Sr.  No

INDICATOR

1a

Time for initial assessment of indoor and emergency patients                  

1b

Time for initial assessment of indoor and emergency patients

2

Percentage of cases (in-patients) Wherein care plan with desired outcomes is documented and counter-signed
by the clinician.

3

Percentage of cases (in-patients) wherein screening for nutritional needs has been done.

4

Percentage of cases (in-patients) Wherein the nursing care plan is documented.

5

Number Reporting Error/1000investigations

i) Radiology

ii) Pathology

6

Percentage of re-dose.

i) Radiology

ii) Pathology

7

Percentage of reports co- relating with  clinical diagnosis.

i) Radiology

ii) Pathology

8

Percentage of adherence to safety precautions by employees working in diagnostics.

i) Radiology

ii) Pathology

9

Incidence of medication errors

10

Percentage of admissions with adverse drug reaction (s)

11

Percentage of medication charts with error prone abbreviations

12

Percentage of patients receiving high risk medications developing drug event.

13

Percentage of modification of anaesthesia  plan

14

Percentage of unplanned ventilation following anesthesia.

15

Percentage of adverse anaesthesia events

16

Anaesthesia related mortality rate

17

Percentage of unplanned return to OT

18

Percentage of re-scheduling of surgeries

19

Percentage of cases where the organization’s procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to

20

Percentage of received appropriate prophylactic antibiotics within the specified time frame. 

21

Percentage of cases in which the planned surgery is changed itraoperatively

22

Re-exploration rate

23

Percentage of transfusion reactions

i)  MT

ii) OT 

24

Percentage of wastage of blood and blood products

i)  MT

ii) OT 

25

Percentage of blood component usage

i)  MT

ii) OT 

26

Turnaround time for issue of blood and components

i) MT

ii) OT 

27

Catheter associated Urinary tract infection rate

28

Pneumonia rate

29

Bloodstream 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 complains

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 organization) reported to the ethics committee within 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 receipt note

42

Percentage of variations from the procurement process

43

Number of variation observed in mock drills

44

Incidence of falls

45

Incidence of bed sores after admission

46

Percentage of employees provide pre-exposure prophylaxis

47

Bed occupancy rate and A

average length of stay B

48

OT and ICU utilization rate  •ICU-NA

49

Critical equipment down time

50

Nurse- Patient ratio for ICUs and wards  • ICU-NA                         

51

Out patient satisfaction index

52

In patient satisfaction index

53

Waiting time for including diagnostics and

Outpatient consolation

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

Number of sentinel events reported, collected and analyzed within the defined timeframe

60

Percentage of near misses

61

Incidence of blood body fluid exposures

Safety Officer

MT

62

Incidence of needle stick injuries.

Safety Officer

ICN

63

Percentage of medical records not having discharge summary

64

Percentage  of medical records not having codification 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 separately for doctors and nurses )-( per patient per shift)

68

Incidence of Patient identification errors

69

Compliance to Hand Hygiene partactice

70

Compliance rate to medication Prescription in capitals

71

Depression status monitoring at the time of discharge

72

Adherence to antibiotic policy

73

Mobility status monitoring at the time of discharge

74

Time for initial assessment of indoor  patients by paramedics

75

TAT for referral and transfer

76

TAT for dispatch of Medical Record at MRD post discharge

77

Response tiime for breakdown of critical equipment

78

Vocational establishment rate and mobility aid provision rate