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QUALITY & PERFORMANCE ( APR 2019 – JUN 2019 )

SR NO Service Quality
Process/ Function/ Department
Unit of measurement
Expected performance
Apr 2019
May 2019
Jun 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