Professional Documents
Culture Documents
Std.
Indicators
Type
Definition/Interpretation
Source
Initiation/
generation of
data
Formula
Sample size
Remarks
Process
Process
Wheel in register
time will be put in
(Bed no. time )
MR by Either Ward
& initial
QA Coordinator
nurse or attending
assessment
doctor
form (start
time )
CQI 3a
CQI 3a
Percentage of
cases (in-patients)
wherein care plan
with desired
Process
outcomes is
documented and
counter-signed by
the clinician
Percentage of
cases (in-patients)
wherein screening
Process
for Nutritional
needs has been
done
Percentage of
cases (in-patients)
wherein the
Process
Nursing care plan
is documented
Medical
record
Record
sheet/ form
Patient Assessment
CQI 3a
Resp./
monitered
by
Plan of care to be
written by doctor
within a definite
time frame
To be documented
by the ward nurse
in MR.
Care Plan
QA Coordinator sheet/In-patietn
case sheet
Nutritional
assessment
QA Coordinator form in Inpatient case
sheet
Nursing
administrator
Nursing
assessment
sheet
CQI 3b
Number of
reporting
errors/1000
investigations
Process
It should be
Lab/Radio reported by the
logy
Lab technician to
records
the HOD
Lab/Radiology.
Log book/
HOD Register/
Laboratory/Rad
Incident Report
iology
form
not applicable
Percentage of Redo's
Pathologist and
Percentage of
Co-relation means that the test
Lab/Radio radiologist will
reports co-relating
results should match either the
logy
decide whether
Outcome
with clinical
diagnosis or differential diagnosis
records
reports are
diagnosis
written in the requisition form.
corelating
Process
Percentage of
adherence to
No. of Employees adhering to
safety precautions
Structure safety precautions e.g. PPE, Lead
by employees
aprons , TLD Badges, Gloves etc.
working in
diagnostics
Observati
on report
10
11
HOD Lab/Radiology
HOD Lab/Radiology
Log book/
Register/
Incident Report
form
Investigation
Slip
QI Register
not applicable
Medication Management
Percentage of
medication errors
MANDATORY
INDICATOR 1
QA Co
ordinator,
Nursing
superintendent
&
pharmacologist
or physician
Log book/
Register/
Incident Report
form
Percentage of
admissions with
adverse drug
reaction(s)
QA Coordinator &
Nursing
administrator
Incident
Report/ADR form
Percentage of
medication charts
with error prone
abbreviations
Process
QA Coordinator &
Nursing
administrator
Medical records
NA
12
Percentage of
patients receiving
high risk
Process
medications
developing adverse
drug event
QA Co
ordinator &
nursing
administrator
Medical records
Not applicable
Anaesthesia
Process
Medical
records
HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator
Not applicable
Process
HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator
not applicable
HOD
anesthesia, OT
In-charge & QA
coordinator
Log book/
Register/
Incident Report
form
Not applicable
HOD
anesthesia, OT
Medical records
In-charge & QA
coordinator
Not applicable
Self Explanatory
13 CQI 3d
Percentage of
modification of
anaesthesia plan
14
Percentage of
unplanned
ventilation
following
anaesthesia
15
16
Anaesthesia
related mortality
rate
Medical
records
Surgical Services
Medical
records
(OT)
OT In-charge
Log book/
Register/
Incident Report
form
No. of unplanned
returns to OT
----------------------------------------X100
No. of patients operated
Not applicable
In-Charge OT
Log book/Daily
OT Report
Not applicable
OT
records
OT In-charge
Log book/
Register/
Incident Report
form
Percentage of
It is equally important that the
cases who received
antibiotic should have been given
appropriate
not more than two hours prior to Medical
prophylactic
Outcome
the incision. This indicator could
Records
antibiotics within
be captured in a register/system
the specified time
before the patient enters the OT.
frame
17 CQI 3e
Percentage of
unplanned return
to OT
18
Percentage of rescheduling of
surgeries
19
Percentage of
cases where the
organisation's
procedure to
prevent adverse
Outcome
events like wrong
site, wrong patient
and wrong surgery
have been adhered
to
20
Outcome
Process
Medical records
Not applicable
Not applicable
21 CQI 3f
Percentage of
transfusion
reactions
MANDATORY
INDICATOR 2
22
Percentage of
wastage of blood
Process
and blood products
23
Percentage of
blood component
usage
Process
Blood
Bank
records
24
Turnaround time
for issue of blood
and blood
components
Process
Blood
Bank
records
Blood
Bank
records
ward sister,ward
in-charge / doctor
can report to blood
bank and will
document it in MR.
In charge
blood bank
will maintain
the record of
reactions
Blood bank
tecnician will
report to the
Incharge blood
bank
In-Charge
Blood Bank will Log Book blood
maintain the
bank
record.
Blood bank
tecnician will
report to the
Incharge blood
bank
blood bank
technician will put
down time of
requisistion & issue
and will document
it.
Trasnfusion
reaction form
In-Charge
Blood Bank
In-Charge
Blood Bank
Not applicable
not applicable
not applicable
NA
Not applicable
Not applicable
Not applicable
not applicable
not applicable
Infection Control
25 CQI 3g
Urinary tract
infection rate (UTI/
As per Latest CDC/ NHSN
SUTI)
Outcome
Definition.
MANDATORY
INDICATOR 3
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
Culture report
26
Ventilator
associated
pneumonia rate
(VAP)
MANDATORY
INDICATOR 4
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
Culture report
27
Central line
associated
Bloodstream
infection
rate(CLABSI)
MANDATORY
INDICATOR 5
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
28
Surgical site
infection rate (SSI)
As per Latest CDC/ NHSN
Outcome
MANDATORY
Definition.
INDICATOR 6
Medical
records
Reporting will be
done by treating
doctor/Surgeon.
Order for culture
report.
Microbiologist
& ICN
Outcome
Outcome
Culture report
Culture report
29 CQI 3h
Mortality rate
30
Percentage of
return to ICU
within 48 hours
Medical
Hospital admission
records
discharge register
Technician
Outcome
HMIS
Outcome
ICU Incharge
Medical records
No. of deaths
-------------------------------------------X100
Total no. of discharges
and deaths
Not applicable
Medical records
Not applicable
31
32
Rate of return to
the emergency
department within
72 hours with
similar presenting
complaints
Re-intubation rate
Emergen
cy Patient
Record
Register
Outcome
Process
nursing in-charge
will report to EMO
and put down in
MR.
ward incharge
ER Incharge
Medical records
Not applicable
NA
Clinical Research
33 CQI 3i
Percentage of
research activities
CAPTURED ON A QUARTERLY
Outcome
approved by ethics
BASIS
committee
Clinical
Research MOM of ethics
Departme committee
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
not applicable
34
Percentage of
patients
withdrawing from
the study
Clinical
Research MOM of ethics
Departme committee
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
not applicable
not applicable
not applicable
not applicable
not applicable
Outcome
CAPTURED ON A QUARTERLY
BASIS
35
Percentage of
protocol
violations/deviatio
ns reported
CAPTURED ON A QUARTERLY
BASIS
Clinical
Research Clinical Research
Departme Coordinator
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
36
Percentage of
serious adverse
events (which have
occurred in the
CAPTURED ON A QUARTERLY
organisation)
Outcome
BASIS
reported to the
Ethics committee
within the defined
time frame
Clinical
Research Clinical Research
Departme Coordinator
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
Outcome
10
37 CQI 4a
Percentage of
drugs &
consumables
procured by local
purchase
38
Percentage of
stock outs
including
emergency drugs
Process
Local Purchase
register
Process
Stockout
Register
Pharmacy
Incharge
Incharge Pharmacy
records
Pharmacy
39
Percentage of
drugs &
consumables
Process
rejected before
preparation of
goods receipt note
40
Percentage of
variations from the
Process
procurement
process
In-chrage stores
In-chrage
stores
Purchase
Store Incharge
records
11
not applicable
Risk Management
Mock drill is a simulation exercise
of preparedness for any type of
event. It could be event or
Mock drill
disaster. This is basically a dry run
QA Coordinator
records
or preparedness drill. For
example, fire mock drill, disaster
drill, Code Blue Drill.
Number of
variations
observed in mock
drills
Process
42
Incidence of falls
MANDATORY
INDICATOR 7
43
Incidence of bed
sores after
admission
MANDATORY
INDICATOR 8
44
Percentage of
employees
provided preexposure
prophylaxis
41 CQI 4b
12
Accreditation
Coordinator
Nursing
administrator
Nursing
administrator
Mock drill
records
not applicable
not applicable
not applicable
No. of employees who were provided preexposure prophylaxis /no. of employees posted
in high risk areas like lab ,dialysis, ICUs, Blood
Bank etc
not applicable
No. of Falls
Incidence Report -------------------------------------------X100
Total no. of discharges
and deaths
Incident Report
Office
Personnel
superintendent records
CQI 4c
45
GRN
ward incharge
QA Coordinator &
MRD
technician
admissiondischarge
register
45
Average length of
stay MANDATORY
INDICATOR 9
46
OT utilization rate
HIS
47
Critical equipment
down time
48
Process
ward incharge
QA Coordinator &
MRD
technician
OT register
ICU in-charge
QA Coordinator &
MRD
technician
HIS/Midnight
census register
ward incharge
chief
paharmacist
Matron
13
49 CQI 4d
admissiondischarge
register
OT incharge/ OT
matron
Complain concerned
t log
department
Records
QA Coordinator &
MRD
technician
Complaint log
Hospital Census
not applicable
not applicable
NA
not applicable
not applicable
Patient Satisfaction
Out patient
satisfaction index
Survey
Hospital manager
Accreditaion
coordinator
Score Achieved
OPD pt
-----------------------------------------satisfaction form
X100
Maximum possible score
50
In patient
satisfaction index
Outcome
Process
Survey
Hospital manager
Hospital manager
Accreditaion
coordinator
Score Achieved
-------------------------------------------IPD pt
satisfaction form X100
Maximum possible score
Accreditaion
coordinator
Registration
time &
Consulting time
(shall be noted
by the
consultant )
not applicable
NA
Accreditaion
coordinator
Registration
time & Sample
collection
time(shall be
noted by the
technician )
not applicable
Accreditaion
coordinator
Discharge note
& time on
discharge slip or
register
not applicable
51
52
Process
Records
Hospital manager
ward incharge
14
Employee Satisfaction
Hospital manager
Score Achieved
-------------------------------------------Employee
satisfaction form X100
Maximum possible score
Hospital manager
Accreditaion
coordinator
HR records
not applicable
HR records
not applicable
53 CQI 4e
54
Employee attrition
rate
Outcome
55
Employee
absenteeism rate
56
Percentage of
Employee awareness is the state
employees who are
or condition of being aware;
aware of employee
having knowledge; consciousness
rights,
Outcome
Survey
about employee rights,
responsibilities
responsibilities and welfare
and welfare
schemes.
schemes.
Records
Hospital manager
15
57 CQI 4f
58
Accreditaion
coordinator
Employee
Satisfaction index
Accreditaion
coordinator
Accreditaion
coordinator
Personnel
interview
records
A relatively infrequent,
unexpected incident, related to
system or process deficiencies,
Data
which leads to death or major and
enduring loss of function for a
recipient of healthcare services
ward incharge
Accreditaion
coordinator
Log book/
Register/
Incident Report
form
Percentage of near
Process
misses
concerned
department
Accreditaion
coordinator
Log book/
Register/
Incident Report
form
not applicable
not applicable
59
60
Incidence of blood
body fluid
exposures
Process
ward incharge
ward incharge
Accreditaion
coordinator
Matron
16
61 CQI 4g
62
Log book/
Register/
Incident Report
form
Needle stick
injury form/
Incident Report
form
not applicable
not applicable
not applicable
Medical Records
Percentage of
medical records
Process
not having
discharge summary
Percentage of
medical records
not having
codification as per
International
Classification of
Diseases (ICD)
Process
Medical
record
MRD Technician
MRD Technician
Hospital
manager
Hospital
manager
63
Percentage of
medical records
having incomplete
and/or improper
consent
Process
64
Percentage of
missing records
Note
MRD Technician
Hospital
manager
MRD Technician
Hospital
manager
Log book/
Register/
Incident Report
form
Unless specified all indicators shall be captured on a monthly basis and the numerator and denominator shall be of that month.
not applicable
not applicable