| SR NO | SERVICE QUALITY | PROCESS/ FUNCTION/ DEPARTMENT | EXPECTED PERFORMANCE | Jan 2016 | Feb 2016 | Mar 2016 |
|---|---|---|---|---|---|---|
| 1 | Lab Reporting errors | Lab | 5 errors per 1000 tests | 0 | 0 | 0 |
| 2 | Radiology reporting errors | Radiology | 5 errors per 1000 tests | 0 | 0 | 0 |
| 3 | Adverse drug reactions | Nursing | 0% | 0 | 0 | 0.15 |
| 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 | 99.18 | 100 |
| 8 | Blood transfusion reactions | Blood Storage Unit | 0% | 1.35 | 2.17 | 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% | 1.56 | 0 | 0 |
| 17 | Bed occupancy | Med Admin | 90% | 76.43 | 71.16 | 72.65 |
| 18 | ALOS | Med Admin | 7.5% | 6.5 | 6.7 | 6.8 |
| 19 | OPD patient satisfaction index | OPD | 87.50% | 85.7 | 85.41 | 88.45 |
| 20 | IPD patient satisfaction index | IPD | 87.50% | 88.02 | 87.13 | 88.19 |
