| SR NO | Service Quality |
Process/ Function/ Department
|
Unit of measurement
|
Expected performance
|
July 2018
|
Aug 2018
|
Sept 2018
|
|---|---|---|---|---|---|---|---|
| 1 | Lab Reporting errors |
Lab
|
Per 1000 tests done
|
5 errors per 1000tests
|
0
|
0
|
0
|
| 2 | Radiology reporting errors |
Radiology
|
Per 1000 tests done
|
5 errors per 1000tests
|
0
|
0
|
0
|
| 3 | Adverse drug reactions |
Nursing
|
% of discharges+deaths
|
0%
|
0
|
0
|
0
|
| 4 | Unplanned ventillation post anasthesia |
OT
|
% of patients anesthesized
|
0.50%
|
0
|
0
|
0
|
| 5 | Adverse anasthesia events |
OT
|
% of patients anesthesized
|
0%
|
0
|
0
|
0
|
| 6 | compliance with Surgical “Time-out” procedure |
OT
|
% of Number of Surgeries performed
|
99%
|
100
|
100
|
100
|
| 7 | Compliance with Prophylactic antibiotic usage within specified time |
OT
|
% of Number of Surgeries performed
|
99%
|
99
|
98
|
99
|
| 8 | Blood transfusion reactions |
Blood Storage Unit
|
% of number of BTs done
|
0%
|
2.43
|
0
|
0
|
| 9 | Catheter associated UTI (CAUTI) |
HIC
|
Per 1000 Urinary catheter days
|
0%
|
4.23
|
0
|
0
|
| 10 | VAP |
HIC
|
Per 1000 Ventilator days
|
0%
|
0
|
0
|
0
|
| 11 | CLABSI |
HIC
|
Per 1000 Central Line days
|
0%
|
0
|
0
|
0
|
| 12 | SSI |
HIC
|
% of number of surgeries in the month
|
0%
|
1.1
|
0.97
|
0
|
| 13 | Return to ICU within 48hrs during same admission |
ICU
|
% of Number of Discharges+ Transfer-outs+ deaths in ICU
|
1%
|
0
|
0
|
0
|
| 14 | Return to emergency within 72 hours with similar complaints |
Emergency
|
% of number of Patients visiting Emergency
|
5%
|
0
|
0
|
0
|
| 15 | Number of Re-intubations within 48 Hours of Extubation |
Med Admin
|
% of number of extubations
|
0%
|
0
|
0
|
0
|
| 16 | Patient falls |
Safety
|
% of discharges+deaths
|
0
|
0
|
0
|
0
|
| 17 | Bed occupancy |
Med Admin
|
% of available bed days
|
90%
|
65
|
76
|
72
|
| 18 | ALOS |
Med Admin
|
Days
|
7.5
|
6.4
|
5.7
|
5.1
|
| 19 | OPD patient satisfaction index |
OPD
|
Percentage
|
87.50%
|
90
|
89
|
89
|
| 20 | IPD patient satisfaction index |
IPD
|
Percentage
|
87.50%
|
83
|
81
|
81
|
