Akhtarul Munim,

Hospital Management Consultant

[email protected]
Introduction
• Quality Indicators assess particular health
structures, processes, and outcomes. They can be
rate- or mean-based, providing a quantitative basis
for quality improvement, or sentinel, identifying
incidents of care that trigger further investigation.
• Indicators provide a quantitative basis for clinicians,
organizations, and planners aiming to achieve
improvement in care and the processes by which
patient care is provided.
Introduction
• Indicator measurement and monitoring serve many
purposes. They make it possible to: document the
quality of care; make comparisons (benchmarking)
over time between places (e.g. hospitals); make
judgments and set priorities (e.g. choosing a
hospital or surgery, or organizing medical care);
support accountability, regulation, and
accreditation; support quality improvement; and
support patient choice of providers.
Key Characteristics of an Ideal
Indicator
An ideal indicator would have the following key
characteristics: (i) indicator is based on agreed
definitions, and described exhaustively and exclusively;
(ii) indicator is highly or optimally specific and sensitive,
i.e. it detects few false positives and false negatives; (iii)
indicator is valid and reliable; (iv) indicator discriminates
well; (v) indicator relates to clearly identifiable events
for the user (e.g. if meant for clinical providers, it is
relevant to clinical practice); (vi) indicator permits useful
comparisons; and (vii) indicator is evidence-based.
 How to use Quality Indicators
As a tool to measure the implementation
of a guideline
Guideline /
QI plan

Adjustment of
implementation
QI plan

Analysis*

* Indicators
How to use Quality Indicators
As a part of Total Quality Management

* Indicators
The Standard – CQI 2
a) Organization may identify the appropriate
key performance indicators in both clinical and
managerial areas.

b) These indicators shall be monitored.

 How to….
a) Identify the QIs feasible for your hospital

b) Decide how you can capture the data in your hospital settings

c) Prepare formats/registers/Reporting system as required

d) Assign Responsible person for data capture & Reports

e) Quality coordinator to summarize and convert to

graph/chart/pie diagram/ suitable display

f) Shall be available with Quality coordinator and displayed at

the department level

1.Out patient satisfaction index
Patient Satisfaction Index = Score Achieved x 100
Maximum Score
• For hospitals with < 20 patients/day: 100%
• For hospitals with 21-50 patients/ day: 50%
• For hospitals with 51-100 patients/ day: 20%
• For hospitals with 101-200 patients/ day: 10%
• For hospitals with 201-400 patients/ day: 5%
• For hospitals with > 400 patients/ day: 2%

• The sample shall be derived from repeat patients.

• In case the organisation is not capturing an overall feedback but
instead only for various parameters, the index shall be calculated by
averaging the satisfaction of various parameters.
2. In patient satisfaction index
Patient Satisfaction Index = Score Achieved x 100
Maximum Score
• For hospitals with < 20 discharges/ day: 100%
• For hospitals with 21-50 discharges /day: 50%
• For hospitals with 51-100 discharges /day: 20%
• For hospitals with > 100 discharges /day: 10%
3. Incidence of falls
Incidence of falls = Number of falls X 100
Number of Discharges +
Deaths
• from beds, wheelchairs or down stairs, as a result of slipping, tripping,
or stumbling, or from a collision, pushing, or shoving, by or with
another person, into a hole or other opening in surface

• All types of falls are to be included whether they result from

physiological reasons (fainting) or environmental reasons.

• Assisted falls (when another person attempts to minimize the impact of

the fall by assisting the patient’s descent to the floor) should be
included.
4. Incidence of bed sores after
admission
Number of Incidences X 100
Number of Discharges + Deaths

• 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
• Worsening of pressure ulcer already present at the time of
admission shall also be counted
5. Number of reporting errors Per
1000 investigations
Number of reporting errors X 1000
Number of tests performed

• Reporting errors include those picked up before and after dispatch.

It shall include transcription errors.
• This shall be captured in the laboratory and radiology
6. Percentage of re-dos.
Number of re-dos X 100
Number of tests performed

• This shall also include tests repeated before release of the result (to
confirm the finding).
• This shall be captured in the laboratory and radiology.
7. Incidence of medication errors
Total number of medication errors X 100
Number of patient days
• Errors in the prescribing, transcribing, dispensing, administering,
and monitoring of medications;
• Wrong drug, wrong strength, or wrong dose errors;
• Wrong patient errors;
• Wrong route of administration errors; and
• Calculation or preparation errors.
In addition to incident reporting, to detect medication errors the
organisation shall either adopt medical record review or direct
observation. The sample size for this shall be as per the preceding
column. The average occupancy shall be of the preceding 3 months.
7. Incidence of medication errors
Sample Size
• For hospitals with average occupancy < 50 patients /day: 10% of
patients/day
• For hospitals with average occupancy 51-100 patients /day: 5% of
patients/day
• For hospitals with average occupancy 101-300 patients /day: 3%
of patients/day
• For hospitals with average occupancy 301-500 patients /day: 2%
of patients/day
8. Percentage of admissions with
adverse drug reactions
Number of adverse drug reactions X 100
Number of discharges and deaths
• A response to a drug which is noxious and unintended and which
occurs at doses normally used in man for prophylaxis,
diagnosis, or therapy of disease or for the modification of
physiologic function
9. Percentage of re-scheduling of
surgeries
Number of cases re-scheduled X 100
Number of surgeries performed
• Re-scheduling of patients includes cancellation and postponement
(beyond 4 hours) of the surgery.
10. Percentage of transfusion
reactions
Number of transfusion reactions X 100
Number of transfusions
• Any adverse reaction to the transfusion of blood or blood
components shall be considered as transfusion reaction. It may
range from an allergic reaction to a life threatening complication
11. Urinary tract infection rate

Number of urinary catheter associated UTIs in a month X

100
Number of urinary catheter days in that month
12.Ventilator Associated Pneumonia

Number of VAP in a month X 1000

Number of ventilator days in that month
13. Surgical site infection rate

Number of surgical site infections in a given month X 100

Number of surgeries performed in that month
14. Mortality rate

Number of deaths X 100

Number of discharges and deaths
15. Percentage of employees
provided pre-exposure prophylaxis
Number of employees who were provided pre- exposure
prophylaxis X 100
Number of employees who were due to be provided pre-
exposure prophylaxis

• This shall include at a minimum prophylaxis against Hepatitis B.

• The denominator shall include new employees (working in patient
care areas) and existing employees whose booster dose is due in that
month
16. Employee satisfaction index
Score achieved x 100
Maximum possible score

• The satisfaction shall be captured from all categories of staff and at

least once in six months
• For hospitals with < 100 staff: 100%
• For hospitals with 101-200 staff: 50%
• For hospitals with 201-500 staff: 20%
• For hospitals with 501-1000 staff: 15%
• For hospitals with > 1000 staff: 10%
17. Waiting time for services
Sum (Patient in Time - Patient Out/Reporting Time)
Number of patients reported in OPD/ Diagnostics

• OP Consultation, Laboratory, Radiology etc

• Waiting time for diagnostics is applicable only for out-patients.
• Waiting time for diagnostics is the time from which the patient has
come to the diagnostic service (requisition form has been presented
to the counter) till the time that the test is initiated.
• 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.
 18. Percentage of modification of
Anesthesia plan
The anaesthesia plan is the outcome of pre-anaesthesia assessment. Any
changes done after this shall be considered as modification of
anaesthesia plan.

Formula :Number of patients with anaesthesia plan modified x 100

Number of patients who underwent anaesthesia

• Patient Anesthesia record or Register in the OT

19. Number of needle stick injuries

Formula : Number of parenteral exposures x 100

Number of in-patient days

• Parenteral exposure means injury due to any sharp.

• All incidences of needle stick injuries should be assessed on a case-by-
case basis.
• Analyze needle stick and other sharps related injuries in the workplace
to identify hazards and injury trends.
• Data from injury reporting should be compiled and assessed to
identify:
▫ where, how, with what devices, and when injuries are occurring and
▫ the groups of health care workers being injured.
20.Percentage of Missing Records
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
• Missing Files Register

Regular checks should be in place to ensure that there are no missing

medical records or medical records are filed in the wrong place.
21. % of Files with out Discharge
Summary
Formula : Number of medical records not having discharge summary x
100
Number of discharges and deaths

• Every medical record that comes to the MRD from the clinical unit
following the discharge of a patient shall be immediately checked for
the presence of discharge summary. If this is not present at this
stage it shall be captured as a part of the numerator.
• A register shall be maintained at the point of checking.
22. % of Medical Records with out (or
with improper) consents
Formula : Number of medical records not proper consents x 100
Number of discharges and deaths

• Every medical record that comes to the MRD from the clinical unit
following the discharge of a patient shall be immediately checked for
the same.
• A register shall be maintained at the point of checking.
 Recommended QI List
1. Incidence of Medication Errors 13. Out Patient Satisfaction Index
2. Percentage of cases who received 14. Inpatient Satisfaction Index
appropriate prophylactic antibiotics 15. No of Reporting Errors – Laboratory
with in specified time frame
16. Percentage of Re-Dos – Laboratory
3. Percentage of Transfusion reactions
17. Percentage of Admissions with ADE
4. Catheter Associated Urinary Tract
Infection (CAUTI) 18. Percentage of Rescheduling of Surgeries
5. Ventilator Associated Pneumonia 19. Percentage of Employees provided pre-
(VAP) exposure prophylaxis
6. Central Line Associated Blood 20. Employee Satisfaction Rate
Stream Infections (CLABSI) 21. Waiting Time for Services
7. Surgical Site Infections (SSI)
22. Percentage of Modification of Anesthesia
8. Total Mortality Rate Plans
9. Compliance To Hand Hygiene
23. Percentage of Missing Medical Records
10. Incidence of Falls
24. Percentage of Files Without Discharge
11. Incidence of Beds Sore After
Summary
Admissions
12. Incidence of Needle Stick Injuries 25. Percentage of Medical records with out
(or with improper) consents