S.N.

Indicator Formula Remark

Average time taken for initial Sum of time taken for initial The time taken can be
assessment of patients assessment of all admitted taken from time when
admitted in IPD patients in a period / total patient was registered
number of patients for admission till the
admitted in that period time at which initial
assessment was
completed and
documented

Percentage of IPD patients (Number of patients for Timeframe for initial

for whom the initial whom the initial assessment of patient
assessment was completed assessment was getting admitted must
within defined timeframe completed within a defined be defined by the
time frame / total number hospital
of patients admitted) x 100

Average time taken for initial Sum of time taken for initial The time taken can be
assessment of patients assessment of all patients taken from time at
coming to emergency who accessed emergency which patient arrived
services in a period / total at emergency
number of patients who department till the
accessed emergency time at which initial
services in that period assessment was
completed and
documented.

Percentage of emergency (Number of patients in Timeframe for initial

patients for whom the initial emergency for whom the assessment of
assessment was completed initial assessment was emergency patients
within defined timeframe completed within a defined must be defined by
time frame / total number the hospital
of patients admitted) x 100

Percentage of in-patients (Number of case records in This can be further

wherein the plan of care with which plan of care with broken down into
desired outcomes is desired outcomes is subcomponents such
documented and documented and as case records with
countersigned by the countersigned by the documented plan of
clinicians clinicians / Total number of care, documented
case records checked) x desired outcomes and
100 countersigned

Percentage of in-patients (Number of admitted Nutritional

wherein screening for patients who has been screening format can
nutritional needs has been screened for nutritional be used and is
done requirements / Total required for all
number of patients admitted patients
admitted) x 100

Reporting error rates (per (Number of lab reports in The error rates can be
1000) in laboratory which errors detected / separately calculated
Number of lab reports for each unit of
checked) x 1000 laboratory
 Percentage of re-dos in (Number of lab tests which Only those repeat test
laboratory has to be repeated in a shall be considered in
period/ Total lab tests calculation, where the
conducted in that period) x reason of repeating is
100 related to errors,
mistake or quality
issues

Percentage of lab reports co- (Number of lab reports in While higher

relating with clinical which the diagnosis correlation shall be
diagnosis matches with the clinical expected, it may not
diagnosis of the doctor / necessarily be 100%
Total lab tests conducted)
x 100

10. Percentage of adherence to (Number of observations Safety precautions

safety precautions by that indicates adherence to must be clearly
employees working in labs safety precautions in a defined. Data must be
period / Total number of gathered through
observations made in that random monitoring of
period) x 100 practices followed by
staff. Most safety
precautions shall be
related safety from
infection, bio-medical
waste and safety from
chemicals.

11. Reporting error rates (per (Number of lab reports in The error rates can be
1000) in Imaging which errors detected / separately calculated
Number of lab reports for each imaging
checked) x 1000 modality

12. Percentage of re-dos in (Number of Imaging tests Only those repeat test
Imaging that has to be repeated in shall be considered in
a period / Total Imaging calculation, where the
tests conducted in that reason of repeating is
period) x 100 related to errors,
mistake or quality
issues
13. Percentage of Imaging (Number of Imaging While higher
reports co-relating with reports in which the correlation shall be
clinical diagnosis diagnosis matches with the expected, it may not
clinical diagnosis of the necessarily be 100%
doctor / Total Imaging tests
conducted) x 100

14. Percentage of adherence to (Number of observations Safety precautions

safety precautions by that indicates adherence to must be clearly
employees working in safety precautions in a defined. Data must be
Imaging period / Total number of gathered through
observations made in that random monitoring of
period) x 100 practices followed by
 staff. Most safety
precautions shall be
radiation safety and
infection control

15. Medication error rate (Number of medication For data on

OR errors reported in a period medication error a
Medication error per 1000 / Total number of strong medication
patient days medication administration error reporting system
events) x 100 must be in place.
OR
(Number of medication This indicator can
errors reported in a period further be divided into
/ Total patient days in that various types of
period) x 1000 medication errors,
such as administration
error, dispensing
error, error of route,
error of dose etc.

16. Percentage of adverse drug (Number of patients who Adverse drug reaction
reactions suffered adverse drug and medication error
reactions in a period / shall be defined and
Number of admitted should not overlap
patients in that period) x with each other
100
17. Percentage of adverse drug (Number of patients List of high-risk
reaction due to high-risk developing adverse drug medicines shall be
medicine reaction from high-risk specified by the
medicines in a period / hospital and any
Number of patients given adverse reaction
high-risk medicine in that happening due to
period) x 100 these medicines shall
be counted for this
indicator

18. Percentage of medical (Number of medical List of accepted

records with error-prone records which contains abbreviations shall be
abbreviations error-prone abbreviations / determined by the
Number of medical records hospital and any
screened) x 100 abbreviation other
than that shall be
considered as error
prone

19. Percentage of modification (Number of patients in Each patient must

of anaesthesia plan whom anaesthesia plan undergo pre-
was modified immediately anaesthesia check-up
before induction of in which anaesthesia
anaesthesia / Number of plan (type of
patients that have anaesthesia and
undergone anaesthesia) x anaesthetic agent) is
100 determined. Any
change in this plan
 shall be considered as
a modification

20. Percentage of unplanned (Number of patients who Unplanned ventilation

ventilation following required unplanned is the situation in
anaesthesia ventilator support following which patient has to
anaesthesia / Number of be put on the
patients who were given ventilator after
anaesthesia) x 100 surgery, due to
complications
resulting from
anaesthesia

21. Percentage of re-scheduling (Number of planned This indicator can

of surgeries surgeries re-scheduled or further be classified as
cancelled / Number of per causes of re-
surgeries planned) x 100 scheduling for the
management to take
appropriate corrective
and preventive
measures

22. Compliance rate to surgical (Number of surgical For surgical safety

safety practices patients in which all practices, ‘WHO
surgical safety practices surgical safety
where adhered / Number checklist can serve
of surgical patients’ cases as a good reference
reviewed) x 100 material’.

The compliance rate

of individual practices
can also be calculated
for detailed analysis

23. Percentage of cases who (Number of surgical The hospital must

received prophylactic patients who has received define the time-frame
antibiotic within specified prophylactic antibiotic / for giving prophylactic
time-frame Total number of patient antibiotic.
undergone surgery) x 100 The documentation of
administration of
antibiotics and the
time shall be done for
getting data

24. Percentage of transfusion (Number of patients who To get data for this
reactions developed blood or blood indicator a transfusion
component transfusion administration form
reaction / Number of must be filled for each
patients who underwent transfusion, which
blood or component shall have a column
transfusion) x 100 for indicating reactions
if any
25. Percentage of blood and (Units of blood and blood Blood and blood
blood components wasted components wasted or components being
discarded in a period / discarded because of
Total units of blood and unfit in lab tests, shall
blood components under not be counted as
storage during that period) wastage. Wastage
x 100 shall be because of
reasons of expiry,
errors, poor storage
conditions etc.

26. Percentage of blood (Total units of blood The percentage

component usage components transfused to should be high
patients / Total units of
whole blood plus blood
components transfused to
patients) x 100

27. Turn-around time for the Sum of time taken for The time taken shall
issue of blood and blood issuing blood and blood be considered from
components taken in each requisition / the time of receipt of
Total number of requisition requisition till the time
received for blood and of dispatch of blood or
blood component blood component

28. Percentage of blood and (Number of blood and The time frame must
blood components issued blood component be defined by the
within defined time frame requisitions that were organization
issued within defined time-
frame / Total number of
requisition received for
blood and blood
component) x 100

29. Catheter associated Urinary (Number of patients CA-UTI shall be

Tract Infection (CA-UTI) rate developing CA-UTI in a determined clinically
period / Total urinary (CDC guidelines must
catheterization days in that be followed)
period) x 1000 The catheterization
days shall be
calculated as sum of
number of days each
patient spent with
urinary catheter in the
period of calculation

30. Ventilator associated (Number of patients VAP shall be

pneumonia (VAP) rate developing VAP in a period determined clinically
/ Total ventilator days in (CDC guidelines must
that period) x 1000 be followed)
The ventilator days
shall be calculated as
sum of number of
days each patient
 spent on ventilator in
the period of
calculation

31. Central line catheter (Number of patients CA-BSI shall be

associated blood stream developing CA-BSI in a determined clinically
infection (CA-BSI) rate period / Total central line (CDC guidelines must
days in that period) x 1000 be followed)
The central line days
shall be calculated as
sum of number of
days each patient
spent with central line
catheter in the period
of calculation

32. Surgical site infection (SSI) (Number of patients CA-BSI shall be

rate developing SSI in a period determined clinically
/ Total number of clean (CDC guidelines must
surgeries performed in that be followed)
period) x 100 This can be further
bifurcated in
superficial, deep and
organ/space infections
due to surgeries

33. Gross mortality rate (Total number of deaths All deaths (including
happened in the hospital in deaths in emergency
a period / Total number of and ICU) shall be
deaths discharges during counted.
that period) x 100 In denominator all
types of discharges
shall be considered

34. Net mortality rate (Total number of deaths Deaths happening

that happened after 48 within 48 hours of
hours of admission of the discharge should also
patient / Total number of be counted in
deaths and discharges numerator
during that period) x 100

35. ICU specific mortality rate (Total number of deaths in On similar lines,
ICU patients in a period / condition specific or
Total number of patients speciality specific
discharged from ICU in deaths rates can also
that period) x 100 be calculated

36. Return to ICU within 48 (Number of patients who The patients who
hours were re-admitted to ICU were discharged
within 48 hours of being against medical
discharged from ICU / advice from ICU
Total number of patients should be ignored
 discharged from ICU) x
100

37. Return to emergency within (Number of patients who The patients who
72 hours with similar returned to emergency were discharged
presenting complaints within 72 hours with similar against medical
presenting complaints / advice from
Total number of patients emergency should be
discharged from ignored
emergency) x 100

38. Re-intubation rate (Number of patients who Data on re-intubation

has to be re-intubated after and ex-tubation shall
ex-tubation / Total number be taken from
of ex-tubation done during individual medical
the period) x 100 record or a master
register

39. Percentage of research (Number of research Applicable to hospital

activities approved by ethics activities approved by undertaking clinical
committee ethics committee / Number research
of research proposal
submitted to ethics
committee) x 100

40. Percentage of patients (Number of patients Applicable to hospital

withdrawing from clinical withdrawing from research undertaking clinical
research study / Number of patients research
originally enrolled in the
study) x 100

41. Percentage of protocol (Incidence of protocol Applicable to hospital

violations/deviations in violations/deviations undertaking clinical
clinical research study observed in clinical research
research study / Number of
observations made) x 100

42. Percentage of serious (Number of serious Applicable to hospital

events in clinical research adverse events reported to undertaking clinical
study reported to ethics ethics committee / Number research
committee of serious adverse events
identified) x 100

43. Error rates during shift hand- (Number of errors detected A handover checklist
overs in patient handovers during must be available
shift changes / Number of against which errors
hand over records can be detected
reviewed) x 100

44. Percentage of medical (Number of medical errors A robust system

error due to reported that happened of medical
wrong identification of due to wrong identification error reporting must
patient of patient / Total number of be in place to get
appropriate data
 medical errors reported) x
100

45. Hand hygiene compliance (Number of observations in Hand hygiene

rate which staff complied with guidelines must be
hand hygiene guidelines / specified.
Total number of Data shall be
observations made) x 100 gathered through
monitoring
46. Compliance rate to (Number of prescriptions in Not applicable, if
medication prescription in which medications are prescription is
capitals written in capital letters / computerized
Total number of
prescriptions checked) x
100

47. Percentage of procurement (Value of drugs and Local purchases are

through local purchase consumables purchased unplanned,
through local purchase / emergency purchases
Total value of drugs and which increase the
consumables purchased in cost of purchasing
that period) x 100

48. Percentage of stockouts for (Number of emergency Stock out is a situation

emergency drugs drugs on the stock-out / when the inventory
Total number of level of the medicine
emergency drugs) x 100 has gone below the
defined minimum level

49. Percentage of drugs and (Number of drugs and The data can be taken
consumables rejected before consumables rejected through a random
preparation of goods receipt before preparation of sample of items that
note goods receipt note / Total were checked
number of drugs and
consumables received) x
100

50. Percentage of variation from (Number of times standard A standard operating

procurement process procurement process was process for
not followed / Total number procurement must be
of procurements done) x in place to calculate
100 this indicator

51. Percentage of variations (Number of variations This should be

observed in mock drills observed in mock drills / separately calculated
Total number of for different mock
observations made) x 100 drills such as code
blue, code red, code
pink, disaster
handling etc.

52. Patient fall rate per 1000 (Number of patient fall Patient fall must be
patient days reported in a period / Total defined. Generally, all
kind of fall (fall from
 patient days in that period) bed, in washroom, on
x 1000 stairs, while walking
etc.) must be counted

53. Hospital-associated pressure (Number of patients Criteria for

ulcer rate developing hospital determining pressure
associated pressure ulcers ulcers shall be
/ Number of bedridden specified.
patient days) x 1000 Patients at risk of
developing pressure
ulcers must be
identified

54. Percentage of staff provided (Number of staff who Pre-exposure

pre-exposure prophylaxis received pre-exposure prophylaxis can be
prophylaxis / Total given for different
healthcare staff) x 100 conditions such as
Hepatitis, certain
kinds of Pneumonia
etc.

55. Bed Occupancy Rate (Total patient days in a Total patient days is
period / Total bed days the sum of days spent
available during that by each admitted
period) x 100 patient in hospital
Total bed days is the
product of number of
functional beds in
hospital with the
number of days in that
period

56. Average Length of Stay Sum of length of stay of ALOS must be

(ALOS) individual patients / Total separately calculated
number of patients whose for different disease
length of stay has been conditions, specialities
taken and ICU/Non-ICU
cases

57. OT utilization rate (Total hours for which Total hours of

actual surgeries were surgeries can be
performed in OT / Total OT calculated by
hours available) x 100 summing up the
duration of each
surgeries performed in
the period

Total OT hours can be

calculated by
multiplying functional
hours available for
each OT with the
number of OT
58. ICU utilization rate (Total ICU patient days in This is similar to
a period / Total ICU bed calculation bed
days available in that occupancy rate, but
period) x 100 only for ICU

59. Percentage of downtime of Total duration (in days or A list of critical

Critical equipment hours) for which a critical equipment shall be
equipment was down / made.
Total duration (in days or This indicator shall be
hours) in that period calculated separately
for each critical
equipment

60. Nurse patient ratio for wards Total number of nurse An average ratio of
working in a shift / Total the month can be
number of patient in that taken. This should be
shift separately calculated
for each shift and
each ward

61. Nurse patient ratio for ICU Total number of nurse An average ratio of
working in ICU in a shift / the month can be
Total number of patient in taken. This should be
that shift separately calculated
for each shift and
each ICU

62. Out-patient satisfaction index Average rating given by A standard patient

patient of OPD to the satisfaction
hospital feedback form can
be used for obtaining
rating from patients.
Number of feedback
collected should be
statistically significant

63. In-patient satisfaction index Average rating given by A standard patient

patient of IPD to the satisfaction
hospital feedback form can
be used for
obtaining rating from
patients. Number of
feedback collected
should be statistically
significant

64. Average waiting time for Total waiting time of all Average waiting time
services patients for a particular shall be separately
service / Total number of calculated for OPD
patients whose waiting consultation, Billing,
time has been taken Pharmacy and
diagnostics
65. Average discharge time Sum of time taken for Time taken for
discharging patients / Total discharge shall be
patients whose discharge taken from the time
time is taken when the discharged
was ordered by the
doctor till the time
when patient was
relieved from
room/bed

66. Employee satisfaction index Average rating given by An employee

employee to the satisfaction study
organization must be conducted for
this.
The index can be
calculated for different
categories of
employees

67. Employee attrition rate (Number of employee who This should be

resigned during a period / calculated overall as
Total number of employee well as category wise
on roll) x 100

68. Employee absenteeism rate (Total number of Absenteeism shall be

absenteeism of employee considered as absent
in a period / Total without information.
employee days) x 100
This indicator shall
also be calculated
category wise

69. Percentage of employee (Number of employee Category-wise

aware of employee rights aware of employee rights / calculation shall be
Total number of employee) done
x 100

. Percentage of sentinel (Number of sentinel events Timeframe and

events analysed within a analysed within defined sentinel events must
defined time frame time frame / Number of be defined
sentinel events reported) x
100

71. Percentage of near misses (Number of near misses A robust system of

reported / Total number of reporting errors and
errors and near-miss near misses must be
reported) x 100 in place

72. Needlestick injury rate (Number of needle stick Needlestick injury

injury reported / Total reporting and data
patient days in that period) collection mechanism
x 100 must be in place
73. Percentage of medical (Number of medical Sufficient sample size
records not having discharge records not having must be ensured
summary discharge summary / Total
number of medical records
screened) x 100

74. Percentage of medical (Number of medical Sufficient sample size

records not having ICD records not having ICD must be ensured
codes codes / Total number of
medical records screened)
x 100

75. Percentage of medical (Number of medical Standard process of

records having incomplete records having incomplete informed consent
and improper consent and improper consent / must be in place to
Total number of medical determine what
records where consent constitutes incomplete
was applicable or improper consent

76. Percentage of missing (Number of medical A definition of missing

records records missing / Total shall be available.
number of medical records Generally, any
in MRD) x 100 medical record which
has been able to be
traced for last 3 days
shall be considered
missing. In case, a
missing record has
been found it shall be
removed from the
missing data