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VISION Healing eacH WitHin His ReacH
“We at EMS Memorial Co-operative Hospital & Research Centre are committed to provide need based patient care affordable to all through continuous innovation and improvements in our system, process and delivery’’
EMS MEMORIAL CO-OPERATIVE HOSPITAL AND RESEARCH CENTRE LTD
QUALITY POLICY
“AT EMS MEMORIAL CO-OPERATIVE HOSPITAL & RESEARCH CENTRE, PERINTHALMANNA, WE ARE
COMMITTED TO PROVIDE QUALITY MEDICAL CARE TO THE SOCIETY IRRESPECTIVE OF CAST, CREED,
FINANCIAL STATUS AT AN AFFORDABLE COST AND AIM FOR CONTINUAL IMPROVEMENT PROGRAMMES “
QUALITY OBJECTIVES
Quality Objectives of EMS Memorial Co-operative Hospital & Research Centre are:
To improve patient satisfaction
To improve training facilities to the staff on regular basis.
To introduce new services with a view of providing modern health care facilities to the patients.
QUALITY INDICATORS
Sl INDICATORSAUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
1. Time for initial assessment :Indoor patients (in minutes) Target – 60 minutes
40(245/511)
40(353/523)
39(345/521)
39(316/481)
37(281/456)
40(306/455)
b. Emergency patients Target – 10 minutes 4.93 1.38 1.78 1.54 1.08 1.48
0
5
10
15
20
25
30
35
40
45
1 2 3 4 5 6
Time for initial assessment :Indoor patients Time for initial assessment :Emeergency patientsLinear (Time for initial assessment :Indoor patients)
Sl
NoINDICATORS
AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
2 Percentage of cases (IP) wherein care plan with desired outcomes is documented and counter signed by the clinician (%) Target – 100 %
96(490/511)
97(510/523)
96(501/521)
96(463/483)
95(432/456)
96(437/455)
96
97
96 96
95
96
94
94.5
95
95.5
96
96.5
97
97.5
AUG SEP OCT NOV DEC JAN
Sl
NoINDICATORS
AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
3Percentage of cases (IP) wherein screening for nutritional needs has been done (%) Target – 100 %
ICU-100 % Ward-90 %
ICU-100 % Ward-92.1
%
ICU-100 % Ward-96.7
%
ICU-100 % Ward-98.75 %
ICU-100 % Ward-98 %
ICU-100 % Ward-91.8
%
84
86
88
90
92
94
96
98
100
AUG SEP OCT NOV DEC JAN
Percentage of cases (IP) wherein screening for nutritional needs has been done (%)
Analysis Decision
screening of nutritional needs has increasing trend
Sl
NoINDICATORS
AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
4 Percentage of cases (IP) wherein the nursing care plan is documented (%) Target – 100 %97
(497/511)99
(518/523)99
(516/521)99
(476/483)98
(448/456)99
(450/455)
97
99 99 99
98
99
96
96.5
97
97.5
98
98.5
99
99.5
AUG SEP OCT NOV DEC JAN
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
5. Number of reporting errors / per 1000 investigations :
a. LabTarget
Sl No INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
5. Number of reporting errors / per 1000 investigations : b. RadiologyMRI
1.3(1/751)
2.6(2/763)
1.2(1/817)
2.6(2/762)
1.4(1/698)
1.2(1/780)
CT 1.57(1/636)0
(0/587)2.1
(1/472)1.8
(1/530)1.7
(1/559)0
(0/635
USG 0.6(1/1562)0.7
(1/1474)0.6
(1/1602)0.67
(1/1475)0
(0/1425)0.6
(1/1605)
Analysis Root cause
0
0.5
1
1.5
2
2.5
3
AUG SEP OCT NOV DEC JAN
MRI
CT
USG
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
6. Percentage of re-dos(Lab) Target Zero
0.24(333/137603)
0.28(387/136281)
0.25(340/135950)
0.18(216/123328)
0.26(318/120654)
0.26(337/128963)
0
0.05
0.1
0.15
0.2
0.25
0.3
AUG SEP OCT NOV DEC JAN
Percentage of re-dos(Lab) (%)
Analysis Root cause
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
7 Percentage of reports correlating with clinical diagnosis : Radiology
82(410/500)
91.4(457/500)
88.6(443/500)
88(441/500)
90(450/500)
92(464/500)
82
91.4
88.688
90
92
76
78
80
82
84
86
88
90
92
94
AUG SEP OCT NOV DEC JAN
Analysis Root cause
INDICATORS AUG2019
SEP
2019
OCT
2019
NOV2019
DEC2019
JAN2020
b. Lab :
1. CLINICAL PATHOLOGY(%)80.64(50/62)
78.33(47/60)
75.81(47/62)
70(42/60)
69.35(43/62)
88.71(55/62)
2. HEMATOLOGY (%)
77.41(48/62)
80(48/60)
77.42(48/62)
80(48/60)
75.81(47/62)
79.03(49/62)
3. BIOCHEMISTRY(%) 82.26(51/62)81.66(49/60)
80.65(50/62)
73.33(44/60)
72.58(45/62)
62.9(39/62)
4. SEROLOGY(%) 80.64(50/62)75
(45/60)74.19(46/62)
71.66(43/60)
71.66(40/62)
64.51(40/62)
5. MICROBIOLOGY(%) 79.03(49/62)76.66(46/60)
72.58(45/62)
76.66(46/60)
69.35(43/62)
66.13(41/62)
6. HISTOPATHOLOGY(%) 64.76(68/105)72.41(84/116)
71.68(81/113)
66.17(88/133)
73.15(109/149)
79.59(117/147)
AVERAGE(%) 76.14(316/415)76.68
(319/416)74.94
(317/423)71.82
(311/433)71.24
(327/459)74.62
(341/457)
76.14
76.68
74.94
71.82
71.24
74.62
68
69
70
71
72
73
74
75
76
77
AUG SEP OCT NOV DEC JAN
Percentage of reports correlating with clinical diagnosis : LAB
0102030405060708090
AUG SEP OCT NOV DEC JAN
Reports correlating with clinical diagnosis
Clinical Pathology
73
74
75
76
77
78
79
80
81
AUG SEP OCT NOV DEC JAN
Hematology
0
10
20
30
40
50
60
70
80
90
AUG SEP OCT NOV DEC JAN
Biochemistry
0
10
20
30
40
50
60
70
80
90
AUG SEP OCT NOV DEC JAN
Serology
55
60
65
70
75
80
AUG SEP OCT NOV DEC JAN
Microbiology
0
10
20
30
40
50
60
70
80
90
AUG SEP OCT NOV DEC JAN
Histopathology
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
8Percentage of adherence to safety precautions by employees working in diagnostics (%) Target – 100 %
77 90 85 83 70 100
77
9085 83
70
100
0
20
40
60
80
100
120
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
9 Incidence of medication errors (per 1000) : Target – Zero a. Prescription Errors
0(0/10423) NIL NIL NIL NIL NIL
b. Dispensing Errors(Wrong drug, wrong strength, wrong dose, wrong patient, wrong route administering & Monitoring errors)
0.19(2/10423) NIL
0.095(1/10436) NIL NIL
0.215(2/9290)
0
0.05
0.1
0.15
0.2
0.25
AUG SEP OCT NOV DEC JAN
Dispensing Errors Analysis Root cause
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
10Percentage of admissions with adverse drug reactionTarget – Zero
NIL NIL NIL 0.078(2/2537) NIL NIL
Analysis Root cause
Sl No INDICATORS AUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
11 Percentage of medication charts with error prone abbreviations Target – Zero NIL NIL NIL NIL NIL0
(0/717)
12 Percentage of patients receiving high risk medications developing adverse drug event (Excludes asymptomatic hypoglycemia)
Target – Zero NIL NIL NIL NIL NIL NIL
13Percentage of modification of anesthesia plan
Target – ZeroNIL NIL NIL NIL NIL NIL
14Percentage of unplanned ventilation following anesthesia
Target – ZeroNIL NIL NIL NIL NIL NIL
15Percentage of adverse anesthesia events
Target – ZeroNIL NIL NIL NIL NIL NIL
16Anesthesia related mortality rate
Target – ZeroNIL NIL NIL NIL NIL NIL
17 Percentage of unplanned return to OT (%) NIL NIL NIL NIL NIL NIL
Sl No
INDICATORS
AUG
2019
SEP
2019
OCT
2019NOV
2019
DEC
2019
JAN
2019
18 Percentage of rescheduling of surgeries (%)
0.34(2/582)
0.17(1/559)
0.74(5/674)
0.53(3/562)
1.01(6/589)
0.64(4/625)
0
0.2
0.4
0.6
0.8
1
1.2
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl No INDICATORS AUG2019
SEP
2019
OCT
2019NOV
2019
DEC
2019
JAN
2019
19Percentage of cases where the organization's procedure to prevent adverse events like wrong site, wrong patient & wrong surgery have been adhered to (%)
100(863/863)
100(909/909)
100(1028/1028)
100(864/864)
100(947/947)
100(970/970)
20 Percentage of cases who received appropriate prophylactic antibiotics with in the specified time frame (%)
100(533/533)
100(545/545)
100(623/623)
100(559/559)
100(593/593)
100(633/633)
21 Percentage of cases in which the planned surgery is changed intraoperatively (%)
0.15(1/635) NIL
0.13(1/719)
0.15(1/639)
0.14(1/712)
NIL
0.15
0
0.13
0.150.14
00
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
AUG SEP OCT NOV DEC JAN
Percentage of cases in which the planned surgery is changed intraoperatively Analysis Root cause
Sl No INDICATORS
AUG
2019
SEP
2019
OCT
2019NOV2019
DEC2019
JAN2020
22 Re exploration rate (%) NIL NIL NIL NIL NIL NIL
23 Percentage of transfusion reactions Target 1% 0(0/521)
0(0/687)
0(0/737)
0.18(1/570)
0(0/685)
0(0/699)
24 Percentage of wastage of blood and blood productsTarget – Zero
0.19(1/521)
0.29 (2/687)
0.95(7/737)
0.18(1/570)
0.44(3/685)
0.28(2/699)
0.19
0.29
0.95
0.18
0.44
0.28
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
AUG SEP OCT NOV DEC JAN
Percentage of wastage of blood and blood products
Analysis Root cause
25 Percentage of blood component usage (%)
Packed cell 70.82(369/521)
55.7(383/687)
56(413/737)
72.1(411/570)
61.6(422/68
5)
55.22(386/69
9)
Whole blood NIL NIL 0.14(1/737)0.18
(1/570)0.73
(5/685)0.29
(2/699)
Plasma 20.72(108/521)
40.69(212/687)
31.4(232/737)
22.45(128/570)
29.19(200/68
5)
29.18(204/69
9)
Platelet 8.4(44/521)
12.5(86/687)
12.2(90/737)
6.49(37/570)
8.9(61/685)
15.3(107/69
9)
Cryoprecipitate NIL NIL NIL NIL NIL NIL
26Turn around time for issue of blood and blood components (Emergency) Target 30 minutes
30 30 30 30 30 30
Sl INDICATORSAUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
27 Catheter Associated Urinary Tract Infection rate/10002
(2/959)2.6
(2/746)0
(0/863)4.3
(4/923)1.2
(1/772)1.24
(1/805)
2
2.6
0
4.3
1.2 1.24
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORSAUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
28 Ventilator Associated Event rate /1000 0(0/133)0
(0/138)0
(0/151)5.9
(1/167)0
(0/116)0
(0/187)
29 Blood Stream Infection rate /1000 0(0/166)0
(0/152)7.2
(1/138)7.9
(1/126)0
(0/86)6.3
(1/157)
0 0
7.2
7.9
0
6.3
0
1
2
3
4
5
6
7
8
9
AUG SEP OCT NOV DEC JAN
Blood Stream Infection rate /1000
Analysis Root cause
Sl INDICATORSAUG
2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2020
30 Surgical Site Infection (%) 0.11(1/863)0
(0/909)0.79
(8/1009)0.1
(1/850)0.21
(2/933)0.4
(4/970)
0.11
0
0.79
0.1
0.21
0.4
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2019
31 a. Mortality rate (%) 3.6(92/2558)3.18
(83/2610)2.54
(66/2595)2.92
(72/2465)2.92
(67/2294)3.6
(81/2250)
b. Proportional Maternal Mortality rate (%) 0(0/92)0
(0/83)0
(0/66)0
(0/72)0
(0/83)0
(0/82)
c. Proportional infant mortality rate (%) 3.26(3/92)3.61(3/83)
9.09(6/66)
1.39(1/72)
4.48(3/67)
2.47(2/81)
3.6
3.18
2.54
2.92 2.92
3.6
0
0.5
1
1.5
2
2.5
3
3.5
4
AUG SEP OCT NOV DEC JAN
Mortality rate
3.263.61
9.09
1.39
4.48
2.47
0
1
2
3
4
5
6
7
8
9
10
AUG SEP OCT NOV DEC JAN
Proportional infant mortality rate
Sl INDICATORS AUG2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2019
32 Return to ICU within 48 hours (%) 0.81(11/1348)0.6
(9/1426)0.6
(9/1397)0.86
(11/1275)0.4
(6/1344)0.52
(7/1354)
0.81
0.6 0.6
0.86
0.4
0.52
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2019
33 Return to emergency department within 72 hours with similar presenting complaints (%)0.11
(2/1753)0.4
(7/1720)0.37
(6/1611)0.59
(9/1541)0.48
(8/1660)0.46
(7/1526)
0.11
0.40.37
0.59
0.48 0.46
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2019
34 Re-intubation rate (%) 1.7(1/56)0
(0/56)1.4
(1/69)1.69(1/59)
0(0/53)
0(0/49)
1.7
0
1.4
1.69
0 00
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1.8
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP
2019
OCT
2019
NOV
2019
DEC
2019
JAN
2019
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 reported to the ethics committee with in the defined time frame (Recommended every three months) (%)
- - - - - -
Sl INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
39
Percentage of drugs and consumables procured by local purchase: (%) a. Drugs
0(0/4465)
0(0/4465)
0(0/4465)
0(0/4465)
0(0/4465)
0(0/4465)
b .Consumables 0.31(5/1605)0.37
(6/1605)0.31
(5/1605)0.37
(6/1605)0.31
(5/1605)0.31
(5/1605)
0.31
0.37
0.31
0.37
0.31 0.31
0.28
0.29
0.3
0.31
0.32
0.33
0.34
0.35
0.36
0.37
0.38
AUG SEP OCT NOV DEC JAN
Consumables
Analysis Root cause
Sl INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
40
Percentage of stock out including emergency medicine : (%) a. Drugs
0.09(4/4465)
0.11(5/4465)
0.11(5/4465)
0.11(5/4465)
0.13(6/4465)
0.07(3/4465)
b .Consumables 0(0/1605)0
(0/1605)0
(0/1605)0
(0/1605)0
(0/1605)0
(0/1605)
0.09
0.11 0.11 0.11
0.13
0.07
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
AUG SEP OCT NOV DEC JAN
Drugs
Analysis Root cause
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
41 Percentage of drugs & consumables rejection before preparation of Goods (%) Receipts Note :
a. Drugs
0.016(2/12474)
0.022(3/13347)
0.025(4/15651)
0.015(2/13131)
0.022(3/13509)
0.021(3/14094)
b .Consumables 0.089(2/2247)0.01
(2/2002)0.12
(3/2492)0.15
(3/1960)0.08
(2/2625)0.08
(2/2345)
0.0160.022 0.025
0.0150.022 0.021
0.089
0.01
0.12
0.15
0.08 0.08
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
0.16
1 2 3 4 5 6
Drugs Consumables Linear (Drugs ) Linear (Consumables )
Analysis Root cause
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
42 Percentage of variations from the procurement process (%)
a. Drugs
0(0/12474)
0(0/13347)
0(0/15651)
0(0/13131)
0(0/13509)
0(0/14094)
b .Consumables 0(0/2247)0
(0/2002)0
(0/2492)0
(0/1960)0
(0/2625)0
(0/2345)
43 Number of variations observed in mock drills (Recommended yearly twice) Target –zero variation
code- Grey-20%
code orange-10%
code Red-10%code orange-Nil
Code Grey-10%code Orange-20%
Code Red-NilCode Red-Nil
Code Blak-5%Code Amber-10%
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
44 Incidence of falls 0.09(1/10423)0
(0/10494)0
(0/10436)0.01
(1/9468)0
(0/8815)0.012
(1/9290)
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
45 Incidence of bed sores after admission(Rate)0.09
(1/10423)0
(0/10494)0
(0/10436)0.11
(1/9468)0.11
(1/8815)0.12
(1/9290)
0.09
0 0
0.11 0.11
0.12
0
0.02
0.04
0.06
0.08
0.1
0.12
0.14
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
46 Percentage of employees provided pre-exposure prophylaxis (%) 100 100 100 100 100 100
47 a. Bed occupancy rate (%) 72(10423/11415)
75.22(10494/13950)
72.39(10436/14415)
67.87(9468/13950)
61.15(8815/14415)
64.45(9290/14415)
7275.22
72.3967.87
61.1564.45
0
10
20
30
40
50
60
70
80
AUG SEP OCT NOV DEC JAN
Bed occupancy rate
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
47 b. Average length of stay (Days) 4(10423/2602)
4.02(104942610)
4.03(10436/2595)
3.84(9468/2465)
3.84(8815/2294)
4.13(9290/2250)
4 4.02 4.033.84 3.84
4.13
2
3
4
5
AUG SEP OCT NOV DEC JAN
Average length of stay (Days)
Sl No INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
48 OT utilization rate (%) Target 80%
73.56(588.5/8)
78.31(626.5/8)
82.23(658/8)
70.06(560.4/8)
74.25(594/8)
77.66(621.33/
8)
73.56
78.31
82.23
70.06
74.25
77.66
65
70
75
80
85
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl No
INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
b. ICU bed utilization rate(%) 93.9(1126.8/12)
98.9(1187.46/12)
94.29(1131.48/1
2)
88.82(1065.84/1
2)
78.12(937.29/
12)
79.4(952.8/
12)
Analysis Root cause
93.998.9
94.2988.82
78.12 79.4
0
10
20
30
40
50
60
70
80
90
100
AUG SEP OCT NOV DEC JAN
breakdown of ICU utilization
Sl No
INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
1. MICU 116.94% 120.83% 106.45% 109.16% 95.96% 108.06%
2. NSICU 91.12% 88.61% 76.95% 77.77% 65.86% 85.49%3. SICU 159.97% 167.38% 179.49% 174.76% 170.96% 140.78
%4. CTICU 52.68% 48.33% 60.75% 48.33% 54.8% 36.55%
5. NMICU 85.48% 96.66% 76.95% 79.28% 65.05% 86.55%6. CCU-I 139.9% 119.3% 139.9% 122.08% 126.2% 135.8%7. CCU-II 139.5% 130.3% 120.96% 124.16% 115.3% 118.58%
8. Nephro ICU 87.74% 89.33% 72.25% 73.33% 58.7% 78.06%
9. EDICU 22.58% 92.69% 10.7% 9.7% - 0.4%
10. PICU 103.76% 126.66% 129.56% 98.3% 48.9% 48.9%
11.NNICU I 86.2% 69.5% 93.9% 86.6% 90.7% 66.1%
12.NNICU II 40.96% 37.87% 51.6% 62.42% 44.86% 47.8%
Sl No
INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2019
C . ICU equipment utilization rate(%) 39.67(476.06/12)
46.67(560.11/12)
43.6(523.6/12)
40.13(481.6/12)
34.15(444/13)
36.13(469.76/13)
39.67
46.67
43.6
40.13
34.1536.13
0
5
10
15
20
25
30
35
40
45
50
AUG SEP OCT NOV DEC JAN
Sl No INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2019
1. Ventilator 14.1% 15.45% 11.72% 12.92% 10.02% 10.72%2. Monitor 88.46% 91.23% 49.7% 80.04% 69.86% 74.1%3. Syringe pump 40.8% 38.49% 45.6% 42.64% 34.5% 38.3%
4. Infusion pump 19.6% 29.75% 24.7% 24.21% 31.4% 32.1%
5. Bi PAP 12.8% 18.2% 15.7% 13.8% 12.1% 14.2%
6. C PAP 4.3% 7.76% 20.38% 9.98% 3.2% 7.5%
7. High flow 8.5% 4.43% 19.4% 25.3% 26.83% 21.4%
8. TPI 19.3% 27% 9.8% 16.66% 3.22% 9.6%
9. ABG (nos) 750 590 599 378 550 456
Sl No INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2019
49 Critical equipment down time (Hours)
387 Hr
55 Min
99 Hr
5 min
675 Hr
55 Min
111 Hr
35 Min
68 Hr
40 Min
146 Hr
45 Min
0
100
200
300
400
500
600
700
800
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
50
a. Nurse –patient ratio for ICU Day-1:2Night-1:2Day-1:2Night-1:2
Day-1:2Night-1:2
Day-1:2Night-1:3
Day-1:2Night-1:3
Day-1:2Night-1:3
b. Nurse –patient ratio for wards Target 1 : 6
Day-1:6Night-1:7
Day-1:5Night-1:6
Day-1:6Night-1:6
Day-1:9Night-1:11
Day-1:8Night-1:10
Day-1:7Night-1:11
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
51 Out patient satisfaction index Target 100%
97.88(3152/3220)
99.7(3008/3016)
96.6(3159/3270)
99.8(3353/3360)
99.6(3685/3700)
99.2(3224/3250)
52 Inpatient satisfaction index Target 100%
68.7(2550/3712)
67.3(2553/3792)
68.5(2568/3750)
68.14(1908/2800)
70.12(1424/2016)
72.66(1767/2432)
97.88 99.7 96.699.8 99.6 99.2
68.7 67.3 68.5 68.14 70.1272.66
0
20
40
60
80
100
120
AUG SEP OCT NOV DEC JAN
Out patient satisfaction index Inpatient satisfaction index
Sl INDICATORS Target AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
53
a)Waiting time for services at diagnostics for OP cases (in minutes)
MRI60 Minutes
CT20 Minutes
USG45 minutes
X-ray20 minutes
41.4
20.2
45.1
20.3
50.1
20
45
20.2
48
20.3
45.2
20
50.25
20.1
42
20.4
49
20.6
40
20
51.5
20
40
20.1
0
10
20
30
40
50
60
AUG SEP OCT NOV DEC JAN
MRI CT USG X-ray
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
b)Waiting time for out patient consultation (minutes) Target 60 ‘
99 98 102 93 85 98
9998
102
93
85
98
75
80
85
90
95
100
105
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS
AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
54 Time taken for discharge (minutes) Target 180 ‘ 223 220 218 214 209 207
195
200
205
210
215
220
225
AUG SEP OCT NOV DEC JAN
Analysis Root cause
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
55 Employee satisfaction index (Once in six months) Target 100 %76 76 76 76 76 76
56 Employee attrition Rate (%) 1.3 1.05 1.05 1.09 0.5 1.2
57 Employee Absentism rate (%) Target Zero 0 0 0 0 0 0
58Percentage of employees who are aware of employee rights responsibilities and welfare schemes (Once in six months) Target 100 %
95 95 95 95 95 95
59 Number of sentinel events reported collected and analyzed with in the defined time frame NIL NIL NIL NIL 1 NIL
60 Percentage of near misses 1(1/14) NIL NIL NIL 1 1
Sl INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
61Incidence of blood body fluid exposure
OP 0(0/29526)0
(0/29218)0
(0/31947)0
(0/27817)0
(0/26486)0
(0/29480)
IP0.09
(1/10423)0
(1/10494)0
(1/10436)0
(0/9468)0
(0/8815)0
(0/8992)
62
Incidence of needle stick injuries (in 1000)
OP 0(0/29526)0
(0/29218)0
(0/31947)0
(0/27817)0
(0/26486)0
(0/29480)
IP 0.19(2/10423)0
(2/10494)0.9
(1/10436)0.1
(1/9468)0.1
(1/8815)0
(0/8992)
63 Percentage of medical records not having discharge summary Target 0 NIL NIL NIL NIL NIL NIL
64 Percentage of medical records not having codification as per ICDTarget0 NIL NIL NIL NIL NIL NIL
65 Percentage of medical records having incomplete / improper consent(%)0.47
(12/2602)0.54
(14/2610)0.23
(6/2596)0.21
(4/1891)0.24
(6/2523)0.27
(7/2617)
67 Percentage of missing records (IP) NIL NIL NIL NIL NIL NIL
Sl No INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
68 Appropriate handovers during shift change (%) 92 93 95 96 95 96
69 Incidence of patient identification errors (%)0.62
(2/320)0
(0/320)0.31
(1/320)0
(0/320)0
(0/320)0
(0/320)
Sl No INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
70 Compliance to hand hygiene practice (%) 82(184/224)86
(193/224)87.5
(196/224)88
(313/352)89
(316/352)90
(317/352)
a Compliance to hand hygiene practiceDoctors(%)71.4
(40/56)78
(44/56)82.1
(46/56)87
(77/88)93
(82/88)89
(79/88)
b Compliance to hand hygiene practice Nurses(%)87.5
(98/112)89
(100/112)89
(100/112)89
(11/112)89
(11/112)94
(166/176)
c Compliance to hand hygiene practice Others(%)82
(44/56)87
(49/56)91.151/56
88(78/88)
86(76/88)
85(75/88)
78
80
82
84
86
88
90
92
AUG SEP OCT NOV DEC JAN
Compliance to hand hygiene practice
0102030405060708090100
AUG SEP OCT NOV DEC JAN
hand hygiene practice breakdown Doctors, Nurses & Others
Doctors Nurses Others
Sl No INDICATORS AUG2019
SEP2019
OCT2019
NOV2019
DEC2019
JAN2020
71 Compliance rate to medication prescription in capitals (%)99.1
(332/335)99.07
(322/325)99.37
(320/322)99.35
(310/312)99.35
(308/310)99.6
(285/286)
99.199.07
99.3799.35 99.35
99.6
98.8
98.9
99
99.1
99.2
99.3
99.4
99.5
99.6
99.7
AUG SEP OCT NOV DEC JAN
DEPARTMENT WISE QUALITY INDICATORS NOEMBER 2019 TO JANUARY 2020
• AAC• COP• MOM• PRE• HIC• FMS• HRM• IMS
END
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