QUALITY & PERFORMANCE ( APR 2019 – JUN 2019 )

SR NO	Service Quality	Process/ Function/ Department	Unit of measurement	Expected performance	Apr 2019	May 2019
1	Lab Reporting errors	Lab	Per 1000 tests done	5 errors per 1000tests	0	0
2	Radiology reporting errors	Radiology	Per 1000 tests done	5 errors per 1000tests	0	0
3	Adverse drug reactions	Nursing	% of discharges+deaths	0%	0	0
4	Unplanned ventillation post anasthesia	OT	% of patients anesthesized	0.50%	0.61	0
5	Adverse anasthesia events	OT	% of patients anesthesized	0%	0.61	0
6	compliance with Surgical “Time-out” procedure	OT	% of Number of Surgeries performed	99%	100	100
7	Compliance with Prophylactic antibiotic usage within specified time	OT	% of Number of Surgeries performed	99%	99	99
8	Blood transfusion reactions	Blood Storage Unit	% of number of BTs done	0%	1.47	0
9	Catheter associated UTI (CAUTI)	HIC	Per 1000 Urinary catheter days	0%	0	0
10	VAP	HIC	Per 1000 Ventilator days	0%	0	0
11	CLABSI	HIC	Per 1000 Central Line days	0%	0	0
12	SSI	HIC	% of number of surgeries in the month	0%	1.23	0.84
13	Return to ICU within 48hrs during same admission	ICU	% of Number of Discharges+ Transfer-outs+ deaths in ICU	1%	0.8	0
14	Return to emergency within 72 hours with similar complaints	Emergency	% of number of Patients visiting Emergency	5%	0	0
15	Number of Re-intubations within 48 Hours of Extubation	Med Admin	% of number of extubations	0%	0	0
16	Patient falls	Safety	% of discharges+deaths	0	0	1.1
17	Bed occupancy	Med Admin	% of available bed days	90%	81	82
18	ALOS	Med Admin	Days	7.5	5.3	4.4
19	OPD patient satisfaction index	OPD	Percentage	87.50%	94	84
20	IPD patient satisfaction index	IPD	Percentage	87.50%	82	68