Quality Indicators For Accreditation

6/9/2021 Checklist of Quality Indicators for NABH accreditation preparation
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Checklist of Quality Indicators for NABH accreditation preparation
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Checklist of Quality Indicators for NABH accreditation preparation
Quality Indicators are the backbone on which quality assurance programme of a hospital relies. NABH ( National Accreditation Board for
Hospitals & Healthcare Providers..Click here to know more) accreditation expects hospitals to calculate several quality indicators and use it
for monitoring the quality of care. These are the list of quality indicators, which a hospital preparing for accreditation must necessarily
monitor.

S.N. Indicator Formula Remark
1. Average time taken Sum of time taken The time taken can be taken from time when patient was registered for admission till the time at
for initial for initial which initial assessment was completed and documented
assessment of assessment of all
patients admitted in admitted patients in
IPD a period / total
number of patients
admitted in that
period
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2. Percentage of IPD (Number of patients Timeframe for initial assessment of patient getting admitted must be de ned by the hospital
patients for whom for whom the initial
the initial assessment was
assessment was completed within a
completed within de ned time frame /
de ned timeframe total number of
patients admitted) x
100
3. Average time taken Sum of time taken The time taken can be taken from time at which patient arrived at emergency department till the
for initial for initial time at which initial assessment was completed and documented.
assessment of assessment of all
patients coming to patients who
emergency accessed
emergency services
in a period / total
number of patients
who accessed
emergency services
in that period
4. Percentage of (Number of patients Timeframe for initial assessment of emergency patients must be de ned by the hospital
emergency patients in emergency for
for whom the initial whom the initial
assessment was assessment was
completed within completed within a
de ned timeframe de ned time frame /
total number of
patients admitted) x
100
5. Percentage of in- (Number of case This can be further broken down into subcomponents such as case records with documented
patients wherein the records in which plan of care, documented desired outcomes and countersigned
plan of care with plan of care with
desired outcomes is desired outcomes is
documented and documented and
countersigned by thecountersigned by the
clinicians clinicians / Total
number of case
records checked) x
100
6. Percentage of in- (Number of Nutritional screening format can be used and is required for all admitted patients
patients admitted patients
wherein screening who has been
for nutritional screened for
needs has been nutritional
done requirements / Total
number of patients
admitted) x 100
7. Reporting error rates (Number of lab The error rates can be separately calculated for each unit of laboratory
(per 1000) in reports in which
laboratory errors detected /
Number of lab
reports checked) x
1000
8. Percentage of re-dos (Number of lab tests Only those repeat test shall be considered in calculation, where the reason of repeating is related
in laboratory which has to be to errors, mistake or quality issues
repeated in a period/
Total lab tests
conducted in that
period) x 100
9. Percentage of lab (Number of lab While higher correlation shall be expected, it may not necessarily be 100%
reports co-relating reports in which the
with clinical diagnosis matches
diagnosis with the clinical
diagnosis of the
doctor / Total lab
tests conducted) x
100
10. Percentage of (Number of Safety precautions must be clearly de ned. Data must be gathered through random monitoring
adherence to safety observations that of practices followed by staff. Most safety precautions shall be related safety from infection,
precautions by indicates adherence bio-medical waste and safety from chemicals.
employees working to safety
in labs precautions in a
period / Total
number of
observations made
in that period) x 100
11. Reporting error rates (Number of lab The error rates can be separately calculated for each imaging modality
(per 1000) in reports in which
Imaging errors detected /
Number of lab
reports checked) x
1000
12. Percentage of re-dos (Number of Imaging Only those repeat test shall be considered in calculation, where the reason of repeating is related
in Imaging tests that has to be to errors, mistake or quality issues
repeated in a period
/ Total Imaging tests
conducted in that
period) x 100
13. Percentage of (Number of Imaging While higher correlation shall be expected, it may not necessarily be 100%
Imaging reports co- reports in which the
relating with clinical diagnosis matches
diagnosis with the clinical
diagnosis of the
doctor / Total
Imaging tests
conducted) x 100
14. Percentage of (Number of Safety precautions must be clearly de ned. Data must be gathered through random monitoring
adherence to safety observations that of practices followed by staff. Most safety precautions shall be radiation safety and infection
precautions by indicates adherence control
employees working to safety
in Imaging precautions in a
period / Total
number of
observations made
15. Medication (Number of For data on medication error a strong medication error reporting system must be in place.
error rate medication errors
OR reported in a period This indicator can further be divided into various types of medication errors, such as
Medication error per / Total number of administration error, dispensing error, error of route, error of dose etc.
1000 patient days medication
administration
events) x 100
OR
(Number of
medication errors
reported in a period
/ Total patient days
in that period) x
1000 AI Assisted- How Can I help?
16. Percentage of (Number of patients Adverse drug reaction and medication error shall be de ned and should not overlap with each
adverse drug who suffered other
reactions adverse drug
reactions in a period
/ Number of
admitted patients in
that period) x 100
17. Percentage of (Number of patients List of high-risk medicines shall be speci ed by the hospital and any adverse reaction happening
adverse drug developing adverse due to these medicines shall be counted for this indicator
reaction due to high- drug reaction from
risk medicine high-risk medicines
in a period / Number
of patients given
high-risk medicine in
that period) x 100
18. Percentage of (Number of medical List of accepted abbreviations shall be determined by the hospital and any abbreviation other
medical records with records which than that shall be considered as error prone
error-prone contains error-prone
abbreviations abbreviations /
Number of medical
records screened) x
100
19. Percentage of (Number of patients Each patient must undergo pre-anaesthesia check-up in which anaesthesia plan (type of
modi cation of in whom anaesthesia and anaesthetic agent) is determined. Any change in this plan shall be considered
anaesthesia plan anaesthesia plan as a modi cation
was modi ed
immediately before
induction of
anaesthesia /
Number of patients
that have undergone
anaesthesia) x 100
20. Percentage of (Number of patients Unplanned ventilation is the situation in which patient has to be put on the ventilator after
unplanned who required surgery, due to complications resulting from anaesthesia
ventilation following unplanned ventilator
anaesthesia support following
anaesthesia /
Number of patients
who were given
anaesthesia) x 100
21. Percentage of re- (Number of planned This indicator can further be classi ed as per causes of re-scheduling for the management to
scheduling of surgeries re- take appropriate corrective and preventive measures
surgeries scheduled or
cancelled / Number
of surgeries
planned) x 100
22. Compliance rate to (Number of surgical For surgical safety practices, ‘WHO surgical safety checklist
surgical safety patients in which all (http://www.who.int/patientsafety/safesurgery/tools_resources/SSSL_Checklist_ nalJun08.pdf?
practices surgical safety ua=1)can serve as a good reference material’.
practices where
adhered / Number of The compliance rate of individual practices can also be calculated for detailed analysis
surgical patients’
cases reviewed) x
100
23. Percentage of cases (Number of surgical The hospital must de ne the time-frame for giving prophylactic antibiotic.
who received patients who has The documentation of administration of antibiotics and the time shall be done for getting data
prophylactic received
antibiotic within prophylactic
speci ed time-frame antibiotic / Total
number of patient
undergone surgery)
x 100
24. Percentage of (Number of patients To get data for this indicator a transfusion administration form must be lled for each
transfusion who developed transfusion, which shall have a column for indicating reactions if any
reactions blood or blood
component
transfusion reaction
/ Number of patients
who underwent
blood or component
transfusion) x 100
25. Percentage of blood (Units of blood and Blood and blood components being discarded because of un t in lab tests, shall not be counted
and blood blood components as wastage. Wastage shall be because of reasons of expiry, errors, poor storage conditions etc.
components wasted wasted or discarded
in a period / Total
units of blood and
blood components
under storage during
that period) x 100
26. Percentage of blood (Total units of blood The percentage should be high
component usage components
transfused to
patients / Total units
of whole blood plus
blood components
transfused to
patients) x 100
27. Turn-around time for Sum of time taken The time taken shall be considered from the time of receipt of requisition till the time of dispatch
the issue of blood for issuing blood of blood or blood component
and blood and blood taken in
components each requisition /
Total number of
requisition received
for blood and blood
component
28. Percentage of blood (Number of blood The time frame must be de ned by the organization
and blood and blood
components issued component
within de ned time requisitions that
frame were issued within
de ned time-frame /
Total number of
requisition received
for blood and blood
component) x 100
29. Catheter associated (Number of patients CA-UTI shall be determined clinically (CDC guidelines must be followed)
Urinary Tract developing CA-UTI in The catheterization days shall be calculated as sum of number of days each patient spent with
Infection (CA-UTI) a period / Total urinary catheter in the period of calculation
rate urinary
catheterization days
in that period) x
1000
30. Ventilator (Number of patients VAP shall be determined clinically (CDC guidelines must be followed)
associated developing VAP in a The ventilator days shall be calculated as sum of number of days each patient spent on
pneumonia (VAP) period / Total ventilator in the period of calculation
rate ventilator days in
that period) x 1000
31. Central line catheter (Number of patients CA-BSI shall be determined clinically (CDC guidelines must be followed)
associated blood developing CA-BSI in The central line days shall be calculated as sum of number of days each patient spent with
stream infection a period / Total central line catheter in the period of calculation
(CA-BSI) rate central line days in
that period) x 1000
32. Surgical site (Number of patients CA-BSI shall be determined clinically (CDC guidelines must be followed)
infection (SSI) rate developing SSI in a This can be further bifurcated in super cial, deep and organ/space infections due to surgeries
period / Total
number of clean
surgeries performed
33. Gross mortality rate (Total number of All deaths (including deaths in emergency and ICU) shall be counted.
deaths happened in In denominator all types of discharges shall be considered
the hospital in a
period / Total
number of deaths
discharges during
that period) x 100
34. Net mortality rate (Total number of Deaths happening within 48 hours of discharge should also be counted in numerator
deaths that
happened after 48
hours of admission
of the patient / Total
number of deaths
and discharges
during that period) x
100
35. ICU speci c (Total number of On similar lines, condition speci c or speciality speci c deaths rates can also be calculated
mortality rate deaths in ICU
patients in a period
/ Total number of
patients discharged
from ICU in that
period) x 100
36. Return to ICU within (Number of patients The patients who were discharged against medical advice from ICU should be ignored
48 hours who were re-
admitted to ICU
within 48 hours of
being discharged
from ICU / Total
number of patients
discharged from
ICU) x 100
37. Return to emergency (Number of patients The patients who were discharged against medical advice from emergency should be ignored
within 72 hours with who returned to
similar presenting emergency within 72
complaints hours with similar
presenting
complaints / Total
number of patients
discharged from
emergency) x 100
38. Re-intubation rate (Number of patients Data on re-intubation and ex-tubation shall be taken from individual medical record or a master
who has to be re- register
intubated after ex-
tubation / Total
number of ex-
tubation done during
the period) x 100
39. Percentage of (Number of research Applicable to hospital undertaking clinical research
research activities activities approved
approved by ethics by ethics committee
committee / Number of
research proposal
submitted to ethics
committee) x 100
40. Percentage of (Number of patients Applicable to hospital undertaking clinical research
patients withdrawing withdrawing from
from clinical research study /
research Number of patients
originally enrolled in
the study) x 100
41. Percentage of (Incidence of Applicable to hospital undertaking clinical research
protocol protocol
violations/deviationsviolations/deviations
in clinical research observed in clinical
study research study /
Number of
observations made)
x 100
42. Percentage of (Number of serious Applicable to hospital undertaking clinical research
serious events in adverse events
clinical research reported to ethics
study reported to committee / Number
ethics committee of serious adverse
events identi ed) x
100
43. Error rates during (Number of errors A handover checklist must be available against which errors can be detected
shift hand-overs detected in patient
handovers during
shift changes /
Number of hand
over records
reviewed) x 100
44. Percentage (Number of medical A robust system of medical error reporting must be in place to get appropriate data
of medical error due errors reported that
to happened due to
wrong identi cation wrong identi cation
of patient of patient / Total
number of medical
errors reported) x
100
45. Hand hygiene (Number of Hand hygiene guidelines must be speci ed.
compliance rate observations in Data shall be gathered through monitoring
which staff
complied with hand
hygiene guidelines /
Total number of
observations made)
x 100
46. Compliance rate to (Number of Not applicable, if prescription is computerized
medication prescriptions in
prescription in which medications
capitals are written in capital
letters / Total
number of
prescriptions
checked) x 100
47. Percentage of (Value of drugs and Local purchases are unplanned, emergency purchases which increase the cost of purchasing
procurement consumables
through local purchased through
purchase local purchase /
Total value of drugs
and consumables
purchased in that
period) x 100
48. Percentage of (Number of Stock out is a situation when the inventory level of the medicine has gone below the de ned
stockouts for emergency drugs on minimum level
emergency drugs the stock-out / Total
number of
emergency drugs) x
100
49. Percentage of drugs (Number of drugs The data can be taken through a random sample of items that were checked
and consumables and consumables
rejected before rejected before
preparation of goodspreparation of goods
receipt note receipt note / Total
number of drugs and
consumables
received) x 100
50. Percentage of (Number of times A standard operating process for procurement must be in place to calculate this indicator
variation from standard
procurement procurement
process process was not
followed / Total
number of
procurements done)
x 100
51. Percentage of (Number of This should be separately calculated for different mock drills such as code blue, code red, code
variations observed variations observed pink, disaster handling etc.
in mock drills in mock drills / Total
number of
observations made)
x 100
52. Patient fall rate per (Number of patient Patient fall must be de ned. Generally, all kind of fall (fall from bed, in washroom, on stairs, while
1000 patient days fall reported in a walking etc.) must be counted
period / Total patient
days in that period) x
1000
53. Hospital-associated (Number of patients Criteria for determining pressure ulcers shall be speci ed.
pressure ulcer rate developing hospital Patients at risk of developing pressure ulcers must be identi ed
associated pressure
ulcers / Number of
bedridden patient
days) x 1000
54. Percentage of staff (Number of staff Pre-exposure prophylaxis can be given for different conditions such as Hepatitis, certain kinds of
provided pre- who received pre- Pneumonia etc.
exposure exposure
prophylaxis prophylaxis / Total
healthcare staff) x
100
55. Bed Occupancy Rate (Total patient days inTotal patient days is the sum of days spent by each admitted patient in hospital
a period / Total bed Total bed days is the product of number of functional beds in hospital with the number of days
days available in that period
during that period) x
100
56. Average Length of Sum of length of ALOS must be separately calculated for different disease conditions, specialities and ICU/Non-
Stay (ALOS) stay of individual ICU cases
patients / Total
number of patients
whose length of stay
has been taken
57. OT utilization rate (Total hours for Total hours of surgeries can be calculated by summing up the duration of each surgeries
which actual performed in the period
surgeries were
performed in OT / Total OT hours can be calculated by multiplying functional hours available for each OT with the
Total OT hours number of OT
available) x 100
58. ICU utilization rate (Total ICU patient This is similar to calculation bed occupancy rate, but only for ICU
days in a period /
Total ICU bed days
available in that
period) x 100
59. Percentage of Total duration (in A list of critical equipment shall be made.
downtime of Critical days or hours) for This indicator shall be calculated separately for each critical equipment
equipment which a critical
equipment was
down / Total
duration (in days or
hours) in that period
60. Nurse patient ratio Total number of An average ratio of the month can be taken. This should be separately calculated for each shift
for wards nurse working in a and each ward
shift / Total number
of patient in that
shift
61. Nurse patient ratio Total number of An average ratio of the month can be taken. This should be separately calculated for each shift
for ICU nurse working in ICU and each ICU
in a shift / Total
number of patient in
that shift
62. Out-patient Average rating given A standard patient satisfaction feedback form can be used for obtaining rating from patients.
satisfaction index by patient of OPD to Number of feedback collected should be statistically signi cant
the hospital
63. In-patient Average rating given A standard patient satisfaction feedback form can be used for obtaining rating from patients.
satisfaction index by patient of IPD to Number of feedback collected should be statistically signi cant
the hospital
64. Average waiting timeTotal waiting time of Average waiting time shall be separately calculated for OPD consultation, Billing, Pharmacy and
for services all patients for a diagnostics
particular service /
Total number of
patients whose
waiting time has
been taken
65. Average discharge Sum of time taken Time taken for discharge shall be taken from the time when the discharged was ordered by the
time for discharging doctor till the time when patient was relieved from room/bed
patients / Total
patients whose
discharge time is
taken
66. Employee Average rating given An employee satisfaction study must be conducted for this.
satisfaction index by employee to the The index can be calculated for different categories of employees
organization
67. Employee attrition (Number of This should be calculated overall as well as category wise
rate employee who
resigned during a
period / Total
number of employee
on roll) x 100
68. Employee (Total number of Absenteeism shall be considered as absent without information.
absenteeism rate absenteeism of
employee in a period This indicator shall also be calculated category wise
/ Total employee
days) x 100
69. Percentage of (Number of Category-wise calculation shall be done
employee aware employee aware of
of employee rights employee rights /
Total number of
employee) x 100
70. Percentage of (Number of sentinel Timeframe and sentinel events must be de ned
sentinel events events analysed
analysed within a within de ned time
de ned time frame frame / Number of
sentinel events
reported) x 100
71. Percentage of near (Number of near A robust system of reporting errors and near misses must be in place
misses misses reported /
Total number of
errors and near-miss
reported) x 100
72. Needlestick injury (Number of needle Needlestick injury reporting and data collection mechanism must be in place
rate stick injury reported
/ Total patient days
73. Percentage of (Number of medical Su cient sample size must be ensured
medical records not records not having
having discharge discharge summary
summary / Total number of
medical records
screened) x 100
74. Percentage of (Number of medical Su cient sample size must be ensured
medical records not records not having
having ICD codes ICD codes / Total
number of medical
records screened) x
100
75. Percentage of (Number of medical Standard process of informed consent must be in place to determine what constitutes
medical records records having incomplete or improper consent
having incomplete incomplete and
and improper improper consent /
consent Total number of
medical records
where consent was
applicable AI Assisted- How Can I help?
76. Percentage of (Number of medical A de nition of missing shall be available. Generally, any medical record which has been able to
missing records records missing / be traced for last 3 days shall be considered missing. In case, a missing record has been found
Total number of it shall be removed from the missing data
medical records in
MRD) x 100

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Quality Indicators For Accreditation

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6/9/2021 Checklist of Quality Indicators for NABH accreditation preparation

Checklist of Quality Indicators for NABH accreditation preparation

Checklist of Quality Indicators for NABH accreditation preparation

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Infrastructure checklist for NABH accreditation (readnews?

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