List of Key performance Indicator as per 5th edition NABH Standards

  

 

LIST OF MANDATORY QUALITY INDICATOR AS PER 5th Edition NABH STANDARDS
1	PSQ3a	QI/01	Initial assessment in wards	Numerator	sum of time taken for the assessment	Minutes	Minutes	Monthly
				Denominator	total number of patients in indoor
	PSQ3a		initial assessment in emergency	Numerator	sum of time taken for the assessment
				Denominator	total number patients in Emergency
2	PSQ3a	QI/02	Reporting error in diagnostic	Numerator	number of reporting error	*1000	/1000 tests	Monthly
				Denominator	number of tests performed
3	PSQ3a	QI/03	Adherence of safety precaution	Numerator	Number of employees adhering to safety precautions	*100	Percentage	Monthly
				Denominator	number of employees Audited
4	PSQ3a	QI/04	Medication error rate	Numerator	Total numbers of medication error	*1000	Percentage	Monthly
				Denominator	Total numbers of opportunities of medication error
	PSQ3a	QI/04	Prescription error	Numerator	Total numbers of prescription error	*1000	*1000	Monthly
				Denominator	number of patient days
	PSQ3a	QI/04	Dispensing error	Numerator	Total numbers of medication Dispensing  error	*1000	*1000	Monthly
				Denominator	number of patient days
5	PSQ3a	QI/05	Medication chart with error prone abbreviation	Numerator	Number of medication charts with Error prone Abbreviation	*100	Percentage	Monthly
				Denominator	number of medication charts reviewed
6	PSQ3a	QI/06	Adverse drug reaction	Numerator	Number of patient developing Adverse drug reactions	*100	Percentage	Monthly
				Denominator	Number of in patients
7	PSQ3a	QI/07	Unplanned return to OT	Numerator	Number of unplanned return to OT	*100	Percentage	Monthly
				Denominator	number of patients who underwent surgeries in the OT
8	PSQ3a	QI/08	Percentage of Surgeries where the organization procedure to prevent adverse events like wrong site, wrong patient and wrong surgeries have been adhere to	Numerator	Number of surgeries where the procedure was followed	*100	Percentage	Monthly
				Denominator	Number of surgeries performed
9	PSQ3a	QI/09	Percentage of Transfusion reactions	Numerator	Number of transfusion reaction	*100	Percentage	Monthly
				Denominator	No. of unit transfused
10	PSQ3a	QI/10	Mortality rate	Numerator	Actual death in ICU	*100	Percentage	Monthly
				Denominator	Predicted death in ICU
11	PSQ3a	QI/11	Return to Emergency within 72 hrs	Numerator	Number of return to Emergency within 72 hrs with similar presenting complaints	*100	Percentage	Monthly
				Denominator	number of patient who have come to emergency
12	PSQ3a	QI/12	Pressure ulcer (Bed sore)	Numerator	Number of patient who develops new/ worsening pressure ulcer	*1000	*1000	Monthly
				Denominator	total number of patient days
13	PSQ3b	QI/13	Catheter associated urinary tract infection rate	Numerator	Number of Urinary catheter associated UTI in month	*1000	/1000 catheter days	Monthly
				Denominator	Number of urinary catheter days in that months
14	PSQ3b	QI/14	VAP	Numerator	number of ventilator associated pneumonias in a months	*1000	/1000 Ventilator days	Monthly
				Denominator	Number of ventilator days in that month
15	PSQ3b	QI/15	CLABSI	Numerator	Number of Centre line associated blood stream infection in a month	*1000	/1000 central line days	Monthly
				Denominator	Number of Centre line days in that months
16	PSQ3b	QI/16	SSI	Numerator	Number of Surgical site infection in given a month	*100	/100 surgical procedures	Monthly
				Denominator	Number of surgeries performed in that months
17	PSQ3b	QI/17	Hand Hygiene	Numerator	Total No. of Hand Hygiene missed	*100	Percentage	Monthly
				Denominator	Total no. Hand Hygiene opportunities
18	PSQ3b	QI/18	Percentage of case who receive appropriate  prophylactic antibiotics within specified	Numerator	Number of Patients who did received appropriate prophylactic antibiotics	*100	Percentage	Monthly
				Denominator	Number of patients who underwent surgeries in the OT
19	PSQ3c	QI/19	Percentage of rescheduling of surgeries	Numerator	Number of cases rescheduled	*100	Percentage	Monthly
				Denominator	Number of surgeries performed
20	PSQ3c	QI/20	TAT for issue of Blood and blood component	Numerator	Sum of time taken		Minutes	Monthly
				Denominator	total number of blood and blood component cross-matched/reserved
21	PSQ3c	QI/21	Nurse patient ratio for ICUs and wards	Numerator	Number of nursing staff	Ratio	Ratio	Monthly
				Denominator	Number of occupied beds
22	PSQ3c	QI/22	Waiting time for OPD consultation	Numerator	Sum (Patient -In time for consultation/ Procedure - patient reporting time in OPD / diagnostic)		Minutes	Monthly
				Denominator	Total number of out patients
23	PSQ4c	QI/23	Waiting time for Diagnostics	Numerator	Sum total patient reporting time in diagnostic		Minutes	Monthly
				Denominator	Total number of patients reported in Diagnostics
24	PSQ4c	QI/24	Time taken for Discharge	Numerator	Sum of time taken for discharge		Minutes	Monthly
				Denominator	Number of patient discharged
25	PSQ4c	QI/25	MR having improper consent form	Numerator	Number of Medical records having Incomplete and or improper consent	*100	Percentage	Monthly
				Denominator	No. of discharges and death
26	PSQ4c	QI/26	stock out rate of emergency medication	Numerator	Number of stock outs of emergency drugs	*100	Percentage	Monthly
				Denominator	Number of drugs listed in hospital formulary
27	PSQ4d	QI/27	variations observed in a mock drill	Numerator	Total number of variations observed in a mock drill		Number	Monthly
				Denominator
28	PSQ4d	QI/28	Patient Fall rate (Fall /1000 patient days	Numerator	Number of patient falls	*1000	/1000 Patient days	Monthly
				Denominator	total number of patient days
29	PSQ4d	QI/29	Near Miss	Numerator	Number of near misses reported	*100	Percentage	Monthly
				Denominator	number of incident reports
30	PSQ3d	QI/30	incidence of Needle stick injuries	Numerator	Number of panetral exposures	*1000	/1000 Patient days	Monthly
				Denominator	Number of In patients days
31	PSQ3d	QI/31	Hand over done appropriately	Numerator	Total No. of handover done appropriately	*100	Percentage	Monthly
				Denominator	Total No. of hand over opportunity
32	PSQ3d	QI/32	Compliance rate to medication Prescription in Capital letter	Numerator	Total no. of prescription in capital letters	*100	Percentage	Monthly
				Denominator	Total No. of Prescription

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