| SR NO | SERVICE QUALITY | PROCESS/ FUNCTION/ DEPARTMENT | EXPECTED PERFORMANCE | JAN-15 | FEB-15 | MAR-15 |
|---|---|---|---|---|---|---|
| 1 | Lab Reporting errors | Lab | 5 errors per 1000 tests | 3.03 | 1.67 | 0.65 |
| 2 | Radiology reporting errors | Radiology | 5 errors per 1000 tests | 4.61 | 0 | 0 |
| 3 | Adverse drug reactions | Nursing | 0% | 0.00 | 0 | 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% | 99.45 | 100 | 100 |
| 7 | Compliance with Prophylactic antibiotic usage within specified time | OT | 99% | 69.35 | 67 | 51.75 |
| 8 | Blood transfusion reactions | Blood Storage Unit | 0% | 0 | 0 | 0 |
| 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% | 0.88 | 0 | 6.25 |
| 14 | Return to emergency within 72 hours with similar complaints | Emergency | 5% | 0.00 | 0 | 0 |
| 15 | Number of Re-intubations within 48 Hours of Extubation | Med Admin | 0% | 0.00 | 0 | 0 |
| 16 | Patient falls | Safety | 0 | 0.00 | 0.07 | 0 |
| 17 | Bed occupancy | Med Admin | 90% | 71.11 | 66.47 | 63.51 |
| 18 | ALOS | Med Admin | 7.5 | 6.70 | 7.91 | 8 |
| 19 | OPD patient satisfaction index | OPD | 85% | 86.25 | 88.24 | 87.18 |
| 20 | IPD patient satisfaction index | IPD | 90% | 85.12 | 85.84 | 88.12 |
