| SR NO | Service Quality | Process/ Function/ Department | Unit of measurement | Expected performance | Oct 2017 | Nov 2017 | Dec 2017 |
|---|---|---|---|---|---|---|---|
| 1 | Lab Reporting errors | Lab | Per 1000 tests done | 5 errors per 1000tests | 0.27 | 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% | 0.06 | 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 | 1.27 | 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% | 100 | 100 | 100 |
| 8 | Blood transfusion reactions | Blood Storage Unit | % of number of BTs done | 0% | 0 | 1.75 | 0 |
| 9 | Catheter associated UTI (CAUTI) | HIC | Per 1000 Urinary catheter days | 0% | 0 | 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% | 0 | 0 | 0 |
| 13 | Return to ICU within 48hrs during same admission | ICU | % of Number of Discharges+ Transfer-outs+ deaths in ICU | 1% | 0 | 0.77 | 1.65 |
| 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% | 62.86 | 64.81 | 52.68 |
| 18 | ALOS | Med Admin | Days | 7.5 | 5.6 | 6.4 | 5.5 |
| 19 | OPD patient satisfaction index | OPD | Percentage | 87.50% | 92.34 | 86.84 | 91.41 |
| 20 | IPD patient satisfaction index | IPD | Percentage | 87.50% | 81.25 | 82.1 | 82.7 |
