OBEID SPECIALIZED HOSPITAL - RIYADH

QUALITY INDICATOR FORM

1 Measure Category : Individual Department/ Services

Hospital Wide
Strategic Priority Improvement
Others

2 Area Monitored : OR

3 Indicator Name : Unplanned Return to OR with in 1 week of Operation

4 Rationale :
To improve quality of surgical services
To decrees mortality
To evaluate surgical staff performance

5 Dimensions of Quality:
Safe Timely Effective Efficient
Equitable Patient-centered Respect Continuity
Appropriateness Availability Accessibility

6 Numerator : No. of Unplanned return to OR within 1 week of operation X 100

· Inclusion Criteria All unplanned surgeries cases who returned to OR within 1 week
· Exclusion Criteria None

7 Denominator : Total Surgeries performed in the same month

· Inclusion Criteria All Surgeries

· Exclusion Criteria None

8 Selection Criteria "Prioritization Mechanism"

High Risk High Cost High Volume Problem Prone

CBAHI

9 Type of Measure/Indicator:

Structure Process Outcome Process and outcome

10 Sample Size: As per the statistical sample size policy

11 Data Collection Methodology : Retrospective Concurrent

12 Target : 0%

13 Benchmark: (if applicable)

14 Indicator Frequency : Daily Weekly Monthly Quarterly

Semi-annual Annual

15 Source of Data : O.R Census

16 Responsibility : OR Secretary
(Ownership)

17 Reporting to : QIPS Committee

 OBEID SPECIALIZED HOSPITAL - RIYADH
QUALITY INDICATOR FORM

18 Aggregation & Analysis :

Month Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

Numerator 0 7 2 2 1 1 2 0 1 2 0 1

Denominator 700 557 632 545 593 542 600 448 631 677 564 620

Rate 0.00 1.26 0.32 0.37 0.17 0.18 0.33 0.00 0.16 0.30 0.00 0.16

Rate of Unplanned Return to OR

1.4 1.26
1.2
1
0.8 Rate
0.6
0.32 0.37 0.33
0.4 0.30
0.17 0.18 0.16 0.16
0.2 0.00 0.00 0.00
0
Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec

19 Actions Taken/Sustainability mechanism:

20 Comments/Remark:

Data Collected by: Data Analysis & Graph:__________________________

OR Head Nurse Quality Management Department

Action/Comment by: Approved by:

Head of O.R Quality Director