Average time taken for initial assessment of patients admitted in IPD

Note: The time taken can be taken from the time when patient was registered for admission till the time at which initial assessment was completed and documented. 

Percentage of IPD patients for whom the initial assessment was completed within defined timeframe 

Note: Timeframe for initial assessment of patient getting admitted must be defined by the hospital 

Average time taken for initial assessment of patients coming to emergency 

Note: The time taken can be taken from the time at which a patient arrived at emergency department till the time at which initial assessment was completed and documented. 

Percentage of emergency patients for whom the initial assessment was completed within defined timeframe 

Note: Timeframe for initial assessment of emergency patients must be defined by the hospital 

Percentage of in-patients wherein the plan of care with desired outcomes is documented and countersigned by the clinicians 

Note: This can be further broken down into subcomponents such as case records with documented plan of care, documented desired outcomes and countersigned 

Percentage of in-patients wherein screening for nutritional needs has been done 

Note: Nutritional screening format can be used and is required for all admitted patients 

Reporting error rates (per 1000) in laboratory

Note: The error rates can be separately calculated for each unit of laboratory  

Percentage of re-dos in laboratory 

Note: Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues 

Percentage of lab reports co-relating with clinical diagnosis 

Note: While higher correlation shall be expected, it may not necessarily be 100% 

Percentage of adherence to safety precautions by employees working in labs 

Note: Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be related to safety from infection, bio-medical waste and safety from chemicals. 

Reporting error rates (per 1000) in Imaging 

Note: The error rates can be separately calculated for each imaging modality 

Percentage of re-dos in Imaging 

Note: Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues 

Percentage of Imaging reports co-relating with clinical diagnosis 

Note: While higher correlation shall be expected, it may not necessarily be 100% 

Percentage of adherence to safety precautions by employees working in Imaging 

Note: Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be radiation safety and infection control 

Medication error rate or Medication error per 1000 patient days

Note: For data on medication errors a strong medication error reporting system must be in place.  

This indicator can further be divided into various types of medication errors, such as administration error, dispensing error, error of route, error of dose etc. 

Percentage of adverse drug reactions 

Note: Adverse drug reaction and medication error shall be defined and should not overlap with each other 

Percentage of adverse drug reaction due to high-risk medicine 

Note: List of high-risk medicines shall be specified by the hospital and any adverse reaction happening due to these medicines shall be counted for this indicator 

Percentage of medical records with error-prone abbreviations

Note: List of accepted abbreviations shall be determined by the hospital and any abbreviation other than that shall be considered as error prone 

Percentage of modification of anesthesia plan 

Note: Each patient must undergo pre-anesthesia check-up in which anesthesia plan (type of anesthesia and anesthetic agent) is determined. Any change in this plan shall be considered as a modification 

Percentage of unplanned ventilation following anesthesia

Note: Unplanned ventilation is the situation in which patient must be put on the ventilator after surgery, due to complications resulting from anesthesia 

Percentage of re-scheduling of surgeries 

Note: This indicator can further be classified as per causes of re-scheduling for the management to take appropriate corrective and preventive measures 

Compliance rate to surgical safety practices

Note: For surgical safety practices, ‘WHO surgical safety checklist can serve as a good reference material’. The compliance rate of individual practices can also be calculated for detailed analysis. 

Percentage of cases who received prophylactic antibiotic within specified timeframe 

Note: The hospital must define the timeframe for giving prophylactic antibiotics. 

The documentation of administration of antibiotics and the time shall be done for getting data 

Percentage of transfusion reactions 

Note: To get data for this indicator a transfusion administration form must be filled for each transfusion, which shall have a column for indicating reactions if any 

Percentage of blood and blood components wasted 

Note: Blood and blood components being discarded because of unfit in lab tests, shall not be counted as wastage. Wastage shall be because of reasons of expiry, errors, poor storage conditions etc. 

Percentage of blood component usage 

Note: The percentage should be high 

Turn-around time for the issue of blood and blood components 

Note: The time taken shall be considered from the time of receipt of requisition till the time of dispatch of blood or blood component 

Percentage of blood and blood components issued within defined time frame 

Note: The time taken shall be considered from the time of receipt of requisition till the time of dispatch of blood or blood component 

Percentage of blood and blood components issued within defined time frame 

Note: The time frame must be defined by the organization 

Catheter associated Urinary Tract Infection (CA-UTI) rate 

Note: CA-UTI shall be determined clinically (CDC guidelines must be followed). The catheterization days shall be calculated as sum of number of days each patient spent with urinary catheter in the period of calculation. 

Ventilator associated pneumonia (VAP) rate 

Note: VAP shall be determined clinically (CDC guidelines must be followed). 

The ventilator days shall be calculated as sum of number of days each patient spent on ventilator in the period of calculation. 

Central line catheter associated blood stream infection (CA-BSI) rate 

Note: CA-BSI shall be determined clinically (CDC guidelines must 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 

Surgical site infection (SSI) rate 

Note: CA-BSI shall be determined clinically (CDC guidelines must be followed). This can be further bifurcated in superficial, deep and organ/space infections due to surgeries. 

Gross mortality rate 

Note: All deaths (including deaths in emergency and ICU) shall be counted. In denominator all types of discharges shall be considered  

Net mortality rate 

Note: Deaths happening within 48 hours (about 2 days) of discharge should also be counted in numerator 

ICU specific mortality rate 

Note: On similar lines, condition specific or specialty specific deaths rates can also be calculated. 

Return to ICU within 48 hours  

Note: The patients who were discharged against medical advice from ICU should be ignored 

Return to emergency within 72 hours with similar presenting complaints 

Note: The patients who were discharged against medical advice from emergency should be ignored 

Re-intubation rate 

Note: Data on re-intubation and ex-tubation shall be taken from individual medical record or a master register 

Percentage of research activities approved by ethics committee

Note: Applicable to hospital undertaking clinical research 

Percentage of patients withdrawing from clinical research 

Note: Applicable to hospital undertaking clinical research 

Percentage of protocol violations/deviations in clinical research study 

Note: Applicable to hospital undertaking clinical research 

Error rates during shift handovers 

Note: A handover checklist must be available against which errors can be detected 

Percentage of medical error due to wrong identification of patient 

Note: A robust system of medical error reporting must be in place to get appropriate data 

Hand hygiene compliance rate 

Note: Hand hygiene guidelines must be specified. Data shall be gathered through monitoring 

Compliance rate to medication prescription in capitals

Note: Not applicable, if prescription is computerized 

Percentage of procurement through local purchase 

Note: Local purchases are unplanned, emergency purchases which increase the cost of purchasing

Percentage of stockouts for emergency drugs 

Note: Stock out is a situation when the inventory level of the medicine has gone below the defined minimum level 

Percentage of drugs and consumables rejected before preparation of goods receipt note 

Note: The data can be taken through a random sample of items that were checked

Percentage of variation from procurement process 

Note: A standard operating process for procurement must be in place to calculate this indicator 

Percentage of variations observed in mock drills

Note: This should be separately calculated for different mock drills such as code blue, code red, code pink, disaster handling etc.

Patient fall rate per 1000 patient days 

Note: Patient fall must be defined. Generally, all kind of fall (fall from bed, in washroom, on stairs, while walking etc.) must be counted 

Hospital-associated pressure ulcer rate 

Note: Criteria for determining pressure ulcers shall be specified. Patients at risk of developing pressure ulcers must be identified

Percentage of staff provided pre-exposure prophylaxis 

Note: Pre-exposure prophylaxis can be given for different conditions such as Hepatitis, certain kinds of Pneumonia etc. 

Bed Occupancy Rate 

Note: Total patient days is the sum of days spent by each admitted patient in hospital. Total bed days is the product of the number of functional beds in hospital with the number of days in that period.