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QUALITY & PERFORMANCE ( APR 2014 – JUNE 2014 )

SR NO SERVICE QUALITY PROCESS/ FUNCTION/ DEPARTMENT EXPECTED PERFORMANCE APRIL-14 MAY-14 JUNE-14
1 Lab Reporting errors Lab 5 errors per 1000tests 0 0 0
2 Radiology reporting errors Radiology 5 errors per 1000tests 0 0 0
3 Adverse drug reactions Nursing 0% 0 0 0
4 Unplanned ventillation post anasthesia OT 0.50% 0 0 0
5 Adverse anasthesia events OT 0% 0.65 0 0
6 Compliance with Surgical  “Time-out” procedure OT 99% 0 0 0
7 Compliance with Prophylactic antibiotic usage within specified time OT 99% 100 0 100
8 Blood transfusion reactions Blood Storage Unit 0% 100 100 100
9 Catheter associated UTI (CAUTI) HIC 0% 0 0 0
10 VAP HIC 0% 0 0 0
11 CLABSI HIC 0% 0 0 0
12 SSI HIC 0% 0 0 0
13 Return to ICU within 48hrs during same admission ICU 1% 0 0 0
14 Return to emergency within 72 hours with similar complaints Emergency 5% 0 0 0
15 Number of Re-intubations within 48 Hours of Extubation Med Admin 0% 0 0 0
16 Patient falls Safety 0 0 0 0
17 Bed occupancy Med Admin 90% 84.72 79.57 91.83
18 ALOS Med Admin 7.5 7.94 10.57 7.91
19 OPD patient satisfaction index OPD 85% 81.54 81.7 80.63
20 IPD patient satisfaction index IPD 90% 79.51 78.73 80.62