% histopathology) and radiology
Pathologist and (at least CT and MRI)
clinical diagnosis written in the requisition form. in a month (sample) 5. For Hospitals with > 500 tests/month: 15%
Lab/Radio radiologist will

logy decide whether these areas: 100%

HOD - Investigation No. of employees adhering to 2. For
Percentage of
records reports are Lab/Radiology Slip safety precautions Hospitals with < 26-50 employees working in Even if the employees is not
adherence to ----------------------------------------
No. of Employees adhering to these areas: 50% adhering with any one of the
8
safety precautions
Structure corelating X100 3. For
safety precautions e.g. PPE, Lead organisation's/statutory safety
by employees No. of employees (sample) Hospitals with > 51-100 employees working in
aprons , TLD Badges, Gloves etc. precautions it shall be
working in these areas: 30% considered as non-adherence.
diagnostics 4. For Hospitals with
> 100 employees working in these areas: 20%
Observati
on report HOD -

Lab/Radiology QI Register
3 Medication Management

A medication error is any •

Wrong patient errors;
preventable event that may cause Wrong route
of administration errors;
or lead to inappropriate and Total no. of medication errors
• ----------------------------------------
medication use or harm to a QA Co
Percentage of Calculatio X100
medication errors patient (USFDA). Examples n or ordinator, Total no. of bed days
9 Outcome
MANDATORY
include, but are not limited to: preparation errors. Log book/
INDICATOR 1
Adverse drug
• reaction: A Nursing
response to a drug
Errors in the prescribing, superintendent Register/
which is
transcribing, dispensing, Medical Incident Report

administering, and monitoring of records &

medications; pharmacologist form
or physician
• Wrong drug, wrong strength, or

wrong dose errors;

 2. c 5% of
with c patients/day.
1.
In
F u
additio
o
average 5 n to p
r
occupanc % inciden a
H
y 51-100 t
o n
patients/ o reporti
s
day: f ng, c
p
to y
i
detect
t
medic
a
ation
l
patients/ 3 errors >
s
day. . the
w
For
i
Hospitals organi
t
h with zation 1
a average shall 0
v occupancy either
101-300 adopt 0
e
r medic 0
a patients/ al
g day: 3% record
e of review
o patients/ or p
c day. direct a
c observ
4.ation.
For t
u
p Hospita
The i
a lssampl
with e
n averag
e size
e for n
c
y occupanc this t
< y 301- shall s
500 be as
/
patients/ per the
5 day: 2% preced d
0 of ing a
p colum
y
a n. The
t averag :
i e
e patients/ occupa
n day. ncy
t 5. For 0
s Hospitals shall .
/ with be of
d average the
a occupanc preced
y y 501- ing 3
: 1000
1 patients/
0 day: 1%
% of
patients/ month
day. s
o 6.
f with
p a
a v
t
i e
e r
n a
t
s g
/ e
d
a
y
. o
 Total no. of adverse
Percentage of noxious and unintended and
QA Co- drug reactions
admissions with Outcome ----------------------------------------
10 which occurs at doses normally NA
adverse drug ordinator & Incident X100
reaction(s) used In man for prophylaxis, Total no. of discharges
Nursing Report/ADR form
and deaths
diagnosis, or therapy of disease or ADR form
administrator
for the modification of physiologic 1. For Hospitals with average occupancy < 50 patients/day: 10% of patients/day.
2. For Hospitals with average
function. Therefore ADR –
occupancy 51-100 patients/day: 5%
adverse event with a causal link of patients/day.
Total no. of medication charts 3. For Hospitals with average occupancy 101-
to a drug with error prone abbreviations 300 patients/day: 3% of patients/day.
Percentage of
---------------------------------------- 4. For Hospitals with
medication charts average occupancy 301-500 patients/day: 2% of
11 Process X100
with error prone patients/day. 5.
QA Co- Total no. of medication
abbreviations ordinator & For Hospitals with average occupancy 501-
Medical records charts reviewed
Nursing 1000 patients/day: 1% of patients/day.
Medication chart with illegible administrator 6. For Hospitals with
average occupancy > 1000 patients/day:
handwriting and unaccepted error Medical 0.5% of patients/day.
prone abbreviations.(Refer MOM records

4g)
Total no. of patients recieving
High risk medications are high risk medications who have
Percentage of
an adverse drug event
patients receiving medications involved in a high QA Co The denominator can be
ordinator & ----------------------------------------
high risk Medical records
captured from the pharmacy for
12 percentage of medication errors X100 Not applicable
medications nursing those patients who have been
Total no. of patients recieving
developing adverse administrator dispensed high risk medications.
drug event or sentinel events and high risk medications
Process medications that carry a high risk Medical

for abuse, error, or other adverse records

4 Anaesthesia
outcomes. A good reference for

this is the “ISMP’s List of High-

Alert Medications”.
anesthesia, OT
Medical records In- Total no. of patients in whom
The anaesthesia plan is the charge & QA anaesthesia plan was modified
Percentage of which does not reco HOD coordinator ----------------------------------------
13 CQI 3d modification of necessarily have a rds
outcome of pre-anaesthesia X100
anaesthesia plan causal relationship anesthesia, OT Anaesthesia
Surgical Services Total no. of patients
Medical with this
in charge & QA record sheet underwent Anaesthesia
Process assessment. Any changes done treatment.
coordinator Total no. of patients requiring
Any death where the
Percentage records unplanned ventilation
cause is
of unplanned following anaesthsia
possible, probable Medi
14 ventilation after this shall be considered as ----------------------------------------
(likely) or cal
following
modification of anaesthesia plan. Outco certain to be due to reco HOD X100
anaesthesia Total no. of patients
me anaesthesia rds anesthesia, OT Anaesthesia
underwent Anaesthesia
shall be included. in charge & QA record sheet Total no. of patients develop
Every anaesthesia plan shall
adverse anaesthsia event
Percentage of coordinator
invariably mention if there is a Medical ----------------------------------------
15 adverse X100
anaesthesia events
Process possibility of the patient requiring records Total no. of patients
ventilation following anesthesia. HOD Log book/ underwent Anaesthesia

anesthesia, OT Register/ No. of patients who

Adverse anaesthesia event is any died due to anaesthsia
Anaesthesia -----------------------------------------
In-charge & QA Incident Report
16 related X100
untoward medical occurrence that
mortality rate Medical coordinator form No. of patients who
may present during treatment
underwent anaesthesia
Outcome with an anaesthetic product but
5
HOD
 Not applicable required ventilation but this was during the procedure like hypoxia,
Modification in anesthesia plan not captured in the anesthesia arrhythmias, cardiac arrest etc.
not applicable could be captured in a plan shall be a part of the
Not
register/system before the patient numerator.
applicable
is shifted out of the OT.

Self Explanatory
Not applicable Adverse anesthesia events
Every case wherein a patient include events, which happen

No. of unplanned
Log book/
Register/ returns to OT Unplanned return shall be
17 CQI 3e Percentage of Medical OT In-charge
----------------------------------------- Not applicable captured only during the same
Incident Report
X100 admission.
unplanned return Outcome records form
No. of patients operated
to OT (OT)

No. of cases re-scheduled

Re-scheduling of patients includes -----------------------------------------
18 Log book/Daily Not applicable
cancellation and postponement X100
In-Charge OT No. of surgeries performed
Percentage of re-
OT Report
(beyond 4 hours) of the surgery OT

scheduling of Process

because of poor communication, records

surgeries inadequate preparation or
inefficiency within the system.

Percentage of

cases where the No. of cases where

organisation's procedure was followed This could be checked in the post-
19 Not applicable op/recovery room and
procedure to Log book/ ------------------------------------------ documented in a register/system.

prevent adverse OT OT In-charge Register/ X100

Outcome Incident Report No. of surgeries performed

events like wrong records form

site, wrong patient

and wrong surgery

have been adhered

to
Percentage of cases This indicator could be captured
who received in a register/system before the
appropriate patient enters the OT.
20 prophylactic It is equally important that the No. of patients who did not Not applicable Prophylactic antibiotics should be
antibiotics within administered ideally within 30-60
antibiotic should have been given Surgeon will order recieve any prophylactic minutes but certainly within two
the specified time
frame hours of the time of incision.
not more than two hours prior to Medical and ward nurse will antibiotics
6
Outcome the incision. This indicator could Records administer and OT In-charge Medical records ------------------------------------------

be captured in a register/system write it in MR. X100

before the patient enters the OT. No. of surgeries performed

Use of Blood and Blood products

MANDATORY INDICATOR 2 A systemic i atible with Outcome blood cell incompatibility; components
response by n that of the allergic Medical of the
the body to c recipient. The sensitivity to the
Percentage of transfused
the o causes include leukocytes, records
transfusion blood; or
administrati m red platelets, plasma protein
21 CQI 3f reactions potassium or
on of blood p
 c r eservatives in the banked blood
i Any adverse reaction to the
No. of transfusion reactions transfusion of blood or blood
t ward sister,ward In charge in- ------------------------------------------ components shall be considered
r charge / doctor blood bank can X100
Trasnfusion as transfusion reaction.It may
a report to blood will maintain Total no. of units transfused Not applicable
range from an allergic reaction to
bank and will the record of reaction form
t a life threatening complication
document it in MR. reactions
e like TRALI & Graft Versus Host
Disease.

This also includes blood products

found unfit for use. In case the
organisation does not have a
Percentage of
22 wastage of blood Process blood bank of its own, the
and blood products denominator shall be the total
number of blood and blood
products collected/indented
from the blood bank
No. of units wasted It is important that the
organisation capture the number
------------------------------------------
Blood bank In-Charge X100
of blood and blood products used
Blood Bank will Log Book Total no. of units issued and not just the number of
not applicable
Blood tecnician will blood maintain the bank transfusions carried out. At times
from the blood bank more than one blood bag or
Bank report to the record.
components may have been
given in a single transfusion
records Incharge blood

bank
No. of components used
Percentage of Blood bank -----------------------------------------
As per NACO Guidelines, the use Log Book
23 blood component X100 not applicable NA
tecnician will blood bank Total no. of blood and
usage Blood
In-Charge blood products issued
of blood products should be
report to the Sum of time taken
Turnaround time Process Bank This will include blood outsourced
-------------------------------X100
for issue of Log Book Total no. of blood and
from other blood banks, for those
24 Blood Bank Not applicable
blood and blood encouraged rather than whole blood bank organisations not having in house
components issued Blood Banks.
components Incharge blood
records
bank
blood usage. blood bank
technician will put
The time shall begin from the down time of In-Charge
requisistion & issue Blood
Blood Bank and will document it.
time that the order is raised to

Process Bank

blood/blood component reaching

records

the clinical unit

7 M cor done by treating
e ds
Urinary tract infection rate (UTI/ SUTI) d doctor. Order for & ICN
MANDATORY As per i Reporting will be
28 Me culture report.
25 CQI 3g INDICATOR 3 Latest c
As per Latest dic
CDC/ a done by treating Microbiologist Reporting will be
CDC/ NHSN al
Ventilator associated pneumonia rate NHSN l
rec doctor. Order for & ICN
(VAP) r
Outco or
MANDATORY INDICATOR 4 e
me Definition. ds culture report.
c done by treating Microbiologist
Central line associated Bloodstream o
26 infection rate(CLABSI) doctor/Surgeon.
Ou r
MANDATORY INDICATOR 5 Me Reporting will be
tco Definition d & ICN
As per Latest dic
me . s done by treating Microbiologist
CDC/ NHSN al
Surgical site infection rate (SSI) Ou M Order for culture
rec doctor. Order for & ICN
MANDATORY tco e
Outco or
INDICATOR 6 me d
me Definition. ds culture report.
As per i
Reporting will be Microbiologist report.
27 Latest c
CDC/ a
NHSN l
Definition r
. e
Infection X100
Control Total no. of central line
No. of catheter associated UTI's in a given
month days in that month However NABH now recommends
CLABSI and transfusion reactions
-------------------------------------------- Symptomatic UTI rate in which
Not applicable not applicable are to be monitored differently.
X100 the statement of treating doctor
Culture is sufficient.
Total no. of urinary catheter days in that month No. of surgical site
report
Culture report No. of ventilator associated pneumonia in a infctions in a given
given month month
-------------------------------------------- --------------------------------------------
X100 X100 In VAP Culture report is must to
Total no. of ventilator days in that month Total no. of Not applicable SSI is to be monitored for one
ascertain the case.
not applicable month in follow up.
No. of central line associated blood stream infections in surgeries in that
Culture
report a month month
Culture report --------------------------------------------
8 Mortality & Morbidity

No. of deaths
--------------------------------------------
29 CQI 3h Mortality rate Outcome Medical Medical records X100 Not applicable
Total no. of discharges
HMIS Hospital admission records
and deaths
discharge register
No. of returns to ICU
Percentage of Technician within 48 hrs. Higher value may repesent a
30 Outcome Medical records -------------------------------------------- Not applicable fairly higher HAI rate in the
return to ICU
X100 hospital.
within 48 hours Total no. discharges, transfers
Admissio ICU nursing staff
and deaths in the ICU
will initiate

n/Transfer followed by in- ICU Incharge

Register
charge ICU.

No. of returns to Emergency within

To capture this indicator it may be
Rate of return to 72 hours with similar presenting a good practice to capture during
the initial assessment itself if the
the emergency Emergen nursing in-charge complaints patient had come within 72 hours
for similar complaints.
31 department within Outcome cy Patient will report to EMO ER Incharge Medical records -------------------------------------------- Not applicable

72 hours with Record and put down in X100

similar presenting Register MR. Total no. patients who have

complaints come to Emergency

No. of re-intubations within

This shall include the re-intubation Medical 48 hrs. of extubations NA

32 Re-intubation rate Process ward incharge No. of re-intubations within 48 hours of

withi 48 hrs. of extubation. Records Ward Incharge Medical records X100-------------------------------------------- extubations/No. of intubations

Total no. of extubations

Clinical Research
CAPTU C MO e CAPTURE Clinic c
RED li M ar D ON A al h
Percentage of Clinical
ON A n of c QUARTE Cl Rese viola Depart
research activities CAPTURED ON A QUARTERLY Research MOM of ethics Perc QUART i ethi h Perce RLY in arch tions me
ent ERLY c cs withd Depart ntage ic /devi m Coordi
33 CQI 3i approved by ethics Outcome BASIS Departme committee age a rawin co me of al atio e BASIS nator
of l g m commit 35 proto Ou R ns
committee nt 34 pati O R from e BASIS tee col tc es repo n
ents ut e the o e rted t
s study nt ar
 No. of research activities
Clinical research approved by ethics committee
-------------------------------------------- This indicator shall be captured
Research documents of not applicable
X100 on a quarterly basis.
Coordinator the hospitals
Total no. of research protocols
Percentage of
submitted to ethics committee
serious adverse
No. of patients who have withdrawn
events (which have from all ongoing activites
Clinical research -------------------------------------------- This indicator shall be captured
Clinical Research documents of X100 not applicable
on a quarterly basis.
Coordinator the hospitals Total no. of patients enrolled
occurred in the
in all ongoing studies.
36 organisation) Outcome CAPTURED ON A QUARTERLY Research Clinical Research
Any protocol violation/deviation
BASIS Departme Coordinator
that gets reported based on an
reported to the No. of protocol internal/external assessment
violations/ deviations finding shall be considered as
nt Clinical research -------------------------------------------- deemed to have happened but
Research documents of X100 not applicable
not reported. Hence, even though
Ethics committee Coordinator the hospitals Total no. of patients enrolled it gets reported it shall be
within the defined in all ongoing studies included to only calculate the
denominator and shall not be
time frame included in the numerator.

Number of serious adverse

events reported
Clinical research -------------------------------------------- This indicator shall be captured
Research documents of not applicable
X100 on a quarterly basis.
Coordinator the hospitals Total no. of patients enrolled
in all ongoing studies

10 Procurement of medication essential to meet patient needs

No. of items purchased by

Percentage of local purchase To capture this, organization
This includes medicines or
drugs & -------------------------------------------- should maintain a register in the
Local Purchase X100
37 CQI 4a consumables consumables which were used by not applicable pharmacy and stores (and also if
register no. of drugs listed in hospital formulary necessary in the wards) wherein
procured by
the patients before admission and Pharmacy Incharge & hospital consumables list all such events are captured
local purchase
Process need to continue but it is not records Incharge Pharmacy Pharmacy

included in the hospital list

No. of stock outs
Percentage of -------------------------------------------- Organisation should maintain a
(generic).
38 stock outs Stockout X100 register in the pharmacy and
not applicable
including Register no. of drugs listed in hospital formulary stores wherein all such events are
emergency drugs captured.
A stock out is an event which & hospital consumables list

occurs when an item in a

Pharmacy Incharge

Process pharmacy or consumable store is records Incharge Pharmacy Pharmacy

temporarily unable to provide for

an intended patient..
Percentage of and Variations
All
requirementsrec
drugs & ordered for in from the
materials the ord stor
consumables written
39 40 received purchase s es
Pr standardi Pu Chief Stor P
rejected before
not in order shall oc zed rc Phar e ur
preparation of
Pro conformity Sto In- In- G be es procurem ha maci Inc ch
goods receipt note
ces with the re chrag chra R s ent se st har as
s specificatio e ge N rejected.
ge e
Percentage of variations from the procurement process ns stores
 prwr uiring No. of Drugs & consumables rejected before the preparation of GRN Denominator is total quantity and
rei e suppli -------------------------------------------- not number. For eg.a single order
ocl c es he X100 may have 30 items of "X"
col o from no. Total no. of drugs & consumables received not applicable
licensed, of
consumable. Of the 30, 10 may
ernr authorize such be rejected. In this case the
d, proce
sdod agencies, sses. No. of variatiosn from the procurement process formula will be 10/30.
ssts whole --------------------------------------------
oi salers X100
ff / Total no. of items procured
ay distri
not applicable
c butor
qt s.
11 Risk Management

Mock drill is a simulation exercise To capture the variation it is

Number of
suggested that every
variations of preparedness for any type of Accreditation Mock drill
41 CQI 4b Total no. of variations in a mock drill not applicable organisation develop a checklist
observed in Coordinator records to capture the events during a
event. It could be event or
mock drills mock drill.
Mock drill

Process disaster. This is basically a dry run records QA Coordinator

or preparedness drill. For 1. At different levels - i.e. from one

level to ground level. E.g. from
example, fire mock drill, disaster
beds, wheelchairs or down
drill, Code Blue Drill. stairs. 2. On the same level
as a result of slipping, tripping or
stumbling from a colllision,
Incidence of falls
The US Department of Veteran No. of Falls pushing or shoving by or with
42 MANDATORY Nursing -------------------------------------------- not applicable
another person. 3. Below
INDICATOR 7 Affairs National Centre for Patient X100 ground level i.e. into a hole or
Incidence Report Total no. of discharges
other opening in surface. All
Safety defines fall as “Loss of types of falls are to be included
administrator and deaths
whether they result from
upright position that results in physiological reasons (fainting) or
landing on the floor, ground or an environmental reasons.

object or furniture or a sudden,

uncontrolled, unintentional, non-

Incidence ward nurse/ward

Outcome purposeful, downward

Report boy/aya

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.
exposure A pressure it in medical or public
Incidence of prophylaxis ulcer is ords MR. health
pressure, or procedure used Perso
bed sores after localized pressure in before exposure nnel Office
43 admission injury Nursing
combination Struct to the disease recor superinte
MANDATORY to the skin with shear ure causing agent, its ds ndent
INDICATOR 8 and/or Incident Report
and/or purpose is to prevent,
underlying
tissue usually rather than administrator
friction.
over a bony Nur ward treat or cure a
Pre-exposure
Out prominence, sin nurse disease.
Percentage of prophylaxis is
employees com as a result of g will any
provided pre- e Rec report
44
 Personnel No. of patients who develop new/worsening of pressure ulcer after No. of employees who were It shall include at a minimum
superintend admission provided pre-exposure prophylaxis prophylaxis against Hepatitis B.
O
-------------------------------------------- /no. of employees posted in high
f ent records will be confirmed by the attending
X100 not applicable risk areas like lab ,dialysis, ICUs,
f Total no. of discharges and deaths Blood Bank etc doctor.
i Number of employees who were provided pre-exposure
c prophylaxis
--------------------------------------------
e
X100
Number of employees who were due to be provided pre-exposure
prophylaxis
12 Utilization of Space, Manpower and Equipment

Inpatient Days: A patient day is

the unit of measure denoting
lodging provided and services
rendered to inpatients between
The bed occupancy rate is the the census taking hours (usually
percentage of official beds at midnight) of two successive
No. of inpatient days in a days. A patient formally admitted
occupied by hospital inpatients for
Bed occupancy rate who is discharged or dies on the
given month
CQI 4c MANDATORY Outcome a given period of time.For a bed HIS ward incharge to be included in not applicable same day is counted as one
the official
INDICATOR 9 count, it must be set up, staffed, QA Co- patient day, regardless of the
equipped and available for patient number of hours the patient
admission- -------------------------------------------- occupies a hospital bed. For
care.
patients switched from
ordinator &
observation to inpatient status,
discharge X100 the patient day count should
45 begin on the day the patient was
MRD officially admitted as an inpatient.

register No. of available bed days in

technician that month

technicia
n
Length of stay (LOS) is a term No. of inpatient days in a
given month
used to measure the duration of a
QA Co- --------------------------------------------
single episode of hospitalization. X100 not applicable
admission- No. of discharges and deaths in
Average length of Inpatient days are calculated by that month
ordinator &
stay MANDATORY Outcome subtracting day of admission from HIS
ward incharge discharge
INDICATOR 9 day of discharge. However,
MRD
persons entering and leaving a
register
hospital on the same day have a
technician
length of stay of one

Actual no. of surgeries performed

--------------------------------------------
X100 not applicable
Max. no. of surgeries that
can be done

OT utilisation is defined as the

quotient of hours of OT time
QA Co-
actually used during elective
OT incharge/ OT ordinator &
46 OT utilization rate Outcome resource hours and the total HIS
number of elective resource hours OT register
available for use.
matron MRD
Available bed days-It is the census. While calculating the occupancy is set in relation to the actual bed occupancy is the sum
product of number of inpatient overall length of stay and maximum bed occupancy. The of calculation days and
beds and number of days in that available number of inpatient maximum bed capacity is the occupancy days, because every
month. beds, emergency, rehabilitation The degree of utilisation depicts result of the product of installed patient occupies one bed per
Number of inpatient days- and day care beds should not be the average utilisation of beds in beds and the number of calendar inpatient day in the facility
It is a sum of daily inpatient considered. per cent. The actual bed days in the reporting year. The

Actual no. of in -patient bed days

ICU utilization rate Outcome HIS ICU in-charge QA Co- NA

--------------------------------------------

ordinator & HIS/Midnight Actual no. of in-patient bed days/max no. of

X100

MRD census register available bed days X 100

Max. no. of available bed days

technician

The term downtime is used to

Any equipment the failure of
47
which could impede patient care
Critical equipment Process shall be considered critical. e.g.
down time ventilators, cardiac monitors,
total no. of hours of downtime refer to periods when a system is
-------------------------------------------- unavailable. Downtime or outage
chief X100 not applicable
duration refers to a period of time
Max. no. of functional that a system fails to provide or
Complain concerned Complaint log
hours of the equipme perform its primary function
t log department paharmacist

pulse oximeter etc. For example, if in the ICU there

are a total of 15 nurses who work
No. of staff per no. of shifts in 3 shifts the numerator will 5
(15/3) and if there are 5 beds the
--------------------------------------------
48 X100
not applicable ratio is 1:1. Similarly for wards It
The HCOs should calculate the is preferable that in case of ICU
No. of beds
the organisation capture the ratio
staffing patterns separately for Matron Hospital Census for ventilated and non-ventilated
Nurse-patient ratio ICUs and for the wards. The in patients separately.

for ICUs & Wards Structure charge/supervisor of the area Records ward incharge

shall not be included for

calculating the number of staff.
13 Patient Satisfaction

The sample shall be derived from

repeat patients. It is preferable
that patients who are coming to
the hospital for the first time not
be included as it is possible that
they would not be in a position to
1. For Hospitals with < 20 patients/day: 100%
Patient Satisfaction is defined in give feedback on some aspects.
2. For Hospitals with 21-50 patients/day:
49 CQI 4d Out patient terms of the degree to which the OPD pt Score Achieved
------------------------------------------
50%3. For Hospitals with 51-100
patients/day: 20% 4. For Hospitals with
The organisation could also
capture satisfaction for various
satisfaction form individual parameters (as laid
satisfaction index patient’s expectations are X100 101-200 patients/day: 10% 5. For Hospitals
with 201-400 patients/day: 5% 6. For down in its feedback form). In case
Maximum possible score
Accreditaion Hospitals with > 400 patients/day: 2% the organisation is not capturing
an overall feedback but instead
Outcome fulfilled. It is an expression of the Survey Hospital manager only for various parameters, the
index shall be calculated by
coordinator averaging the satisfaction of
various parameters.
gap between the expected and

perceived characteristics of a

service.
50
 1. For Hospitals with < 20 discharges/day: 100%
Score Achieved 2. For Hospitals with 21-50
discharges/day: 50% 3. For Hospitals with
In patient Accreditaion IPD pt -------------------------------------------- 51-100 discharges/day: 20% 4. For Hospitals
satisfaction index Outcome Survey Hospital manager coordinator satisfaction form X100 with > 100 discharges/day: 10%
51 Maximum possible score

not applicable NA
Sum( patient in time for
Registration

consultation-patient reporting

Wating time for A waiting time is a length of time time &

time in OPD waiting time for diagnostics is

not applicable
applicable only for out-patients.
services out which one must wait in order for a Accreditaion Consulting time --------------------------------------------

patient Process specific action to occur, after that Records Hospital manager coordinator (shall be noted X100

consultation action is requested or mandated. by the No. of patients reported

consultant ) in OPD

Sum( patient in time for

Registration

consultation-reporting

time & Sample

time in diagnostics

Wating time for Accreditaion collection

service diagnostics Process Records Hospital manager coordinator time(shall be

--------------------------------------------X100

noted by the

No. of patients reported

technician )
in diagnostics
Discharge is the process by which
a patient is shifted out from the In case patients request
hospital with all concerned additional time to leave the
medical summaries after ensuring Discharge note Sum of time taken for discharge clinical unit that shall not be
Time taken for
52 Process stability. The discharge process is Records ward incharge not applicable added. The discharge is deemed
discharge Accreditaion
deemed to have started when the & time on to have been complete when the
consultant formally approves formalities for the same have
discharge and ends with the coordinator discharge slip or X100-------------------------------------------- been completed.
patient leaving the clinical unit. register No. of patients discharge
14

Employee Satisfaction
Attrition Acc Score Achieved
rate is the red --------------------------------------------
Employee The satisfaction shall be captured percentag itai X100
53 CQI 4e
Satisfaction index e of on Maximum possible score
Accreditaion Employee people
Outcome from all categories of staff Survey Hospital manager Ou leaving Re Hosp coo HR
tco the co ital rdi rec
No. of employees who have left
coordinator satisfaction form m organisati rd man nat ord
Employee --------------------------------------------
e on. s ager or s
54 CAPTURED ONCE IN 6 MONTHS X100
attrition rate No. of employees at the beginning of the month+newly joined staff
1. For with < 100 staff: 2. For Hospitals with 101-200 staff: 50% 1000 staff: 10%
Hospitals 100% 3. For Hospitals with 201-500 staff:
20% 4. For Hospitals with 501-1000
staff: 15% 5. For Hospitals with >
not applicable
No. of employees who are on
Absenteeism in employment law
un-authorised absence
55 is the state of not being present -------------------------------------------- not applicable
X100
Employee that occurs when an employee is Personnel Office Accreditaion No. of employees
absenteeism rate Outcome absent or not present at work records superintendent coordinator HR records
No. of employees who are aware 1. For Hospitals with < 100 staff: 30%
during a normally scheduled work
of their rights, responsibilities 2. For Hospitals with 101-200 staff: 15%
period. and welfare schemes 3. For Hospitals with 201-500 staff:
56 -------------------------------------------- 8% 4. For Hospitals with 501-
X100 1000 staff: 15% 5. For Hospitals with
Percentage of
No. of employees interviewed 501- 1000 staff: 4% 6. For hospitals
Employee awareness is the state with > 1000 staff: 2%
employees who are

or condition of being aware;

aware of employee Personnel

having knowledge; consciousness Accreditaion

rights, Outcome about employee rights, Survey Hospital manager coordinator interview

responsibilities records

responsibilities and welfare

and welfare

schemes.

schemes.
15 Adverse events and near misses

Number of sentinel A relatively infrequent, No. of sentinal events reported,

events reported, unexpected incident, related to collected and analysed within the If there is deviation in either
collected and Log book/ defined time frame reporting/collecting/analysis it
57 CQI 4f Process system or process deficiencies, Data -------------------------------------------- not applicable
analysed within the shall not be included in the
which leads to death or major and Accreditaion Register/ X100
defined time frame enduring loss of function for a numerator.
No. of sentinal events reported
recipient of healthcare services ward incharge
collected and analyzed
A near miss is an unplanned event coordinator Incident Report
that did not result in injury, illness, form No. of near misses reported Near miss reporters can describe
or damage – but had the -------------------------------------------- what they observed of the
Percentage of
58 Process potential to do so. Errors X100 not applicable beginning of the event, and the
near misses that did Data not result in patient No. of incident reports factors that prevented loss from
harm, but occuring.
could have, can be categorized Log book/
as near misses. concerned Accreditaion Register/

department coordinator Incident Report

form
INDICATOR 10 An exposure is when blood, blood components or
Outcome may result in exposure to blood or Data
other potentially other body fluids. Needle stick injuries
Incidence of blood body fluid
59 60 infectious materials come in Data contact with a staff’s eyes, are wounds caused by needles that
exposures accidentally Accreditaion
mucous membranes, non-intact skin or mouth.
puncture in the skin
ward incharge

coordinator

Needle stick injury is a penetrating stab wound from a

needle (or other sharp object) that
16 Incidence of needle stick injuries
MANDATORY
 Needle injury trends. Data from injury
stick reporting should be compiled and
Matron Log book/ injury Incidence of needle assessed to identify: (1) where,
Number of blood body fluid not applicable
form/ stick injuries how, with what devices, and
Register/ exposures
Incident reported during the when injuries are occurring and
w Incident
Report given period (2) the groups of health care
ar Report in the given period
d workers being injured.
form
in form
Parenteral exposure means injury
ch
due to any sharp. All incidences
ar
of needle stick injuries should be
ge
assessed on a case-by-case basis.
Analyze needle stick and other
sharps related injuries in the
Medical Records workplace to identify hazards and
not applicable

A discharge summary is the part

Every medical record that comes
of a patient record that No. of medical records not to the MRD from the clinical unit
summarizes the reasons for having discharge summary following the discharge of a
Percentage of
-------------------------------------------- patient shall be immediately
medical records
admission, significant clinical MRD check list X100 not applicable checked for the presence of
61 CQI 4g not having
No. of discharges & deaths discharge summary. If this is not
discharge summary findings, procedures performed, present at this stage it shall be
captured as a part of the
treatment rendered, patient’s numerator.
Medical Hospital

Process condition on discharge and any MRD Technician

record manager

specific instructions given to the

patient or family (for example

follow-up medications). It is a

summary of the patient’s stay in

hospital written by the attending

doctor.
The ICD is the international
standard diagnostic classification
for all general epidemiological,
many health management purposes
and clinical use. These include the
Percentage of analysis of the general health
medical records situation of population groups and No. of medical records not
not having monitoring of the having codification as per ICD
62 codification as per Process incidence and prevalence of Medical Hospital MRD check list --------------------------------------------
International diseases and other health X100
Classification of problems in relation to other MRD Technician No. of discharges & deaths
Diseases (ICD) variables such as the
characteristics and circumstances record manager
of the individuals affected,
reimbursement, resource
allocation, quality and guidelines
(WHO).
 ICD codification shall be done by

the concerned staff within the

1. For Hospitals with < 20 discharges/day: 100% specified period following

2. For Hospitals with 21-50 discharge. After completion of

discharges/day: 50% 3. For Hospitals with this specified period an audit

51-100 discharges/day: 20% 4. For Hospitals shall be done (using sample size

with > 100 discharges/day: 10% mentioned in the previous

column) by an independent
person to capture this

Consent is the willingness of a

patient to undergo examination/

procedure/ treatment by a health

care provider. Informed consent is

a type of consent in which the No. of medical records not

having complete consent(s)
health care provider has a duty to --------------------------------------------
Medical Hospital not applicable
X100
inform his/her patient about the No. of discharges & deaths
MRD Technician MRD check list
procedure, its potential risk and
record manager
Percentage of benefits, alternative procedure

medical records with their risk and benefits so as

63 having incomplete Process to enable the patient to take an

and/or improper informed decision of his/her

consent health care. If any of the essential

element/requirement of consent is
missing it shall be considered as
incomplete. If any consent
obtained is invalid/void (consent
obtained from wrong
person/consent obtained by
wrong person etc.) it is considered
as improper.

No. of missing medical records Regular checks should be in place

A medical record is considered as -------------------------------------------- to ensure that there are no
Log book/
64 X100 not applicable missing medical records or
missing when the record could not No. of records
Medical Hospital Register/ medical records are filed in the
Percentage of wrong place.
MRD Technician
Outcome be found out from the MRD after
record manager Incident Report
missing records
form
the 72nd hour of the record

request.
Note Unless specified all indicators shall be captured on a monthly basis and the numerator and denominator shall be of that month.