QUALITY INDICATOR OF OPD FOR D

SR NO DATE PATIENT NAME CONSUTANT NAME SPECIALITY

TOTAL

NOTE: For the consultation not the junior doctor/resident begins the asessment.

DATA COLLECTION FOR MONTHLY BASIS

TOTAL NUMBER OF
DATE SPECIALITY NAME
OPD PATIENT
1
2
3
4
 5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL 0
UALITY INDICATOR OF OPD FOR DAILY BASIS
PATIENT REGISTERATION TIME(in CONSULTATION START
WAITING TIME(in minutes)
minutes) TIME(in minutes)

R MONTHLY BASIS
TOTAL WAITING TIME (in minutes)
0
REMARKS
 QUALITY IND

Total number
Total number
of handovers Return to ICU within 48
Nurses Patient of handover Mortaility Ratio for ICU Blood transfu
done hours
done
appropriately
Total
Department/
Date Admitted
Floor Total Number
Patient Number of
of Number of
returns to ICU Predicted
M E N M E N M E N M E N discharges/tra Actual death transfusion
within 48 death in ICU
nsferred from reaction
hours
the ICU

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
 24
25
26
27
28
29
30
31
TOTAL #REF! #REF! #REF! #REF! #REF!

Average % #DIV/0!
LITY INDICATORS FOR CRITICAL UNIT(MONTHLY BASIS)

Percentage of sepsis patie

ood transfusion reaction
care as per the Hour-1

Referrals for Needle

New/Worsening Total Foley's Bed
DAMA/LAMA outsource Extubation Reintubation Death stick
Pressure Ulcer No Ridden Number of sepsis
services Injury
patients who receive
Number of units transfused
care as per the
to the patient
Hour-1 sepsis
bundle
#REF! #REF! 0 0
 DATA COLLECTION FOR QUA

sepsis patients who receive

Doctor care plan
he Hour-1 sepsis bundle

Total time Total time taken

taken for initial for initial
Incidence of fall Near Miss Sr. No Patient Name Uhid Age
assessment by assessment by
RMO(in Min) Nurses(in Min) Care plan
Total number of
documented
sepsis cases
RMO(YES/No)
#REF! 0

#REF!
LECTION FOR QUALITY INDICATOR SHEET FOR ICU DAILY BASIS

Percentage of stroke patients in whom the (DTN) of 60

octor care plan TAT for the issue of blood and blood components
minutes is achieved

Nursing care plan

documented(YES/N
o)
Received Number of blood Number of stroke patients
Counter sign by Request Time(in Number of stroke patients who
Time(in components cross in whom the DTN of 60
consultant(Yes/No) minutes) receive thrombolytic therapy
minutes) matched/reserved minutes is achieved
 QUALITY INDICATORS FOR WA
Total number of
Total number of
Nurses Patients handovers done
handover done
appropriately
Total In
Date Department/Floor
patient
M E N M E N M E N M E N

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
 29
30
31
TOTAL
QUALITY INDICATORS FOR WARDS(MONTHLY BASIS)

Blood transfusion reaction

Referrals for
New/Worsening Bed Total Needle stick
DAMA/LAMA outsource Incidence of fall
Pressure Ulcer Ridden Foley's No Injury
Number of Number of units services
transfusion transfused to
reaction the patient
#REF! #REF! #REF! 0 0 #REF!
 QUALITY INDICATOR SHEET FOR WARD( DAILY BASIS)

TOTAL TIME TOTAL TIME TAKEN

TAKEN FOR INITIAL FOR INITIAL
Birth Near Miss SR NO PATIENT NAME UHID
ASSESSMENT OF ASSESSMENT OF
RMO(in Min) NURSING (in Min)
0
SHEET FOR WARD( DAILY BASIS)

DOCTORS CARE PLAN

NURSING CARE PLAN
DOCUMENTED(Yes/No)
CARE PLAN COUNTER SIGN BY
DOCUMENTED CONSULTANT(Yes
RMO(Yes/No) /No)
 Blood transfusion reaction

Rexploration
Number of No of Planned No of Planned done during
Date
surgeries surgeries surgeries same
admission Number of
transfusion
reaction

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL #REF! #REF! #REF! #REF!
 QUALITY INDICATOR SHEET FOR O

ood transfusion reaction

Total No of
Number of Adverse
Number of Anesthesia patients
unplanned anethesia
anethesia related death undergoing
Number of returns to OT event
cases anesthesia
units
transfused

#REF!
UALITY INDICATOR SHEET FOR OT ON MONTHLY BASIS

No of modified
Number of unplanned v
anesthesia plan New/Worsening Total Foley's Needle stick
entilations post- Bed Ridden
before Pressure Ulcer No Injury
anaesthesia
induction

0 #REF!
 Bile Duct injury rate requiring operative interven
Postoperative Endoophthalmitis rate
Laproscopic cholecystectomy

Incidence of Number of cases where bile

Near Miss
fall duct injuries occurred during
No of cases of
Total no of laproscopic cholecystectomy
postoperative
Opthalmic and required subsequent
endoopthalmitis
operative intervention to
repair the injury

0
ate requiring operative intervention during
aproscopic cholecystectomy

Laproscopic cholecystectomies
performed
 DISCHARGE LIST FOR DAILY BASIS
Dishcarge time initiated(in
[Link] Patient Name Department/Floor UHID
mimutes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
T FOR DAILY BASIS
Time Patient wheel out(in Total Time taken for discharge ( in Remarks
minutes) minutes)
 QUALITY INDICATORS FOR CLINICAL - PHARMACO
Medication error

Patient receiving
Adverse Drug
Date High Risk
Reactions
Medications Prescription Dispensing Administration Transcription
error error error error

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
CAL - PHARMACOLOGIST(MONTHLY BASIS)
Percentage of medication charts with
Rational use of medicines
error prone abbreviations

Total number of
Total number of Total number of Total number of
medication chart
Other error safe and rational prescriptions medication charts
with error prone
prescription audited reviewed
abbreviatons
 Adherence to Safety precautions by staff
working in Imaging

Number of
Total number of
Date reporting
imaging test
errors
Number of staff
adhering to safety Number of staff audited
precaution

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
 QUALITY INDICATORS FOR RADIOLOGY (MONTHLY BASIS)

Number of imaging Number of test results de

Number of re-dos tests in
reports co-relating layed beyond standard tu
imaging
with clinical diagnosis rnaround time
OR RADIOLOGY (MONTHLY BASIS)

Compliance of radiation safety practices Critical result reporting compliance

Number of observations indic

Number of Critical Re
ating adherence to radiation Total Number of observation
sults Reported
safety practices
 Percentage of Intravenous Contrast Media
cal result reporting compliance
Extravasation

Total number of critical Number of contrast Number of patients

results extravasation receiving contrast
 QUALITY INDICATOR FOR INFECTION CONTROL (MONTH

Catheter associated urinary Ventilator associated Central line- associated

tract infection rate pneumonia rate bloodstream infection rate

Date
Number of
Number of Number of Number of
Number of central line- Total number
patient urinary ventilator
ventilator associated of central line
developing catheter days associated
days bloodstream days
CAUTI in a month pneumonia
infection

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
N CONTROL (MONTHLY BASIS)

Surgical site infection rate Compliance to hand hygiene practices

Number of Number of Total number of

Total number of
surgical site surgeries hand hygiene
action performed
infections performed opportunities
 QUALITY INDICATORS FOR LABORATORY

Adherence to Safety precautions by

staff working in Lab
Number of Number of re-dos
Date Total Lab Test
reporting errors tests

Number of staff
Number of staff
adhering to safety
audited
precaution
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
FOR LABORATORY(MONTHLY BASIS)

Critical result reporting compliance

Number of test reports Number of test results delayed
co-relating with clinical beyond standard turnaround ti
diagnosis me

Number of Critical Results R Total number of

eported critical results
 QUALITY INDICATOR FOR MEDICAL RECORD DEPART
Percentage of medical records with incomplete or Percentage of medical record missing discharg
improper consent summary

Date
Number of medical records wit
Total Number of medical Number of medical records mis
h incomplete or improper cons
records with consent sing discharge summary
ent​

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
 ICAL RECORD DEPARTMENT (MONTHLY BASIS)
medical record missing discharge
Percentage of missing medical record
summary

Number of medical records mi

ssing ICD codes​ Total Number of
Total number of medical Number of medical
medical record in
record screened record missing
MRD
 QUALITY INDICATOR FOR HUMAN RESOURCE DEPARTMENT
Percentage of employee aware of employee rights Employee absenteesim rate

Date
Number of employee Total Number of
Total Number of employee
aware of employee rights absent

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
MAN RESOURCE DEPARTMENT (MONTHLY BASIS)
mployee absenteesim rate Employee attribution rate

Employee satisfaction Number of

index employee who Total number of
Total employee days
resigned during a employee on roll
period
 QUALITY INDICATOR FOR (MONTH

Percentage of patients with

Percentage of beta-blocker prescription with myocardial infarction for whom
a diagnosis of CHF with reduced EF Door to ballon time of 90 minutes is
achieved

Number of acute
Date myocardial
Number of patient infarction (AMI)
discharge with a patients Total Number of
diagnosis of CHF with Number of patients undergoing AMI patients
reduced EF and discharge with a primary undergoing
prescribed a beta diagnosis of CHF angioplasty for primary
blocker prescription at whom door to angioplasty
the time of discharge balloon time of 90
minutes is
achieved

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Y INDICATOR FOR (MONTHLY BASIS)

Percentage of patients with hypoglycemia who Percentage of COPD patients receiving COPD action
achieved targeted blood glucose level. plan at the time of discharge

Number of patients with

Number of COPD patients
hypogylcemic events
Number of patients with provided with a COPD
where the target glucose
Hypoglycemic action plan at the time of
level was achieved post-
discharge
treatment
f COPD patients receiving COPD action
an at the time of discharge

Number of COPD patients

discharged
 QUALITY INDICA

Percentage of patients undergoing dialysis who are able to achieve target

hemoglobin levels
Date Total In patient
Number of patients undergoing
dialysis who are able to achieve
target hemoglobin levels
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
 QUALITY INDICATOR FOR DIALYSIS(MONTHLY BASIS)

undergoing dialysis who are able to achieve target

hemoglobin levels
No of blood Blood
products Transfusion Near Miss
Total number of patients undergoing transfused in AKD reactions
dialysis
 Blood fluid Total Foley's
Patient fall NSI Bed Ridden
spillage No
 QUALITY INDICATOR FOR PHYSIOTHERAPY(MONTHLY BASIS)
Functional gain following rehabilitation

Date The sum of improvement in physical quality

achieved before the discharge in patients
undergoing neuro-rehabilitation

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
YSIOTHERAPY(MONTHLY BASIS)
in following rehabilitation

Total number of patients undergoing

neuro-rehabilitation
 QUALITY INDICATOR FOR LABOUR ROOM(MONTHLY BASIS)

Spontaneous Perineal Tear Rate

Date
Number of cases where a
Total Vaginal deliveries
spontaneous perineal tear occurs

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL
 QUALITY INDICATOR FOR ENDOSCOPY(MONTHLY BASIS)
Percentage of patients undergoing colonoscopy who are sedated

Date
No of patients sedated for Total number of patients undergoing
the colonoscopy procedure colonoscopy

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
TOTAL