Ethics Committee Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
Ethics committee
1	Percentage of Research activities approved by Ethics Committee	Number of research activities approved by ethics committee     X 100 Number of research protocols submitted to ethics committee	Percentage
2	Percentage of patients withdrawing from the study	Number of patients who have withdrawn from all ongoing studies  X 100 Number of patients enrolled in all on-going studies	Percentage
3	Percentage of protocol violations/ deviations reported	Number of protocol violations/ deviations reported                  X 100 Number of protocol violations/deviations that have occurred	Percentage
4	Percentage of serious adverse events (which have occurred in the organisation) reported to the ethics committee within the defined timeframe.	Number of serious adverse events reported within the defined timeframe     X 100 Number of serious adverse events reported within and outside the defined timeframe	Percentage

BME Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
BME
1	Critical equipment down time	Sum of down time for all critical equipment in hours in a month	Value
3	Percentage of calls which having total breakdown time 24 hours	numbers of Total breakdown calls are counted in a month           X 100  number of calls with total breakdown time less then 24 hours	Percentage
4	Percentage of callswhich are not repeated in month	total numbers of breakdown calls are counted in a month   X 100 total number of calls (with similar nature) which are not  repeated even once in a month	Percentage

Central Store Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
Stores
1	Percentage of consumables procured by local purchase	a. Number of drugs/items purchased by local purchase within formulary  X 100      Number of drugs/ items in hospital formulary list                                                                         b. Number of drugs/items purchased by local purchase outside formulary X 100      Number of drugs-Items procured in hospital within as well as outside	Percentage
2	Percentage of Consumable rejected before Goods Received Note (GRN) Preparation	Total quality rejected                          X 100 Total quantity received before GRN	Percentage
3	Percentage of stock outs including emergency items	Number of stock outs                                                                                       X 100 Number of drugs listed in hospital formulary and hospital consumables list	Percentage
4	Percentage of variations from the procurement process	Total number of variations from the defined procurement process X 100 Total number of items procured	Percentage

Medical Record Deptt Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
MRD
1	Mortality Rate	a. Number of Deaths                          X 100     Number of discharges and deaths     b. Proportional maternal mortality rate= Total no. of Maternal deaths  X 100                                                                   Total no. of deaths          c. Proportional infant mortality rate= Total No. of infant deaths  X 100                                                             Total no. of Deaths	Percentage
2	Bed Occupancy rateaverage length of stay	Number of inpatient days in a given month   X 100 Number of available bed days in that month	Percentage
3	average length of stay	Number of inpatient days in a given month           Number of Discharges and Deaths in that month	Value
4	Percentage of medical records not having discharge summary	Number of medical records not having discharge summary X 100 Number of discharges and deaths	Percentage
5	Percentage of medical records mot having codification as per International Classification of Diseases (ICD)	Number of medical records not having codification as per International Classification of Diseases(ICD)              X 100  Number of discharges and deaths	Percentage
6	Percentage of medical records having incomplete and/or improper consent	Number of medical records having incomplete and/or improper consent  X 100 Number of discharges and deaths	Percentage
7	Percentage of missing records	Number of missing record   X 100 Number of records	Percentage

Blood Bank Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
Blood Bank
1	Percentage of transfusion reactions recipient.	Number of transfusion reactions  X 100 Number of units transfused	Percentage
2	Percentage of wastage of blood and blood component	a. Number of Blood and Blood Components units     wasted among those issued                                    X 100     Number of blood and Blood  Components units       issued from the blood bank   b. Number of blood and blood components units     wasted at blood bank/ blood storage centre              X 100     Number of blood and blood components units        stored in the blood bank	Percentage
3	Percentage of blood component usage	Number of components used                            X 100 Number of Blood and Blood Products used	Percentage
4	Turnaround time for issue of blood and blood components	Sum of time taken                                                          Total number of Blood and Blood Components issued	Value

Emergency Deptt Quality Indicator

 

QI N	QI Name	Formula	Unit of Measurement
Emergency
1	Time taken for initial assessment of patients attending emergency services.	Sum of time taken for the assessment Total Number of patients in emergency	Value
2	Return to Emergency department within 72 hours with similar presenting complaints	Number of returns to emergency within 72 hours with similar presenting complaints                                     X 100 Number of patients who have come to the emergency	Percentage
3	Incidnece of needle stick injuries	a. In IPD Areas: Number of parenteral exposures X 100                           Number of in-patient days                   b, In OPD Areas: Number of Parentral exposures  X 100                         Number of OPD Patient visits	Percentage

IPD patients quality indicator

 

QI N	QI Name	Formula	Unit of Measurement
Inpatients
1	Time for initial assessment of indoor patients	Sum of time taken for the assessment Total Number of patients in indoor	Value
2	Percentage of cases (in-patients) wherein care plan with desired outcomes is documented and countersigned by the clinician	Number of in-patient case records wherein the care plan with desired outcomes has been documented    X 100 Total number of patients	Percentage
3	Percentage of cases (in-patients) wherein screening for nutritional needs has been done.	Number of in-patient case records wherein the nutritional assessment has been documented     X 100 Total number of patients*100	Percentage
4	Percentage od cases (in-patients) wherein the nursing care plan is documented	Number of in-patient case records wherein the nursing care plan has been documented    X 100 Total number of Patients	Percentage
5	Incidence of medication errors ( Medication errors per patient days)	Total number of medication errors    X 1000 Number of patient days                                                                                                                                                   a. Total no. of prescription errors  X 1000     No. of patient days              b. Total no. of medication dispensing errors  X 1000     No. of patients days	Percentage
6	Percentage of medication charts with error prone abbreviations	Number of medication charts with error prone abbreviations   X 100 Number of medication charts reviewed	Percentage
7	Percentage of admissions with adverse drug reaction(s) ( Adverse drug reactions per 100 separations)	Number of adverse drug reactions   X 100 Number of discharges and death	Percentage
8	Number of variations observed in mock drills	Total number of variations in a mock drill	Value
9	Incidence of hospital associated pressure ulcers after admission (Bed sore per 1000 patient days)	Number of patients who develop new/worsening of pressure ulcer   X 1000 Total no.of patient days	Percentage
10	Nurse-patient ratio for ICUs and wards	Number of nursing staff  Number of beds                                                                         (To be calculated for each shift seperately)	Value
11	In patient satisfaction index	Average Score achieved      X 100 Maximum possible score	Percentage
12	Time taken for discharge	Sum of time taken for discharge Number of patients dicharged	Value
13	Number of sentinal events reported, collected and analysed within the defined timeframe	Number of sentinal events analysed within the defined timeframe   X 100 Number of sentinal events reported/collected	Percentage
14	Percentage of near misses	Number of near misses reported   X 100 Number of incidents	Percentage
15	Incidence of blood body fluid exposures	a. In IPD Areas: Number of blood body fluid exposures    X 1000                           Number of in-patient days                                                                                        b. In OPD Areas: Number of blood body fluid exposures   X 1000                             Number of OPD Patient visits	Percentage
16	Appropriate handovers during shift change ( To be done deperately for doctors and nurses)- (per patient per shift)	Total no. of handovers done appropriately   X 100  Total no.of handovers opportunities	Percentage
17	Incidence of Patient identification errors	No. of patient identification errors   X 100 No. of patients	Percentage
18	Percentage of Thrombo Phlebitis	Number of patients having phlebitis                           X 100 Total Number of patient days with invasive lines / tubes	Percentage
19	Percentage of Patient Falls	Total Number of Patient Fall                         X 100 Total Number of Discharges and Deaths	Percentage
20	Percentage of Accidental removal of lines and tubes	Total Number of accidental removal of invasive lines/ tubes   X 100    Total Number of Patient Days with invasive lines/tubes	Percentage