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Showing posts with label Guidelines. Show all posts
Showing posts with label Guidelines. Show all posts

Sunday, March 20, 2022

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Number of patients who have withdrawn from all ongoing studies  X 100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