MANDATORY PERFORMANCE INDICATORS 1.

The following mandatory performance indicators will be monitored on an ongoing basis by the hospital and used for improvement in the quality of services. Indicators for Patient Assessment 2. Time taken for initial assessment of Indoor & Emergency patients by the specialist (a) MPI-1 (time taken for assessment of indoor patients) (i) (ii) (iii) Numerator. Time taken for assessment by specialist Denominator. Number of indoor patients sampled Data required. Time of reporting to HMC / OPDs Time of writing of initial case sheet by specialist

(b)

MPI-2 (time taken for assessment of emergency patients) (i) Numerator. Time taken for assessment of Emergency patients by the specialist (ii) Denominator. Number of emergency patients sampled (iii) Data required. Patient requiring direct admission to ICU / HDU Patient placed directly on SIL / DIL at admission Patient requiring emergency surgery within 24 hrs of admission

3. Percentage of documents where the care plan is documented & countersigned by the clinician (a) MPI-3 (Percentage of documents where care plan is documented) (i) Numerator. Number of case sheets where care plan has been documented (ii) Denominator. Total number of case sheets sampled (iii) Multiplier. 100 (iv) Data required. Number of case sheets where care plan has been documented Total number of case sheets sampled (b) MPI-4 (Percentage of documents where care plan is countersigned by the clinician) (i) Numerator. Number of case sheets where care plan has been countersigned by clinician (ii) Denominator. Total number of case sheets sampled (iii) Multiplier. 100 (iv) Data required. Number of case sheets where care plan has been countersigned by the clinician

2 4. Total number of case sheets sampled

MPI-5 (Percentage of cases where screening of nutritional needs is done) (a) Numerator. Number of case sheets where screening for nutritional needs has been documented (b) Denominator. Total number of case sheets sampled (c) Multiplier. 100

5. MPI-6 (Percentage of cases where predefined initial nursing assessment is completed within 30 min) (a) Numerator. Number of case sheets where initial nursing assessment has been documented within 30 min (b) Denominator. Total number of case sheets sampled (c) Multiplier. 100 Indicators for Diagnostics 6. Number of reporting errors / 1000 investigations (a) MPI-7 (Number of reporting errors before dispatch of Investigations) (i) (ii) (iii) (b) Numerator. Number of reporting errors Denominator. Total number of Inv done in that time period Multiplier. 1000

MPI-8 (Number of reporting errors after dispatch of Investigations) (i) (ii) (iii) Numerator. Number of reporting errors Denominator. Total number of Inv done in that time period Multiplier. 1000

(c) Notes on Para 6 (a) and 6 (b). Feedback from clinicians to be documented in the clinical correlation register, Investigation to be re-done / Result re-analyzed in case of differences between clinical assessment & diagnostic reports. Reporting errors to be calculated on basis of differences between initial and re-do / re-evaluation reports. 7. MPI-9 (Percentage of Re-dos) (a) Numerator. Number of investigations re-done (b) Denominator. Total number of Investigations done in that time period (c) Multiplier. 1000 (d) Notes. Maintain Re-do register in all Diagnostics areas ( Lab / Imaging / Nuclear medicine) with reason for Re-do recorded (Sample haemolyzed, Sample insufficient, Sample not labeled, Inv Form missing, Positioning of patient unsatisfactory, Exposure unsatisfactory, Bladder not full, Angle of insonation not possible, Clinical correlation unsatisfactory etc)

3 8. MPI-10 (Percentage of reports correlating with clinical diagnosis) (a) Numerator. Total reports (minus) Reports not clinically correlating (b) Denominator. Total reports generated in that time period (c) Multiplier. 100 (d) Notes. Feedback from clinicians to be documented in the clinical correlation register. Reason for lack of clinical correlation to be documented. Reporting differences to be documented on basis of differences between initial and re-do / reevaluation reports if applicable. 9. MPI-11 (Percentage of adherence to safety precautions by employees working in diagnostics) (a) Numerator. Total employees sampled in diagnostics (minus) Employees not adhering to safety precautions (b) Denominator. Total employees sampled (c) Multiplier. 100 Indicators for Invasive procedures 10. MPI-12 (Re-exploration rate) (a) Numerator. Total number of patients requiring re-exploration (b) Denominator. Total number of major surgeries performed during the defined time period (c) Multiplier. 100 11. MPI-13 (Accidental removal of tubes & catheters) (a) Numerator. Total number of patients with accidental removal of endotracheal tubes & urinary catheters (b) Denominator. Total number of patients with endotracheal tubes & urinary catheters in situ during the defined time period (c) Multiplier. 100 12. MPI-14 (Haematoma at puncture sites) (a) Numerator. Total number of patients with haematoma at puncture sites (b) Denominator. Total number of interventional punctures performed during the defined time period (c) Multiplier. 100 (d) Note. Data to be captured at Interventional radiology & CCL in addition to sites where central line placements are done 13. MPI-15 (Re-scheduling of procedures) (a) Numerator. Number of procedures rescheduled (b) Denominator. Total number of procedures performed during the defined time period (c) Multiplier. 100

4 (d) Note. Data to be captured at all sites where procedures are performed i.e. OT, CCL, Dialysis centre, Depts (Gastro-enterology, Pulmonology, Urology, Psychiatry and Imaging) Indicators for Adverse Drug Events 14. MPI-16 (Percentage of medication errors) (a) Numerator. Number of medication errors reported and detected in the sample (b) Denominator. Total prescriptions sampled + Total Case sheets sampled in the defined time period (c) Multiplier. 100 (d) Note. Medication errors may be detected concurrently and reported or later during the course of a prescription audit. Both categories will contribute to the numerator of the performance indicator 15. MPI-17 (Incidence of adverse drug reactions) (a) (b) 16. Numerator. Number of adverse drug reactions reported in in-patients Denominator. Total Inpatient days in the defined time period

MPI-18 (Percentage of medication charts with illegible writing) (a) Numerator. Number of prescriptions with illegible writing (b) Denominator. Total prescriptions sampled during the defined time period (c) Multiplier. 100 (d) Note. Even if one prescription medicine cannot be understood by the person dispensing the prescription, it will be considered as an illegible prescription

17.

MPI-19 (Percentage of contrast related reactions) (a) Numerator. Total number of contrast related reactions (b) Denominator. Total number of patients administered contrast during the defined time period (c) Multiplier. 100 (d) Notes. Data capture to be carried out at all sites where contrast is administered i.e. Imaging, CCL

Indicators for Use of Anaesthesia 18. MPI-20 (Percentage of modification of anaesthesia plan) (a) (b) (c) 19. Numerator. Total number of anaesthesia plans modified Denominator. Total anaesthesia administered during the defined time period Multiplier. 100

MPI-21 (Percentage of unplanned ventilation following anaesthesia) (a) (b) Numerator. Total number of unplanned ventilation following anaesthesia Denominator. Total anaesthesia administered during the defined time period

5 (c) 20. Multiplier. 100

MPI-22 (Percentage of adverse anaesthesia events) (a) Numerator. Total number of adverse anaesthesia events occurring during administration of anaesthesia (b) Denominator. Total anaesthesia administered during the defined time period (c) Multiplier. 100

21.

MPI-23 (Anaesthesia related mortality rate) (a) Numerator. Anaesthesia related mortality (b) Denominator. Total anaesthesia administered during the defined time period (c) Multiplier. 1000 (d) Note. Anaesthesia related mortality is defined as death directly attributable to the administration of anaesthesia and occurring during the administration of anaesthesia or within 24 hrs of administration of anaesthesia.

Indicators related to use of Blood & Blood products 22. MPI-24 (Percentage of transfusion reactions) (a) Numerator. Number of transfusion reactions reported (b) Denominator. Total number of transfusions performed within the defined time period (c) Multiplier. 100 23. MPI-25 (Percentage of wastage of Blood & Blood products) (a) Numerator. Number of Blood & Blood product bags discarded (b) Denominator. Total number of transfusions performed within the defined time period (c) Multiplier. 100 (d) Notes. Discarded Blood & Blood products will include bags not utilized within life span at the blood bank as well as bags discarded at wards before & during use. The reasons for discarding bags at wards are to be notified to the Blood bank. 24. MPI-26 (Blood component usage as a percentage of total transfusions) (a) Numerator. Number of blood component units used (b) Denominator. Total number of transfusions performed within the defined time period (c) Multiplier. 100 25. MPI-27 (Blood component usage as a percentage of total components) (a) Numerator. Number of individual blood component units used (b) Denominator. Total number of components transfused within the defined time period (c) Multiplier. 100

6 (d) 26. Notes. To be calculated separately for each blood component.

MPI-28 (Turn around time for issue of blood & blood components) (a) Numerator. Time taken for issue of emergency requisitions (b) Denominator. Total number of emergency requisitions within the defined time period. (c) Data required. Time of receipt of emergency requisition Time of issue of blood / blood component (d) Notes. Data for turnaround time only of emergency requisitions to be captured as routine; requisitions for blood /blood components are raised one day in advance.

Indicators for Medical records 27. MPI-29 (Percentage of medical records not having discharge summary) (a) (b) (c) 28. Numerator. Number of Medical Records not having discharge summary Denominator. Total number of medical records sampled Multiplier. 100

MPI-30 (Percentage of Medical Records not having initial assessment and plan of care) (a) (b) (c) Numerator. Number of Medical records not having initial assessment Denominator. Total number of medical records sampled Multiplier. 100

29.

MPI-31 (Percentage of Medical Records not having plan of care) (a) (b) (c) Numerator. Number of Medical records not having plan of care Denominator. Total number of medical records sampled Multiplier. 100

30.

MPI-32 (Percentage of medical records having incomplete and / or improper consent) (a) Numerator. Number of Medical records having incomplete or improper consent (b) Denominator. Total number of medical records sampled (c) Multiplier. 100

31.

MPI-33 (Percentage of missing records) (a) Numerator. Number of missing medical records (b) Denominator. Total number of medical records requisitioned in the defined time period (c) Multiplier. 100

Indicators for Infection control activities

7 32. MPI-34 (Urinary tract infection rate) (a) Numerator. Number of Urine or catheter tip samples positive in catheterized patients (b) Denominator. Total number of patients catheterized for 24 hrs or more in the defined period (c) Multiplier. 100 (d) Notes. Infection Control Nurse & all wards to capture data on patients catheterized for 24 hrs or more 33. MPI-35 (Lower respiratory tract infection rate) (a) Numerator. Total number of Ventilator Associated pneumonias (b) Denominator. Total number of ventilated patients in the defined period (c) Multiplier. 100 (d) Notes. Criteria for diagnosing VAP as per criteria laid out in AFMRC research project underway 34. MPI-36 (Intra- vascular device infection rate) (a) Numerator. Total number of Intra-vascular device infections (b) Denominator. Total number of patients with intra-vascular devices in situ in the defined period (c) Multiplier. 100 35. MPI-37 (Surgical site infection rate) (a) Numerator. Total number of Surgical site infections (b) Denominator. Total number of patients undergone major surgeries in the defined period (c) Multiplier. 100 (d) Notes. Time line for diagnosis of SSI is within 30 days of surgery, and that for diagnosis of deep seated SSI i.e. implants is within 1 yr of surgery Indicators for Clinical research 36. Number of research activities being carried out (a) MPI-38 [Total number of AFMRC (Armed Forces Medical Research Committee) projects underway] - Being monitored by the Hospital AFMRC cell (b) MPI-39 (Total number of MD / MS thesis projects underway by Post-graduate students) - Being monitored by the Hospital PG cell 37. MPI-40 (Percentage of patients withdrawing from study) (a) Numerator. Number of patients withdrawing from studies (b) Denominator. Total number of patients enrolled in studies within the specified time period (c) Multiplier. 100

8 (d) Notes. Individual enrollment and withdrawal data will be maintained by individual researches and put to the monitoring cell every quarter. 38. MPI-41 (Percentage of protocol violations / deviations reported) (a) Numerator. Number of protocol violations or deviations reported or detected (b) Denominator. Total number of patients enrolled in studies within the specified time period (c) Multiplier. 100 (d) Notes. Protocol adherence will be monitored by PG guides. Protocol changes (if any) will be put up to Institutional Ethics Committee for approval, before implementation. 39. MPI-42 (Percentage of serious adverse events) (a) Numerator. Serious adverse events reported within 24 hrs (b) Denominator. Total number of serious adverse events occurring in research studies within the specified time period (c) Multiplier. 100 (d) Notes. Any serious adverse event during the course of a study will be reported to the Institutional Ethics committee and the NABH cell within 24 hrs of occurrence. Indicators for Procurement of medication 40. Percentage of drugs procured by local purchase (a) MPI-43 (Percentage of drugs procured by local purchase, in terms of items) (i) Numerator. number of items procured by local purchase (ii) Denominator. total number of items procured (Rate contract supply + Local purchase) (iii) Multiplier. 100 (b) MPI-44 (Percentage of drugs procured by local purchase, in terms of items) (i) Numerator. cost of items procured by local purchase (ii) Denominator. total cost of procurement through local purchase (iii) Multiplier. 100 (iv) Notes. Cost of items procured by local purchase will be calculated by the total cost of Supply orders placed + Cost o f retail purchase within the specified time period (every quarter) 41. MPI-45 (Percentage of stock outs of emergency drugs) (a) Numerator. Stock outs of emergency drugs (b) Denominator. Total number of stock-outs in the specified time period (c) Multiplier. 100 (d) Record of stock-outs of emergency drugs to be maintained at Medical stores and monitored by the Pharmaceutical & Therapeutics committee

9 42. MPI-46 (Percentage of consumables rejected before preparation of CRV (a) Numerator. Total number of items (consumables) rejected before preparation of CRV (b) Denominator. Total number of items procured during the specified time period (c) Multiplier. 100 (d) Notes. Calculations will be based on the number of items procured rather than the quantity of the individual items 43. MPI-47 (Incidence of variation from the procurement process) (a) Numerator. Number of audit objections (b) Denominator. Audit observations related to procurement of medical stores in the financial year Indicators for Reporting of activities 44. MPI-48 (Number of Births & Deaths) (a) Data required. Total number of births and deaths (b) Remarks. As reported to Registrar of Births & Deaths, Bangalore Mahanagar Palike and to Jt Director Economics & Statistics Dept, Govt of Karnataka 45. MPI-49 (Number of notifiable diseases) (a) Data required. Total number of notifiable diseases (b) Remarks. As reported to Health Officer, Bangalore Mahanagar Palike and to HQ Training Command IAF 46. MPI-50 (Submission of reports / Returns related to Bio- med waste disposal, PNDT Act & Radiation safety within the defined time frame) (a) Numerator. Returns submitted within the time frame (b) Denominator. Total number of returns required to be submitted within the defined time frame. (c) Multiplier. 100 (d) Data Source. Annual report of Bio- medical waste disposal and Status of Biomedical waste management submitted to Office of DGAFMS, Air HQ (RKP) and DPMO HQ Training Command IAF. (e) Returns. (i) USG machines registered with Appropriate authority in Aug 2007. Registrations valid till Aug 2012. Meetings of PNDT advisory committee held Quarterly at HQ Training Command IAF and minutes / reports forwarded to The Commissioner Health & Family welfare service Govt of Karnataka and the Dept of Information, Govt of Karnataka. (ii) Annual safety return sent to AERB, Anushakti Nagar, Mumbai from Depts of Nuclear Medicine and Radiotherapy

10 (iii) TLD (Thermo- luminescent dosimeter) badges sent every two months to DRL, Jodhpur for analysis 47. MPI-51 (Submission of Tax returns and deduction of taxes at the specified time frame). Not applicable as deduction of taxes done centrally at Air Force Central Accounts Office, New Delhi Indicators for Risk manage ment 48. MPI-52 (Number of variations observed in mock drills). The variations observed in mock drills will be recorded and feedback provided to all concerned to improve performance in subsequent drills. 49. MPI-53 (Incidence of falls) (a) Numerator. Total number of patient falls (b) Denominator. Total in-patient days within a specified time period (c) Multiplier. 1000 (d) Note. All patient falls will be reported to NABH cell within 24 hrs of occurrence 50. MPI-54 (Incidence of bed sores after admission) (a) Numerator. Total number of bed sores in patients occurring after admission (b) Denominator. Total in-patient days within a specified time period (c) Multiplier. 1000 (d) Note. All bed sores in admitted patients will be reported to NABH cell within 24 hrs of occurrence 51. MPI-55 (Percentage of employees provided pre-exposure prophylaxis) (a) (b) (c) (d) Numerator. Total number of employees provided Hepatitis B vaccination Denominator. Total number of employees. Multiplier. 100 Notes. Data to be obtained from SHO on a half yearly basis

Indicators for Utilization of space, manpower and equipme nt 52. MPI-56 (Bed occupancy rate) (a) Numerator. Daily average number of beds occupied (Average daily bed occupancy) (b) Denominator. Authorized hospital beds (c) Multiplier. 100 53. MPI-57 (Average length of stay) (a) (b) Numerator. Patient days in a year (Sum of daily census) Denominator. Total discharges and deaths in a year

11 54. OT utilization Rate (a) MPI-58 (OT Utilization Rate during normal working hours) (i) Numerator. Anaesthesia time (ii) Denominator. Total available time during a specified time period (iii) Note. Total available time = Total working hrs available during a specified time period x Total number of OTs available (b) MPI-59 (OT Utilization Rate after working hours). Total anaesthesia time after working hours during the specified time period. 56. MPI-60 (ICU utilization rate) (a) Numerator. In patient days in the ICU (b) Denominator. Total available in-patient days in the ICU during the specified time period. (c) Note. Total available in-patient days in ICU = Total beds in ICU X Number of days during the specified time period. 57. MPI-61 (Equipment Down-time) (a) Numerator. Total number of hours the eqpt available is not in functional condition (b) Denominator. Total number of hours within the specified time period (c) Note. Equipment down time to be monitored at wards / departments where the equipment is installed 58. MPI-62 (Nurse patient ratio) (a) (b) Numerator. Average of the in-patient days in the specified time period Denominator. Average number of nursing staff available during the specified time period (c) Note. Nurse patient ratio will be monitored in the ICU and over the whole hospital Patient satisfaction Indices 59. MPI-63 (Out patient satisfaction index) (a) (b) period (c) (d) 60. Numerator. Number of outpatients satisfied with services Denominator. Total number of outpatients sampled in the specified time Multiplier. 100 Note. Survey of outpatients satisfaction will be done using a specified format

MPI-64 (In-patient satisfaction index) (a) (b) Numerator. Number of In-patients satisfied with services Denominator. Total number of In-patients sampled in the specified time period

12 (c) (d) 61. Multiplier. 100 Note. Survey of in-patients satisfaction will be done using a specified format

MPI-65 (Waiting time for services) (a) Numerator. waiting period for services (b) Denominator. Total number of patients sampled (c) Note. Waiting period = Time of reporting to Time of consultation or start of diagnostic procedure (d) Data required. (i) Time of reporting to OPD / Department (ii) Time of consultation or time of start of diagnostic proced ure to be captured by a designated staff personnel

62.

MPI-66 (Time taken for discharge) (a) Numerator. Time taken for urgent discharge (b) Denominator. Total number of urgent discharges in the specified time period (c) Note. Time taken for urgent discharge = Time of writing urgent discharge to Time the urgent discharge is effected (d) Data required. (i) Time of writing urgent discharge to be noted by MO / Ward Master on case documents (ii) Time of effecting urgent discharge to be entered at Statistics Section

Indicators for Employee Satisfaction 63. MPI-67 (Employee satisfaction index) (a) (b) (c) (d) 64. Numerator. Number of employees satisfied with working environment Denominator. Total number of employees sampled in the specified time period Multiplier. 100 Note. Survey of employees satisfaction will be done using a specified format

MPI-68 (Employee attrition rate) (a) (b) (c) (d) Numerator. Total number of employees retired, prematurely retired, deserted every quarter Denominator. Total number of employees Multiplier. 100 Note. Data will be collected by the Adjutant

65.

MPI-69 (Employee absenteeism) (a) Numerator. Total number of employees absence days (Civil Admin) + AWOL days (Service personnel) (b) Denominator. Total number of employee days in the specified time period (c) Multiplier. 100 (d) Note. Data on civilian absentees and AWOL will be provided by O i/c Civil Admin and Adjutant respectively

13

66. MPI-70 (Percentage of employees aware of employee rights, responsibilities & welfare schemes) (a) Numerator. Number of employees aware of employee rights, responsibilities & welfare schemes (b) Denominator. Total number of employees sampled in the specified time period (c) Multiplier. 100 (d) Note. Survey will be done along with employees satisfaction survey Monitoring of adverse events & near misses 67. MPI-71 (Number of sentinel events). Total number of sentinel events in the specified time period 68. MPI-72 (Percentage of near misses analyzed). (a) (b) (c) Numerator. Total number of near miss events analyzed Denominator. Total number of near miss events reported during the specified time period Multiplier. 100

69. MPI-73 (Number of security related incidents). Total number of security related incidents (including thefts) in the specified time period 70. MPI-74 (Incidence of needle stick injuries) (a) Numerator. Total number of needle-stick injuries (b) Denominator. Total number of employees on strength during the specified time period (c) Multiplier. 100