| SR NO | SERVICE QUALITY | PROCESS/ FUNCTION/ DEPARTMENT | EXPECTED PERFORMANCE | Oct 2016 | Nov 2016 | Dec 2016 |
|---|---|---|---|---|---|---|
| 1 | Lab Reporting errors | Lab | 5 errors per 1000 tests | 0.2 | 0 | 0 |
| 2 | Radiology reporting errors | Radiology | 5 errors per 1000 tests | 0 | 0 | 0 |
| 3 | Adverse drug reactions | Nursing | 0% | 0 | 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% | 100 | 100 | 100 |
| 7 | Compliance with Prophylactic antibiotic usage within specified time | OT | 99% | 100 | 100 | 100 |
| 8 | Blood transfusion reactions | Blood Storage Unit | 0% | 1.69 | 0 | 0 |
| 9 | Catheter associated UTI (CAUTI) | HIC | 0.0% | 0 | 0 | 7.6 |
| 10 | VAP | HIC | 0.0% | 0 | 0 | 0 |
| 11 | CLABSI | HIC | 0.0% | 0 | 0 | 0 |
| 12 | SSI | HIC | 0.0% | 1.12 | 0.56 | 0.57 |
| 13 | Return to ICU within 48hrs during same admission | ICU | 1% | 1.6 | 0 | 0.88 |
| 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% | 0 | 0.37 | 0.36 |
| 17 | Bed occupancy | Med Admin | 90% | 71.28 | 77.1 | 80.36 |
| 18 | ALOS | Med Admin | 7.5% | 6.03 | 5.8 | 5.85 |
| 19 | OPD patient satisfaction index | OPD | 87.50% | 81.77 | 83.63 | 82.42 |
| 20 | IPD patient satisfaction index | IPD | 87.50% | 91.5 | 87.5 | 86.85 |
