2021 Kpi Jan To Dec

KEY PERFORMANCE INDICATORS
2021
PSQ 3a :Time taken for initial assessment of indoor patients
Definition The time shall begin from the time that the patient has arrived at
the bed of the ward till the time that the initial assessment has been
completed by a doctor
Formula Sum of time taken for initial the assessment
Total number of admissions
SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least monthly

REPORTED BY : In Charge BENCHMARK :
2021 JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC
N 280 286 291 277 282 271 279 284 276 285 291 285
D 357 357 370 357 357 357 370 370 370 370 370 370
QI(PK) 47 48 47 47 47 46 45 46 45 46 47 46
CQI 3b Number of reporting errors per 1000 investigations(Microbiology).
Definition Number of reporting errors per 1000 investigations.
Formula Number of reporting errors

X 1000
Number of tests performed
SAMPLE SIZE : SAMPLE INDICATOR : Continuous

N 0 0 0 0 0 0 0 0 0 0 0 0
D 5889 6411 7174 6621 5927 6861 3738 3467 4823 3994 6916 6749
QI(PK) 0 0 0 0 0 0 0 0 0 0 0 0
PSQ 3a Number of reporting errors per 1000 investigations( Biochem & Pathology).
Definition Reporting errors include those picked up before and after dispatch.
It shall include transcription errors.
X 1000

REPORTED BY : In-charge BENCHMARK :
N 5 6 9 11 4 8 7 4 13 11 11 11
D 31458 31703 37926 31115 26308 30912 14533 14915 35061 35298 35675 36231
QI(PK) 0.16 0.19 0.24 0.35 0.15 0.26 0.48 0.27 0.37 0.31 0.31 0.30
PSQ 3a Percentage of adherence to safety precautions by staff working
in diagnostics.
Definition Percentage of adherence to safety precautions by staff working in

diagnostics.
SAMPLE SIZE : SAMPLE INDICATOR : Periodic At least quarterly

REPORTED BY : BENCHMARK :
Formula Number of staff adhering to safety precautions

X 100
Number of staff audited
N
D
QI(PK)
CQI 3b Percentage of adherence to safety precautions by employee
working in diagnostics. (Micro Biology)
Definition
Formula Number of employees adhering to safety precautions
X 100
Number of employees sampled
SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least quarterly

N 8 8 7 8 8 8 8 8 8 8 8 8
D 8 8 7 8 8 8 8 8 8 8 8 8
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
CQI 3b Number of reporting errors per 1000 investigations (Nuclear Medicine)
X 1000

N 0 0 0 0 0 0 0 0 0 0 0 0
D 709 771 860 650 398 643 802 699 721 687 719 692
QI(PK) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3b Percentage of reports co-relating with clinical diagnosis(Nuclear
Medicine).
Definition Co-relation means that the test results should match either the
diagnosis or differential diagnosis written in the discharge Summary.
Formula Number of reports co-relating with clinical diagnosis
X 1000

N 709 771 860 650 398 643 802 699 721 687 719 692
D 709 771 860 650 398 643 802 699 721 687 719 692
QI(KP) 100 100 100 100 100 100 100 100 100 100 100 100
working in diagnostics. (Nuclear Medicine)
Definition
X 100

N 22 21 21 21 21 21 21 23 23 23 23 23
D 22 21 21 21 21 21 21 23 23 23 23 23
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
CQI 3b Number of reporting errors per 1000 investigations (MRI).

X 1000

N 0 4 2 1 0 1 3 1 0 3 0 2
D 543 585 590 425 293 508 632 548 577 604 538 569
QI(PK) 0 7 3 2 0 2 5 2 0 5 0 4
CQI 3b Rate of re-dos (MRI )
Definition This shall include repeated also tests before release of the result (to
confirm the finding).
Formula Number of tests re-done in a given month
X 1000
Total no of tests done in that month

N 0 0 0 0 0 0 0 0 0 0 0 0
D 278 278 278 217 217 278 278 278 278 278 278 278
QI(PK) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3b Percentage of reports co-relating with clinical diagnosis(MRI).

X 100

N 541 584 589 424 292 505 631 546 576 603 537 568
D 543 585 590 425 293 508 632 548 577 604 538 569
QI(%) 100 100 100 100 100 99 100 100 100 100 100 100
working in diagnostics. (MRI)
Definition
X 100

N 4 4 4 4 4 4 4 4 4 4 4 4
D 4 4 4 4 4 4 4 4 4 4 4 4
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
CQI 3b Number of reporting errors per 1000 investigations (CT).

N 15 13 20 16 16 14 11 17 10 8 15 6
D 1298 1330 1525 1329 1081 1303 1640 1525 1548 1434 1477 1465
QI(PK) 12 10 13 12 15 11 7 11 6 6 10 4
CQI 3b Rate of re-dos ( CT )
Definition This shall include repeated also tests before release of the result (to
confirm the finding).
Formula Number of tests re-done in a given month
X 1000
Total no of tests done in that month

N 0 0 0 0 0 0 0 0 0 0 0 0
D 322 322 322 322 322 322 322 322 322 322 322 322
QI(PK) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3b Percentage of reports co-relating with clinical diagnosis( CT ).

X 100

N 1295 1328 1523 1325 1080 1300 1638 1524 1545 1433 1475 1464
D 1298 1330 1525 1329 1081 1303 1640 1525 1548 1434 1477 1465
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
working in diagnostics. ( CT )
Definition
X 100

N 18 18 18 18 18 18 18 18 18 18 18 18
D 18 18 18 18 18 18 18 18 18 18 18 18
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
CQI 3c Prescription error
Definition: A medication error is any preventable event that may cause or lead
to inappropriate medication use or harm to a patient (US- FDA).
Formula Total number of Prescription errors
X 1000
No. of patient days
SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least

Monthly REPORTED BY : In-charge BENCHMARK :
N 45 51 55 41 51 57 62 74 57 51 49 55
D 9700 10307 12482 11141 9025 9741 12112 13193 12608 13187 13406 14368
QI(%) 5 5 4 4 8 6 5 6 5 4 4 4
CQI 3c Dispensing error
Definition: A medication error is any preventable event that may cause or lead
to inappropriate medication use or harm to a patient (US- FDA).
Formula Total number of medication dispensing errors

X 1000
No. of patient days

SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least Monthly
N 3 2 5 3 2 5 4 5 3 2 3 3
D 9700 10307 12482 11141 9025 9741 12112 13193 12608 13187 13406 14368
QI(%) 0 0 0 0 0 1 0 0 0 0 0 0
PSQ 3a Percentage of medication charts with error prone abbreviations
Definition: Error prone abbreviations shall be defined in consonance with the
guidelines laid down by institution for safe medicaion practices.
Formula Number of medication charts with error prone abbreviations
X 100
Number of medication charts reviewed
SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least Monthly

2021 JUN JUL AUG SEP OCT NOV DEC

N 20 1 2 1 2 2 3
D 370 370 370 370 370 370 370
QI(%) 5 0 1 0 1 1 1
PSQ 3a Medication errors
Definition A medication error is any preventable event that may cause or lead to inappropriate
medication use or patient harm while the medication is in the control of the healthcar profssional,
patient or consumer.(Ref: NCC-MERP).
Examples include, but are not limited to:
Prescribing error, Transcribing error, Dispensing error, Administration error, Monitoring error
Wrong drug, Wrong strengh,Wrong dose errors;

Wrong patient errors; Wrong route of administration error).
Formula Total number of Medication errors
X 100
Total number of opportunities of medication errors
SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least

Monthly
REPORTED BY : In -Charge BENCHMARK :
N 0 0 4 2 1 2 2 2 0 0 0 2
D 522 602 699 490 267 547 691 656 572 570 642 584
QI(%) 0 0 1 0 0 0 0 0 0 0 0 0
CQI 3c Percentage of in patients developing adverse drug reaction..
Definition An adverese drug reaction is a response to a drug which is noxious
and unintended and which occurs at doses normally used in man for
prophylaxis, diagnostics, or therapy of disease or for the modification of
physiologic function
Formula Number of patients developing adverse drug reactions
Number of in patients X 100

2021 JUN JUL AUG SEP OCT NOV DEC

N 2 0 0 2 2 4 7
D 4271 5196 5353 5176 5337 5209 5722
QI(%) 0.05 0.00 0.00 0.04 0.04 0.08 0.12
CQI 3d percentage of modification of anaesthesia plan.
Definition: The Anaesthesia plan is the outcome of preanaesthesia assessment.
Any changes done after this shall be considered as modification of anaesthesia
plan.
Formula Number of patients whom the anaesthesia plan was modified X 100
Number of patients who underwent anaesthesia

REPORTED BY : Anaesthesia(dept) BENCHMARK :
N 0 0 4 2 1 2 2 2 0 0 0 2
D 522 602 699 490 267 547 691 656 572 570 642 584
QI(%) 0 0 1 0 0 0 0 0 0 0 0 0
CQI 3d Percentage of unplanned ventilation following anaesthesia.
Definition
Formula Number of patients requiring unplanned ventilation following anaesthesia X 100


N 0 0 0 0 0 0 0 0 0 0 0 0
D 522 602 699 490 267 547 691 656 572 570 642 584
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3d Percentage of adverse anaesthesia events.
Definition: Adverse anaesthesia event is any untoward medical occurrence
that may present during treatment with an anaesthetic product but which
does not necessarily have a causal relationship with this treatment.
Formula Number of patients who developed adverse anaesthesia event X 100


N 0 0 0 0 0 0 1 0 1 0 0 0
D 522 602 699 490 267 547 691 656 572 570 642 584
QI(%) 0.00 0.00 0.00 0.00 100.00 0.00 0.14 0.00 0.17 0.00 0.00 0.00
CQI 3d Anaesthesia related mortality rate.
Definition: Any death where the cause is possible, probable (likely) or certain
to be due to anaesthesia shall be included.
Formula Number of patients who died due to anaesthesia
Number of patients who underwent anaesthesia X 100
N 0 0 0 0 0 0 0 0 0 0 0 0
D 522 602 699 490 267 547 691 656 572 567 642 584
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
PSQ 3a Percentage of unplanned returns to OT.
Definition Unplanned return to OT is defined as any secondary procedure

required for a complication resulting directly from the index operation during
same admission. For example, post-operative bleeding,
debridement,secondary sutureing,embolectomy,evaluation under anaesthesia
etc.
Formula Number of unplanned returns to OT
X 100
Number of patients who underwent surgeries in the OT

N 5 8 5 10 6 2 6 1 3 5 9 5
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 1 1 1 2 2 0 1 0 1 0.88 1.40 0.86
PSQ 3c Percentage of re-scheduling of surgeries
Definition: Re- scheduling of surgeries includes cancellation and

postponement(beyond4 hours) of the surgery.
Formula Number of cases re-scheduled
X 100
Number of surgeries planned

N 3 9 2 2 0 3 1 5 2 1 4 8
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 1 1 0 0 0 1 0 1 0 0.18 0.62 1.37
PSQ 3a Percentage of cases where the organization’s
procedure to prevent adverse events like wrong site, wrong
patient and wrong surgery have been adhered to.
Definition
Formula Number of cases where the procedure was followed

X 100
Number of surgeries performed

N 522 602 699 490 348 507 691 656 584 570 642 584
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
PSQ 3b Percentage of cases who received appropriate prophylactic
antibiotics within the specified time frame.
Definition
Formula Number of patients who received prophylactic antibiotic(s)
X 100
Number of patients who underwent surgeries in OT

N 422 506 578 423 280 453 555 549 478 474 532 478
D 426 509 583 426 285 457 557 552 480 478 536 478
QI(%) 99 99 99 99 98 99 100 99 100 99 99 100
CQI 3e Percentage of cases in which the planned surgeries is changed
intra-operatively
Definition
Formula Number of cases in which the planned surgery is changed intra-operatively
X 100
Total number of surgeries performed

N 0 0 0 0 0 0 0 0 0 0 0 0
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3e Re-exploration rate
Definition
Formula Number of re-exploration done during same admission
X 100
Total number of surgeries

N 4 8 4 10 6 2 6 1 3 5 9 5
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 1 1 1 2 2 0 1 0 1 0.88 1.40 0.86
PSQ 3a Percentage of transfusion reactions.
Definition Any adverse reaction to transfusion of blood or blood components
shall be considerd as tansfusion reaction. It may range from a mild allergic
reaction (including chills/rigors) to life threatening complication like TRALI and
Graft-Versus-Host Disease
Formula Number of transfusion reactions
X 100
Number of units transfused

N 0 0 1 0 0 0 0 0 0 1 0 0
D 1879 1488 2781 1305 1869 1426 1869 2172 1898 2248 2123 2150
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3f Percentage of wastage of blood and blood products.
Definition
Formula Number of wastage of blood and blood products
X 100
Number of blood and blood products issued from the blood bank

N 0 0 0 0 0 0 0 0 0 0 0 0
D 1879 1488 2781 1305 1869 1426 1869 2172 1898 2248 2123 2150
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3f Percentage of blood & blood component usage.
Definition
Formula Number of blood components used
X 100
Number of blood and blood products used

N 1879 1488 2781 1305 1869 1426 1869 2172 1898 2248 2123 2150
D 1879 1488 2781 1305 1869 1426 1869 2172 1898 2248 2123 2150
QI(%) 100 100 100 100 100 100 100 100 100 100 100 100
PSQ 3c Turnaround time for issue of blood and blood components.
Definition Time taken to be calculated from time the time the request is
received in the blood is cross matched/reserved and available for transfusion.
Formula Sum of time taken
Total Number of blood and blood components Cross matched or reserved

REPORTED BY : Blood Bank BENCHMARK :
N 23674 23218 27888 28665 18088 22040 31776 32265 26617 23408 28294 29526
D 623 611 664 637 476 551 662 717 619 616 658 703
QI(%) 38 38 4 2 4 3 3 3 3 4 3 3
CQI 3h Mortality Rate.
Definition
Formula No of deaths
X 100
No of Discharges & Deaths

N 17 30 27 36 50 36 37 30 41 38 30 39
D 4343 4504 5085 4670 3943 4235 5159 5323 5135 5299 5179 5683
QI(%) 0 1 1 1 1 1 1 1 1 1 1 1
CQI 3h Return to ICU within 48 Hrs(SICU).
Definition
Formula No of returns to ICU within 48 hrs
X 100
No of discharges/ Transfers in the ICU

N 0 2 3 0 0 1 1 1 1 3 5 3
D 187 231 276 205 140 185 233 261 246 235 247 219
QI(%) 0 1 1 0 0 1 0 0 0 1 2 1
CQI 3h Return to ICU within 48 Hrs(MICU).
Definition
Formula No of returns to ICU within 48 hrs

X 100
No of discharges/ Transfers in the ICU

N 2 1 0 0 0 0 1 1 2 2 2 3
D 33 49 49 40 21 21 36 45 39 48 47 66
QI(%) 6 2 0 0 0 0 3 2 5 4 4 5
CQI 3h Re-intubation rate(SICU).
Definition
Formula No. of re-intubations within 48 hours of extubation
X 100
Number of intubations

N 0 1 1 1 3 0 1 2 0 0 2 0
D 108 99 150 70 51 92 110 133 108 101 120 128
QI(%) 0 1 1 1 6 0 1 2 0 0 2 0
PSQ 3a Return to the emergency department within 72 hours with
similar presenting complaints.
Definition
Formula Number of returns to emergency within 72 hours with similar presenting complaints
X 100
Number of patients who have come to the emergency

N 0 0 0 0 0 0 0 0 0 0 0 0
D 914 848 977 983 907 858 1063 976 1067 1177 1106 1231
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3h Re-intubation rate (MICU).
Definition
Formula No. of re-intubations within 48 hours of extubation
X 100
Number of intubations

N 0 0 0 0 0 0 0 0 0 0 0 0
D 3 2 2 5 19 7 4 9 6 6 4 4
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 3j Incidence of patient identification errors (OT)
Definition
Formula Number of patient identification errors
X 100
Number of patients

N 0 0 0 0 0 0 0 0 0 0 0 0
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%)
CQI 3j Incidence of patient identification errors (Nursing)
Definition
Formula Number of patient identification errors
X 100
Number of patients

N 0 0 0 0 0 0 0 0 0 0 1 0
D 11306 11307 13643 11675 9524 11337 13910 13970 13264 13970 13273 2004
QI(%) 0 0 0 0 0 0 0 0 0 0 0.01 0
CQI 3j Compliance rate to medication prescription in capitals.
Definition
Formula Total no of prescriptions in capital letters
X 100
Total no of prescriptions
SAMPLE SIZE : SAMPLE INDICATOR : Periodic Monthly

N 304 335 303 335 334 309 310 315 284 287 289 329
D 377 377 377 377 377 377 377 377 377 377 377 377
QI(%) 81 89 80 89 89 82 82 84 75 76 77 87
CQI 3j Appropriate handovers during shift change. (nursing)
Definition
Formula Total number of handovers done appropriately
X 100
Total number handover opportunities

N 25638 24901 28752 24539 20710 25890 31244 28283 27224 30433 27305 27785
D 25575 24935 28822 24543 20682 24659 31244 28334 27289 30518 27366 27345
QI(%) 99.8 99.9 99.8 100.0 99.9 95.2 100.0 99.8 99.8 99.7 99.8 98.4
CQI 3j Compliance to hand hygiene practice.
Definition
Formula Total number of hand hygiene missed opportunities
X 100
Total number of hand hygiene missed opportunities

2021 JAN FEB MAR APR MA JUN JUL AUG SEP OCT NOV DEC
Y
N 107 117 111 116 119 122 113 115 124 114 122 120
D 132 132 132 132 132 132 132 132 132 132 132 132
QI(%) 81 89 84 88 90 92 86 87 94 86 92 91
CQI 3g Urinary tract infection rate.
Definition As Per The Latest CDC/NHSN Definition

Formula No. of urinary catheter associated UTIs in a month
X 1000
Number of urinary catheter days in a month

N 2 4 3 4 5 3 3 4 4 3 3 7
D 951 1032 1194 1013 809 1010 967 1228 1244 1253 1279 1253
QI(%) 2 4 3 4 6 3 3 3 3 2 2 6
CQI 3g Pneumonia rate.

Formula No. of Ventilator associated pneumonias in a month
x 1000
Number of ventilator days in that month

N 0 1 0 1 1 2 0 1 1 1 0 0
D 157 152 177 170 245 144 156 159 170 164 155 117
QI(PK) 0 7 0 6 4 14 0 6 6 6 0 0
CQI 3g Blood stream infection rate.

Formula Number of central line associated blood stream infections in a month
X 1000
No. of central line days in that month X 1000

N 5 5 4 3 5 5 2 6 4 4 5 3
D 1416 1383 1665 1118 1016 1062 1124 1444 1217 1386 1444 1721
QI(PK) 4 4 2 3 5 5 2 4 3 3 3 2
CQI 3g Surgical-site infection rate.

Formula No. of surgical site infections in a given month
X 100
Total No. of surgeries performed in that month

N 6 12 13 15 8 13 14 19 14 15 21 20
D 522 602 699 490 348 507 691 656 584 570 642 584
QI(%) 1 2 2 3 2 3 2 3 2 3 3 3
CQI 3i Percentage of research activities approved by ethics committee.
Definition
Formula Number of research activities approved by ethics committee
X 100
Number of research Protocol submitted to ethics committee

2021 1st Quarter 2nd Quarter 3rd Quarter 4th Quarter
N 1 0 1 1
D 1 0 1 1
QI
100 100 100 100
CQI 3i Percentage of patients withdrawing from the study.
Definition
Formula Number of patients who have withdrawn from all on-going studies
X 100
Number of patients enrolled in all on-going studies


N 2 1 1 2
D 20 11 10 20
QI 10 9 10 10
CQI 3i Percentage of protocol violations/deviations reported.
Definition
Formula Number of protocol violations\deviations reported
X 100
Number of protocol violations\deviations that have occurred


N 0 0 0 0
D 0 0 0 0
QI 0 0 0 0
CQI3i Percentage of serious adverse events (which have occurred in the
Organization) reported to the ethics committee within the defined time frame.
Definition: The timeframe for reporting shall be as per ICMR guidelines or as
laid down by the sponsor.
Formula Number of serious adverse events reported within the defined time frame
X 100
Number of serious adverse events reported within and outside the defined time frame


N 0 0 0 0
D 0 0 0 0
QI 0 0 0 0
CQI 4a Percentage of consumables procured by local
purchase(procurement).
Definition
Formula Number of items purchased by local purchase
X 100
Number of consumables listed in hospital consumables list

REPORTED BY : PROCUREMENT BENCHMARK :
N 9 6 15 3 12 17 4 2 16 9 14 14
D 811 975 1235 919 847 887 1048 1142 984 988 886 1292
QI(%) 1 1 1 0 1 2 0 0 2 1 2 1
CQI 4a Percentage of drugs procured by local purchase.
Definition These include drugs and consumables which are not included in the
hospital formulary at the time of prescription, but are then arranged by the
hospital pharmacy itself for the patient within a short time
Formula Number of items purchased by local purchase
X 100
Number of drugs listed in hospital formulary and hospital consumables list

N 2 1 1 0 1 3 2 0 1 0 0 0
D 2125 2125 2125 2125 2125 2125 2125 2125 2125 2125 2125 2125
QI(%) 0.1 0.0 0.0 0.0 0.0 0.1 0.1 0.0 0.0 0.0 0.0 0.0
CQI 4a Percentage of stock outs including emergency(Pharmacy -
Stores).
Definition A stock out is an event which occurs when an item in a pharmacy or
consumable store is temporarily unable to provide for an intended patient.
Formula Number of stock outs
X 100
Number of consumables listed in the consumables list

N 8 5 4 4 1 3 1 1 2 2 3 3
D 5841 5921 5976 6030 6104 6168 6219 6280 6329 6389 6437 6485
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4a Percentage of stock outs(Stores/Materials).
Definition A stock out is an event which occurs when an item in a pharmacy or

consumable store is temporarily unable to provide for an intended patient.
Formula Number of stock outs
X 100
Number of consumables listed in the consumables list

N 0 0 0 0 0 0 0 0 0 0 0 0
D 512 512 512 512 512 512 512 512 512 512 512 512
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4a Percentage of drugs and rejected before preparation of Goods
Receipt Note(Pharmacy - Stores).
Definition All materials received not in conformity with the specifications and
requirements ordered for in the purchase order shall be rejected.
Formula Total Quantity rejected
X 100
Total quantity received before Goods Receipt Note

2021 JAN FEB MAR AP MAY JUN JUL AUG SEP OC NOV DEC
R T
N 43 20 24 14 210 425 300 60 140 180 905 51
D 1156867 1099279 1318144 1403009 1465089 1088211 1403269 1288435 1466531 1472976 1E+06 1751125
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4a Percentage of consumables and rejected before preparation of
Goods Receipt Note(Stores/Materials)
Definition All materials received not in conformity with the specifications and
requirements ordered for in the purchase order shall be rejected.
Formula Total Quantity rejected
X 100
Total quantity received before Goods Receipt Note

N 0 0 0 0 0 0 0 0 4 0 0 0
D 811 975 1219 919 847 887 1048 1142 984 980 1027 1292
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4a Percentage of variations from the procurement
process(Procurement).
Definition: Variations from the written standardised procurement process of
acquiring supplies from licensed, authorized, agencies, wholesaler/distributors
Formula Total number of variations from the usual procurement process
X 100
Total number of items procured

N 56 76 69 68 60 83 89 59 73 48 66 72
D 811 975 1235 919 847 887 1048 1142 984 988 886 1292
QI(%) 7 8 6 7 7 9 8 5 7 5 7 6
CQI 4a Percentage of variations from the procurement
process(Pharmacy - Procurement).
Definition Variations from the written standardized procurement process of
acquiring supplies from licensed authorised agencies, wholesaler / distributer
Formula Total number of variations from the usual procurement process
X 100
Total number of items procured

N 8 7 11 6 5 6 5 4 3 6 12 7
D 2752 2815 3132 3231 2519 2674 3233 3268 3538 3682 2971 3530
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4b : Incidence of falls.
Definition : The US Department of Veteran Affairs National Centre for Patient Safety defines fall
as “Loss of upright position that results in landing on the floor, ground or an object or furniture or a
sudden, uncontrolled, unintentional, nonpurposeful, downward displacement of the body to
thefloor/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.
Formula Number of falls X 1000

Total number of patient days

Y
N 0 0 1 1 1 0 0 1 0 0 1 0
D 9700 10307 12482 11141 9025 9741 12112 13193 12608 13187 13406 14368
QI(PK) 0.00 0.00 0.08 0.09 0.11 0.00 0.00 0.08 0.00 0.00 0.07 0.00
CQI 4b : Incidence of bed sores after admission
Definition A Pressure Ulcer Is Localized Injury To The Skin And/Or Underlying
Tissue Usually Over A Bony Prominence, As A Result Of Pressure, Or Pressure
In Combination With Shear And /Or Friction
Formula Number of patients who develop new
X 1000
worsening of pressure ulcer / Total number of patients

REPORTED BY : In Charging BENCHMARK :
N 1 0 0 0 0 0 0 10 0 0 1 0
D 11306 11307 13643 11675 9524 11337 13910 13970 13264 13970 13273 2004
QI(PK) 0.09 0.00 0.00 0.00 0.00 0.00 0.00 0.72 0.00 0.00 0.08 0.00
CQI 4b : Percentage of employees provided pre-exposure prophylaxis.
Definition: Pre-exposure prophylaxis is any medical or public health procedure
used before exposure to the disease causing agent, its purpose is to prevent,
rather than treat or cure a disease.
Formula Number of employees who were provided pre-exposure prophylaxis
x100
Number of employees who were due to be provided pre-exposure prophylaxis

N 25 12 23 30 40 30 18 32 24
nil nil nil
D 25 12 23 30 40 30 18 32 24
QI(%) 100 100 100 100 100 100 100 100 100
CQI 4e Employee Attrition rate.
Definition : Attrition rate is the percentage of people leaving the organization
Formula Number of employees who have left during the month

X 100
Number of employees at the beginning of month + newly joined staff

Y
N 21 24 20 39 36 26 21 14 32 28 18 18
D 1139 1157 1178 1185 1162 1152 1167 1195 1221 1214 1237 1258
QI(%) 2 2 2 3 3 2 2 1 3 2 1 1
CQI 4e Employee absenteeism rate.
Definition : Absenteeism in employment law is the state of not being present
that occurs when an employee is absent or not present at work during a
normally scheduled work period.
Formula Number of employees who are on Unauthorized absence
X 100
Number of employees X 100

Y
N 15 13 14 13 20 13 15 16 16 14 14 12
D 1118 1133 1158 1146 1126 1126 1146 1181 1189 1186 1219 1240
QI(%) 1.3 1.1 1.2 1.1 1.8 1.2 1.3 1.4 1.3 1.2 1.1 1.0
CQI 4e Percentage of employees who are aware of employee rights,
responsibilities and welfare schemes.
Definition Employee awareness is the state or condition of being aware; having
knowledge; consciousness about employee rights,
responsibilities and welfare schemes
Formula Number of employees who are aware of employee rights, responsibilities and
welfare schemes
Number of employees interviewed X100.
SAMPLE SIZE : SAMPLE INDICATOR : Periodic Monitoring done at least

quarterly
N 110 110 112 92 93 93 94 91 90 98 90 92

D 125 130 125 100 100 100 100 100 100 110 90 100
QI(%) 88 85 90 92 93 93 94 91 90 89 100 92
CQI 4C : Bed occupancy rate (IN PATIENT)
Definition The bed occupancy rate is the percentage of official beds occupied by hospital
inpatients for a given period of time. The occupancy rate is a calculation used to show the actual
utilization of an inpatient health facility for a given time period. the duration of a single episode of
hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge.
However, persons entering and leaving a hospital on the same day have a length of stay of one
Formula Number of in-patient days in a given month

X 100
Number of available bed days in that month

N 6989 7758 9209 8225 6494 7233 8666 9475 9025 9557 9834 10378
D 10044 9793 10813 10152 10362 10166 10465 10354 10082 10590 10404 10709
QI(%) 70 79 85 81 63 71 83 92 90 90 95 97
CQI 4c OT utilization rate.
Definition : utilization is occupancy days, because every patient occupies one

bed per inpatient day in the facility
Formula OT utilization time in hours
X 100
Resource hours

N 1348 1491 1821 1302 898 1411 1766 1880 1567 1637 1865 1611
D 1656 1728 1944 1728 1800 1872 1944 1872 1728 1728 1800 1512
QI(%) 81 86 94 75 50 75 91 100 91 95 104 107
CQI 4C : Bed occupancy rate in patient + day care
Definition The bed occupancy rate is the percentage of official beds occupied by hospital
inpatients for a given period of time. The occupancy rate is a calculation used to show the actual
utilization of an inpatient health facility for a given time period. the duration of a single episode of
hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge.
However, persons entering and leaving a hospital on the same day have a length of stay of one

Number of available bed days in that month X 100

N 9700 10307 12482 11141 9025 9741 12112 13193 12608 13187 13406 14368
D 13663 12652 14011 13326 13797 13594 13931 13931 13460 13797 13450 13931
QI(%) 71 81 89 84 72 87 87 95 94 96 100 103
CQI 4c : Average length of stay (IN PATIENT)
Definition The bed occupancy rate is the percentage of official beds occupied by
hospital inpatients for a given period of time. The occupancy rate is a calculation used to
show the actual utilization of an inpatient health facility for a given time period. the
duration of a single episode of hospitalization. Inpatient days are calculated by
subtracting day of admission from day of discharge. However, persons entering and
leaving a hospital on the same day have a length of stay of one
Number of discharges & deaths in that month X 100

N 6989 7758 9209 8225 6494 7233 8666 9475 9025 9557 9834 10378
D 1632 1955 1812 1454 1412 1727 1788 1605 1552 1669 1607 1693
QI(DAYS 4.28 3.97 5.08 5.66 4.19 4.85 4.85 5.90 5.82 5.73 6.12 6.13
)
CQI 4c: Average length of stay (TOTAL)
Definition The bed occupancy rate is the percentage of official beds occupied by
hospital inpatients for a given period of time. The occupancy rate is a calculation used to
show the actual utilization of an inpatient health facility for a given time period. the
duration of a single episode of hospitalization. Inpatient days are calculated by
subtracting day of admission from day of discharge. However, persons entering and
leaving a hospital on the same day have a length of stay of one
Formula Number of in-patient days in a given month - with day care

Number of discharges & deaths in that month - with day care X 100
N 9700 10307 12482 11141 9025 9741 12112 13913 12608 13187 13406 14368
D 4343 4504 5085 4670 3943 4235 5234 5323 5135 5299 5179 5683
QI(days) 2.23 2.29 2.45 2.39 2.29 2.30 2.31 2.61 2.46 2.49 2.59 2.53
CQI 4c : Critical equipment down time.
Definition The term downtime is used to refer to periods when a system is

unavailable Downtime or outage duration refers to a period of time that a
system fails to provide or perform its primary function.
Formula Sum of down time for all critical equipment in hours.

REPORTED BY : In charge BENCHMARK :
QI(HRS) 1036 505 422 1562 991 3051 949 1952 1603 1781 1507 1068
CQI 4b : ICU Utilization rate (MICU)
Definition
Formula No of equipment utilized days
X 100
Equipment days available

N 21 15 35 51 187 42 51 36 29 52 29 23
D 62 56 62 150 248 240 248 248 240 248 240 248
QI(%) 34 27 56 34 75 18 21 15 12 21 12 9
CQI 4c : ICU Utilization rate (MICU)
Definition The degree of utilisation depicts the average utilisation of beds in per cent. The actual
bed occupancy is set in relation to the maximum bed occupancy. The maximum bed capacity is the
result of the product of installed beds and the number of calendar days in the reporting year. The
actual bed occupancy is the sum of calculation days and occupancy days, because every patient
occupies one bed per inpatient day in the facility
Formula Number of Bed utilized days

Bed days Available X100
N 110 133 165 162 271 93 141 173 163 201 201 238
D 310 280 310 300 300 300 310 310 300 310 300 310
QI(%) 35 48 53 54 90 31 45 56 54 65 67 77
CQI 4c :ICU Utilization rate (SICU)
Definition The degree of utilisation depicts the average utilisation of beds in per cent.
The actual bed occupancy is set in relation to the maximum bed occupancy. The
maximum bed capacity is the result of the product of installed beds and the number of
calendar days in the reporting year. The actual bed occupancy is the sum of calculation
days and occupancy days, because every patient occupies one bed per inpatient day in
the facility
Formula Number of Bed utilized days

Bed days Available X100
N 370 414 500 399 301 461 492 480 461 472 497 415
D 620 560 620 600 620 600 620 620 600 620 600 620
QI(%) 60 74 81 67 49 77 79 77 77 76 83 67
CQI 4c : ICU Utilization rate (SICU)
Definition
Formula No of equipment utilized days
X 100
Equipment days available

N 106 119 161 88 53 92 110 124 124 105 133 151
D 217 196 217 206 106 210 217 262 300 130 300 310
QI(%) 49 61 74 43 50 44 51 47 41 81 44 49
CQI 4d :Waiting time for services. OP consultation (Mins)
Definition Waiting time for out- patient consultation is the time from which
the patient has come to the concerned out patient department (it may or may
not be the same time as registration) till the time that the concerned
consultant (not the junior doctor/resident) begins the assessment
Formula Sum (Patient in Time for consultation - patient reporting time in OPD)
No. of patients reported in OPD.
SAMPLE SIZE : SAMPLE INDICATOR :Periodic Monitoring And Audit Should Be

Done At Least Quarterly
N 8310 8010 7240 8350 7630 6450 6800 6100 7650 7050 7650 8130
D 377 377 377 377 377 377 377 377 377 377 377 377
QI(Mins 23 22 24 20 25 21 24 19 18 22 21 19
)
CQI 4d :Waiting time for diagnostic services (Nuclear Medicine) PET.
Definition
Formula Total Waiting Time For Out Patient Services

No. Of Patients Reported In Diagnostics

N 7210 8795 8926 7371 4696 7911 9803 7302 8041 8150 8230 8271
D 217 278 278 217 217 217 278 217 217 217 217 217
QI(Mins 33 32 32 34 22 36 35 34 37 38 38 38
)
CQI 4d :Waiting time for diagnostic services (Nuclear Medicine)Gamma.
Definition
Formula Total Waiting Time For Out Patient Services

No. Of Patients Reported In Diagnostics

N 3758 4461 5499 3974 1968 3143 3766 4258 3790 3560 3997 3750
D 217 217 217 217 108 132 217 217 217 217 217 217
QI(Mins 17 21 25 18 18 24 17 20 17 16 18 17
)
CQI 4d :Time taken for discharge.
Definition
Formula Sum of time taken for discharge

No of patients discharged.
SAMPLE SIZE : SAMPLE INDICATOR : Periodic Monthly And Audit Should Be

N 1273.5 1267.2 1341.5 1302 1283.5 1261.5 1301 1378 1349 1381 1398 1391
D 357 357 370 357 357 357 370 370 370 370 370 370
QI(HRS) 4 4 4 4 4 4 4 4 4 4 4 4
CQI 4f :Number of sentinel events.
Definition : A near miss is an unplanned event that did not result in injury,
illness, or damage – but had the potential to do so. Errors that did not result in
patient harm, but could have, can be categorized as near misses.
Formula Number of sentinel events reported, collected and analyzed within the defined timeframe
X 100
Number of sentinel events reported, collected and analyzed

N NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
D NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL NIL
QI(%)
CQI 4f :Percentage of near misses (Nursing)
Definition A near miss is an unplanned event that did not result in injury,
illness, or damage – but had the potential to do so. Errors that did not result in
patient harm, but could have, can be categorized as near misses.
Formula Number near misses reported
X 100
Number of incident reports

N 0 0 0 0 0 0 0 0 0 0 0 0
D 0 0 1 4 2 0 2 5 0 1 2 1
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4f Incidence of blood body fluid exposures.
Definition An exposure is when blood , blood components or other potentially
infectious materials come in contact with a staff’s eyes, mucous membranen
Non intact skin or mouth
Formula In IPD areas: No. of blood body fluid exposures

X 1000
No. of inpatient days

Y
N 0 0 0 0 0 0 0 0 0 0 0 0
D 9700 10307 12482 14057 9025 9741 12112 13193 12608 13187 13406 14368
QI(%) 0 0 0 0 0 0 0 0 0 0 0 0
CQI 4f Incidence of Needle stick injuries(IP).
Definition Needle stick injury is a penetrating stab wound from a needle (or other sharp object) that may result in
exposure to blood or other body fluids. Needle stick injuries are wounds caused by needles that accidentally puncture
the skin.Needle stick injuries are a hazard for people who work with hypodermic syringes and other needle equipment.
These injuries can occur at any time when people use, disassemble, or dispose of needles. When not disposed of properly,
needles can become concealed in linen or garbage and injure other workers who encounter them unexpectedly. (Canadi an
Centre for Occupational Health and Safety)C
Formula In IPD areas: No. of parenteral exposures

No. of inpatient days X 1000

Y
N 2 0 1 1 3 0 1 0 0 1 2 6
D 9700 10307 12482 14057 9025 9741 12112 13193 12608 13187 13406 14368
QI(%) 0.2 0.0 0.1 0.1 0.3 0.0 0.1 0.0 0.0 0.1 0.1 0.4
CQI 4f Incidence of Needle stick injuries(OPD).
Definition Needle stick injury is a penetrating stab wound from a needle (or other sharp object) that
may result in exposure to blood or other body fluids. Needle stick injuries are wounds caused by
needles that accidentally puncture the skin.Needle stick injuries are a hazard for people who work with
hypodermic syringes and other needle equipment. These injuries can occur at any time when people use,
disassemble, or dispose of needles. When not disposed of properly, needles can become concealed in linen
or garbage and injure other workers who encounter them unexpectedly. (Canadi an Centre for Occupational
Health and Safety)C
Formula OPD areas: No. of parenteral exposures

No. of OPD X 1000
Y
N 0 2 0 0 0 0 1 0 0 0 0 0
D 15876 16371 18642 14217 14268 9742 17642 16604 16631 16595 17109 18020
QI(PK) 0.0 0.1 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0
CQI 4g Percentage of medical records not having discharge summary.
Definition : A discharge summary is the part of a patient record that summarizes the
reasons for admission, significant clinical findings, procedures performed, treatment
rendered, patient’s condition on discharge and any 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
Formula Number of medical records not having discharge summary

Number of discharges & deaths X 100
N 4 2 3 4 3 2 3 4 3 3 2 2
D 4343 4504 5085 4670 3943 4235 5159 5323 5135 5299 5179 5683
QI(%) 0.9 0.4 0.6 0.9 0.8 0.5 0.6 0.8 0.6 0.6 0.4 0.4
CQI 4g Percentage of medical records not having codification as per international classification of diseases. (ICD) (20 %
Sample)
Definition : The ICD is the international standard diagnostic classification for all general
pidemiological, many health management purposes and clinical use. These include the
analysis of the general health situation of population groups and monitoring of the
incidence and prevalence of diseases and other health problems in relation to other
variables such as the Characteristics andCircumstances of the individuals
affected,reimbursement, resource allocation, quality and guidelines (WHO ).
Formula Number of medical records not having codification as per international classification of diseases (ICD)

Y
N 2 3 4 4 8 6 3 4 3 4 3 5
D 357 357 370 357 357 357 370 370 370 370 370 370
QI(%) 5.6 8.4 10.8 11.2 22.4 16.8 8.1 10.8 8.1 10.8 8.1 13.5
CQI 4g Percentage of medical records having incomplete and\or improper consent
Definition: A Consent is the willingness of a patient to undergo examination
procedure/ treatment by a healthcare provider. 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.
Formula Number of medical records having incomplete and\or improper consent
N 1 1 2 3 1 2 1 2 1 2 3 2
D 357 357 370 357 357 357 370 370 370 370 370 370
QI(%) 2.8 2.8 5.4 8.4 2.8 5.6 2.7 5.4 2.7 5.4 8.1 5.4
CQI 4g Percentage of missing records.
Definition A medical record is considered as missing when the record could

not be found out from the MRD after the 72nd hour of the record request.
Formula Number of missing records
X 100
Number of records X 100

N 0 0 0 0 0 0 0 0 0 0 0 0
D 4343 4504 5085 4670 3943 4235 5159 5323 5135 5299 5179 5683
QI(%)

2021 Kpi Jan To Dec

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KEY PERFORMANCE INDICATORS

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least monthly

Definition Number of reporting errors per 1000 investigations.

Formula Number of reporting errors

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

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Definition Percentage of adherence to safety precautions by staff working in

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At least quarterly

Formula Number of staff adhering to safety precautions

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least quarterly

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least quarterly

Formula Number of reporting errors

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least monthly

Formula Number of reports co-relating with clinical diagnosis

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least quarterly

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least monthly

Formula Number of reports co-relating with clinical diagnosis

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic At Least quarterly

SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least

Formula Total number of medication dispensing errors

No. of patient days

SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least Monthly

2021 JUN JUL AUG SEP OCT NOV DEC

Wrong drug, Wrong strengh,Wrong dose errors;

SAMPLE SIZE : SAMPLE INDICATOR : Continuous And Periodic At least

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

2021 JUN JUL AUG SEP OCT NOV DEC

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Formula Number of patients requiring unplanned ventilation following anaesthesia X 100

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Formula Number of patients who developed adverse anaesthesia event X 100

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Definition Unplanned return to OT is defined as any secondary procedure

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Definition: Re- scheduling of surgeries includes cancellation and

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Formula Number of cases where the procedure was followed

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

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Formula No of returns to ICU within 48 hrs

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

Number of patients who have come to the emergency

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Continuous

SAMPLE SIZE : SAMPLE INDICATOR : Periodic Monthly

SAMPLE SIZE : SAMPLE INDICATOR : Periodic Monthly