SURGERY DEPARTMENT

Performance Indicator Data Collection and Analysis Form

No. Performance Indicator ID Indicator Title Target Threshold Numerator/Denominator

Value Value = Result Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022 TOTAL
1 KPI-N-SUR-CI-P-001 Prophylactic 100% 80%
Total number of surgical patients
Antibiotic (knee arthroplasty) with prophylactic
10 10
Received within antibiotics initiated within one (1)
hour prior to surgical incision
One Hour Prior to
Surgical Incision
Knee Arthroplasty All selected surgical patients (Knee
Arthroplasty) with no evidence of 10 10
prior infection and >= 18 years

Result (%) 100.0% 100.0%

Definition: Measure the time for administering the prophylactic antibiotic prior to surgical knee arthroplasty.
Note: Target Value ( ) is the value you aim to achieve in the measurement being monitored while Threshold Value ( ) is the minimum acceptable value or level, it can be based on internationally acceptable rate or level or it can also be defined as an average plus a certain percentage
when enough data is accumulated.

Category of Indicator: Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision Knee Arthroplasty
Clinical 120%
Type of Indicator: Process 100% 100.0%
Risk Rating of the Indicator: Moderate
80%
Data Collection Methodology: Retrospective
Method of Data Collection: Drug Card 60%
Special Log/Tool: Physician Order Sheet
Dimension of Quality: Timeliness 40%
Frequency of Data Gathering: Daily 20%
Frequency of Reporting: Quarterly 0%
Data Collector: Ms. Elizabeth Miguel Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022

Analysis
1. There was no reporting of any ADR through this period.
2. Poor reporting of ADR.

Recommendations
1. Orientation lecture to all doctors how they will report ADR form.
2. Encourge all doctors to report ADR.

Prepared by: Reviewed and Approved by: Approved by:

Ms. Elizabeth Miguel Dr. Muhammad Al-Gailani Dr. Emad Bukhari

Surgical Ward, Head Nurse Head of Surgery Department Medical Director
 SURGERY DEPARTMENT
Performance Indicator Data Collection and Analysis Form

No. Performance Indicator ID Indicator Title Target Threshold Numerator/Denominator

Value Value = Result Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022 TOTAL
1 KPI-N-SUR-CI-P-001 Prophylactic 100% 80%
Total number of surgical patients
Antibiotic (knee arthroplasty) with prophylactic
10 11 21
Received within antibiotics initiated within one (1)
hour prior to surgical incision
One Hour Prior to
Surgical Incision
Knee Arthroplasty All selected surgical patients (Knee
Arthroplasty) with no evidence of 10 11 21
prior infection and >= 18 years

Result (%) 100.0% 100.0% 100.0%

Definition: Measure the time for administering the prophylactic antibiotic prior to surgical knee arthroplasty.
Note: Target Value ( ) is the value you aim to achieve in the measurement being monitored while Threshold Value ( ) is the minimum acceptable value or level, it can be based on internationally acceptable rate or level or it can also be defined as an average plus a certain percentage
when enough data is accumulated.

Category of Indicator: Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision Knee Arthroplasty
Clinical 120%
Type of Indicator: Process 100% 100.0% 100.0%
Risk Rating of the Indicator: Moderate
80%
Data Collection Methodology: Retrospective
Method of Data Collection: Drug Card 60%
Special Log/Tool: Physician Order Sheet
Dimension of Quality: Timeliness 40%
Frequency of Data Gathering: Daily 20%
Frequency of Reporting: Quarterly 0%
Data Collector: Ms. Elizabeth Miguel Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022

Analysis
there is only one case of Total hip replacement or the month of february

Recommendations

Prepared by: Reviewed and Approved by: Approved by:

Ms. Elizabeth Miguel Dr. Muhammad Al-Gailani Dr. Emad Bukhari

Surgical Ward, Head Nurse Head of Surgery Department Medical Director
 SURGERY DEPARTMENT
Performance Indicator Data Collection and Analysis Form

No. Performance Indicator ID Indicator Title Target Threshold Numerator/Denominator

Value Value = Result Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022 TOTAL
1 KPI-N-SUR-CI-P-001 Prophylactic 100% 80%
Total number of surgical patients
Antibiotic (knee arthroplasty) with prophylactic
10 11 21
Received within antibiotics initiated within one (1)
hour prior to surgical incision
One Hour Prior to
Surgical Incision
Knee Arthroplasty All selected surgical patients (Knee
Arthroplasty) with no evidence of 10 11 21
prior infection and >= 18 years

Result (%) 100.0% 100.0% #DIV/0! 100.0%

Definition: Measure the time for administering the prophylactic antibiotic prior to surgical knee arthroplasty.
Note: Target Value ( ) is the value you aim to achieve in the measurement being monitored while Threshold Value ( ) is the minimum acceptable value or level, it can be based on internationally acceptable rate or level or it can also be defined as an average plus a certain percentage
when enough data is accumulated.

Category of Indicator: Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision Knee Arthroplasty
Clinical 120%
Type of Indicator: Process 100% 100.0% 100.0%
Risk Rating of the Indicator: Moderate
80%
Data Collection Methodology: Retrospective
Method of Data Collection: Drug Card 60%
Special Log/Tool: Physician Order Sheet
Dimension of Quality: Timeliness 40%
Frequency of Data Gathering: Daily 20%
Frequency of Reporting: Quarterly 0%
Data Collector: Ms. Elizabeth Miguel Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022

Analysis

Recommendations

Prepared by: Reviewed and Approved by: Approved by:

Ms. Elizabeth Miguel Dr. Muhammad Al-Gailani Dr. Emad Bukhari

Surgical Ward, Head Nurse Head of Surgery Department Medical Director
 SURGERY DEPARTMENT
Performance Indicator Data Collection and Analysis Form

No. Performance Indicator ID Indicator Title Target Threshold Numerator/Denominator

Value Value = Result Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022 TOTAL
1 KPI-N-SUR-CI-P-001 Prophylactic 100% 80%
Total number of surgical patients
Antibiotic (knee arthroplasty) with prophylactic
10 11 21
Received within antibiotics initiated within one (1)
hour prior to surgical incision
One Hour Prior to
Surgical Incision
Knee Arthroplasty All selected surgical patients (Knee
Arthroplasty) with no evidence of 10 11 21
prior infection and >= 18 years

Result (%) 100.0% 100.0% #DIV/0! #DIV/0! 100.0%

Definition: Measure the time for administering the prophylactic antibiotic prior to surgical knee arthroplasty.
Note: Target Value ( ) is the value you aim to achieve in the measurement being monitored while Threshold Value ( ) is the minimum acceptable value or level, it can be based on internationally acceptable rate or level or it can also be defined as an average plus a certain percentage
when enough data is accumulated.

Category of Indicator: Prophylactic Antibiotic Received within One Hour Prior to Surgical Incision Knee Arthroplasty
Clinical 120%
Type of Indicator: Process 100% 100.0% 100.0%
Risk Rating of the Indicator: Moderate
80%
Data Collection Methodology: Retrospective
Method of Data Collection: Drug Card 60%
Special Log/Tool: Physician Order Sheet
Dimension of Quality: Timeliness 40%
Frequency of Data Gathering: Daily 20%
Frequency of Reporting: Quarterly 0%
Data Collector: Ms. Elizabeth Miguel Jan 2022 Feb 2022 Mar 2022 Apr 2022 May 2022 Jun 2022 Jul 2022 Aug 2022 Sep 2022 Oct 2022 Nov 2022 Dec 2022

Analysis

Recommendations

Prepared by: Reviewed and Approved by: Approved by:

Ms. Elizabeth Miguel Dr. Muhammad Al-Gailani Dr. Emad Bukhari

Surgical Ward, Head Nurse Head of Surgery Department Medical Director