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QUALITY & PERFORMANCE ( APR 2016 – JUN 2016 )

SR NO SERVICE QUALITY PROCESS/ FUNCTION/ DEPARTMENT EXPECTED PERFORMANCE Apr 2016 May 2016 Jun 2016
1 Lab Reporting errors Lab 5 errors per 1000 tests 0.3 0.2 0.18
2 Radiology reporting errors Radiology 5 errors per 1000 tests 0 0 0
3 Adverse drug reactions Nursing 0% 0 0.07 0
4 Unplanned ventillation post anasthesia OT 0.50% 0 0 0
5 Adverse anasthesia events OT 0% 0 0 0
6 Compliance with Surgical  “Time-out” procedure OT 99% 100 100 100
7 Compliance with Prophylactic antibiotic usage within specified time OT 99% 100 100 100
8 Blood transfusion reactions Blood Storage Unit 0% 2.56 0 0
9 Catheter associated UTI (CAUTI) HIC 0.0% 0 0 0
10 VAP HIC 0.0% 0 0 0
11 CLABSI HIC 0.0% 0 0 0
12 SSI HIC 0.0% 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 0.65 0.32
17 Bed occupancy Med Admin 90% 69.08 79.57 80.1
18 ALOS Med Admin 7.5% 6.5 5.41 6.01
19 OPD patient satisfaction index OPD 87.50% 88.7 87.71 86.21
20 IPD patient satisfaction index IPD 87.50% 85.51 89.91 85.95