Continuous Quality Improvement Indicators for PHC

accreditation preparation
Quality Indicators are the backbone on which quality assurance programme of a hospital relies.
PHC 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. (Also check - Performance measures for hospital business)

S.N. Indicator Formula Remark

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