| 1. |
a.Time for initial assessment of indoor patient's |
| b.Time taken for initial assessment of patient's attending Emergency services |
| 2. |
Percentage of cases(IP) wherein care plan with desired outcomes is documented and countersigned by the clinician. |
| 3. |
Percentage of cases(in patient's) wherin screening for nutritional needs has been done. |
| 4. |
Percentage of cases (in patient) where in the nursing care plan is documented |
| 5. |
Number of reporting errors per 1000 investigations |
| 6. |
Rate of re-dos |
| 7. |
Percentage of reports corelating with clinical diagnosis. |
| 8. |
Percentage of adherence to safety precautions by Employees working in Diagnostics. |
| 9. |
Incidence of medication errors (medication errors per patient days) |
| 10. |
Percentage of admissions with adverse drug reaction(s) (adverse drug reactions per 100 seperations) |
| 11. |
Percentage of medication charts with error prone abbreviations |
| 12. |
Percentage of patient receiving high risk medications developing adverse drug event |
| 13. |
Percentage of modifications of anesthesia plan |
| 14. |
Percentage of unplanned ventilation following anesthesia |
| 15. |
Percentage of adverse anesthesia events. |
| 16. |
Anaesthesia related mortality rate |
| 17. |
Percentage of unplanned return to OT |
| 18. |
Percentage of rescheduling of surgeries |
| 19. |
Percentage of cases by the organization procedure to prevent adverse events like wrong site,wrong patient and wrong surgery have been adhered to. |
| 20. |
Percentage of cases who received appropriate prophylactic antibiotics within the specified time frame |
| 21. |
Percentage of cases in which the planned surgery is changed intraoperatively |
| 22. |
Re-exploration rate |
| 23. |
Percentage of transfusion reactions recepients. The causes include red blood cells incompatibility sensitivity to the leukocytes, platelets, plasma protein components of the transfused blood; or potassium or citrate preservatives in the bank blood. |
| 24. |
Pecentage of wastage of blood and blood components |
| 25. |
Percentage of blood components usage |
| 26. |
Turn-around time for issue of blood and blood components |
| 27. |
Catheter associated urinary tract infection rate |
| 28. |
Ventilator associated pneumonia rate |
| 29. |
Central line associated blood stream infection rate |
| 30. |
Surgical site infection rate |
| 31. |
Mortality rate |
| 32. |
Return to ICU within 48 hours. |
| 33. |
Return to the emergency department within 72 hours with similar presenting complaints. |
| 34. |
Re-intubation rate |
| 35. |
Percentage of research activities approved by Ethics committee |
| 36. |
Percentage of patients withdrawing from the study |
| 37. |
Percentage of protocol violations/ deviations reported |
| 38. |
Percentage of serious adverse events (which have occurred in the organisation) reported to the ethics committeewithin the defined time frame |
| 39. |
Percentage of drugs and consumables procured by local purchase |
| 40. |
Percentage of stock outs including emergency drugs |
| 41. |
Percentage of drugs and consumables rejected before preparation of Goods Reciept Note (GRN) |
| 42. |
Percentage of variations from the procurement process |
| 43. |
No. of variations observed in mock drills |
| 44. |
Incidence of falls |
| 45. |
Incidence of hospital associated pressure ulcers after admission (Bed Sore per 1000 patient days) |
| 46. |
Percentage of staff provided pre- exposure prophylaxis |
| 47. |
Bed occupancy rate and average length of stay |
| 48. |
OT and ICU utilization rate |
| 49. |
Critical equipment downtime |
| 50. |
Nurse patient ratio for ICUs and wards |
| 51. |
Our Patient Satisfaction index |
| 52. |
In patient satisfaction index |
| 53. |
Waiting time for services including diagnostics and out-patient consultation. |
| 54. |
Time taken for discharge |
| 55. |
Employee satisfaction index |
| 56. |
Employee attrition rate |
| 57. |
Employee absenteeism rate |
| 58. |
Percentage of employees who are aware of employee rights, responsibilities and welfare schemes |
| 59. |
No. of sentinel events reported, collected and analyzed within the defined time frame. |
| 60. |
Percentage of near misses |
| 61. |
Incidence of blood body fluid exposures |
| 62. |
Incidence of needle stick injuries |
| 63. |
Percentage of medical records not having discharge summary |
| 64. |
Percentage of medical records not having codification as per International Classification of Diseases (ICD) |
| 65. |
Percentage of medical records having incomplete and /or improper consent |
| 66. |
Percentage of missing records |
| 67. |
Appropriate handovers during shift change(to be done seperately for doctors and nurses)-(per patient per shift) |
| 68. |
Incidence of patient identification errors |
| 69. |
Compliance to hand hygiene practice |
| 70. |
Compliance to rate to Medication Prescription in capitals |
