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QUALITY & PERFORMANCE ( JAN 2015 – MAR 2015 )

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