Checklist of Quality Indicators for NABH accreditation preparation

Checklist of Quality Indicators for NABH accreditation preparation

Quality Indicators are the backbone on which quality assurance programme of a hospital relies. NABH ( National Accreditation Board for Hospitals & Healthcare Providers..Click here to know more) accreditation expects hospitals to calculate several quality indicators and use it for monitoring the quality of care. These are the list of quality indicators, which a hospital preparing for accreditation must necessarily monitor.

 

S.N.

Indicator

Formula

Remark

1.        

Average time taken for initial assessment of patients admitted in IPD

Sum of time taken for initial assessment of all admitted patients in a period / total number of patients admitted in that period

The time taken can be taken from time when patient was registered for admission till the time at which initial assessment was completed and documented

2.        

Percentage of IPD patients for whom the initial assessment was completed within defined timeframe

(Number of patients for whom the initial assessment was completed within a defined time frame / total number of patients admitted) x 100

Timeframe for initial assessment of patient getting admitted must be defined by the hospital

3.        

Average time taken for initial assessment of patients coming to emergency

Sum of time taken for initial assessment of all patients who accessed emergency services in a period / total number of patients who accessed emergency services in that period

The time taken can be taken from time at which patient arrived at emergency department till the time at which initial assessment was completed and documented.

4.        

Percentage of emergency patients for whom the initial assessment was completed within defined timeframe

(Number of patients in emergency for whom the initial assessment was completed within a defined time frame / total number of patients admitted) x 100

Timeframe for initial assessment of emergency patients must be defined by the hospital

5.        

Percentage of in-patients wherein the plan of care with desired outcomes is documented and countersigned by the clinicians

(Number of case records in which plan of care with desired outcomes is documented and countersigned by the clinicians / Total number of case records checked) x 100

This can be further broken down into subcomponents such as case records with documented plan of care, documented desired outcomes and countersigned

6.        

Percentage of in-patients wherein screening for nutritional needs has been done

(Number of admitted patients who has been screened for nutritional requirements / Total number of patients admitted) x 100

Nutritional screening format can be used and is required for all admitted patients

7.        

Reporting error rates (per 1000) in laboratory

(Number of lab reports in which errors detected / Number of lab reports checked) x 1000

The error rates can be separately calculated for each unit of laboratory

8.        

Percentage of re-dos in laboratory

(Number of lab tests which has to be repeated in a period/ Total lab tests conducted in that period) x 100

Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues

9.        

Percentage of lab reports co-relating with clinical diagnosis

(Number of lab reports in which the diagnosis matches with the clinical diagnosis of the doctor / Total lab tests conducted) x 100

While higher correlation shall be expected, it may not necessarily be 100%

10.    

Percentage of adherence to safety precautions by employees working in labs

(Number of observations that indicates adherence to safety precautions in a period / Total number of observations made in that period) x 100

Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be related safety from infection, bio-medical waste and safety from chemicals.

11.    

Reporting error rates (per 1000) in Imaging

(Number of lab reports in which errors detected / Number of lab reports checked) x 1000

The error rates can be separately calculated for each imaging modality

12.    

Percentage of re-dos in Imaging

(Number of Imaging tests that has to be repeated in a period / Total Imaging tests conducted in that period) x 100

Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues

13.    

Percentage of Imaging reports co-relating with clinical diagnosis

(Number of Imaging reports in which the diagnosis matches with the clinical diagnosis of the doctor / Total Imaging tests conducted) x 100

While higher correlation shall be expected, it may not necessarily be 100%

14.    

Percentage of adherence to safety precautions by employees working in Imaging

(Number of observations that indicates adherence to safety precautions in a period / Total number of observations made in that period) x 100

Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be radiation safety and infection control

15.    

Medication error rate

OR

Medication error per 1000 patient days

(Number of medication errors reported in a period / Total number of medication administration events) x 100

OR

(Number of medication errors reported in a period / Total patient days in that period) x 1000

For data on medication error a strong medication error reporting system must be in place.

 

This indicator can further be divided into various types of medication errors, such as administration error, dispensing error, error of route, error of dose etc.

16.    

Percentage of adverse drug reactions

(Number of patients who suffered adverse drug reactions in a period / Number of admitted patients in that period) x 100

Adverse drug reaction and medication error shall be defined and should not overlap with each other

17.    

Percentage of adverse drug reaction due to high-risk medicine

(Number of patients developing adverse drug reaction from high-risk medicines in a period / Number of patients given high-risk medicine in that period) x 100

List of high-risk medicines shall be specified by the hospital and any adverse reaction happening due to these medicines shall be counted for this indicator

18.    

Percentage of medical records with error-prone abbreviations

(Number of medical records which contains error-prone abbreviations / Number of medical records screened) x 100

List of accepted abbreviations shall be determined by the hospital and any abbreviation other than that shall be considered as error prone

19.    

Percentage of modification of anaesthesia plan

(Number of patients in whom anaesthesia plan was modified immediately before induction of anaesthesia / Number of patients that have undergone anaesthesia) x 100

Each patient must undergo pre-anaesthesia check-up in which anaesthesia plan (type of anaesthesia and anaesthetic agent) is determined. Any change in this plan shall be considered as a modification

20.    

Percentage of unplanned ventilation following anaesthesia

(Number of patients who required unplanned ventilator support following anaesthesia / Number of patients who were given anaesthesia) x 100

Unplanned ventilation is the situation in which patient has to be put on the ventilator after surgery, due to complications resulting from anaesthesia

21.    

Percentage of re-scheduling of surgeries

(Number of planned surgeries re-scheduled or cancelled / Number of surgeries planned) x 100

This indicator can further be classified as per causes of re-scheduling for the management to take appropriate corrective and preventive measures

22.    

Compliance rate to surgical safety practices

(Number of surgical patients in which all surgical safety practices where adhered / Number of surgical patients’ cases reviewed) x 100

For surgical safety practices, ‘WHO surgical safety checklist can serve as a good reference material’.

 

The compliance rate of individual practices can also be calculated for detailed analysis

23.    

Percentage of cases who received prophylactic antibiotic within specified time-frame

(Number of surgical patients who has received prophylactic antibiotic / Total number of patient undergone surgery) x 100

The hospital must define the time-frame for giving prophylactic antibiotic.

The documentation of administration of antibiotics and the time shall be done for getting data

24.    

Percentage of transfusion reactions

(Number of patients who developed blood or blood component transfusion reaction / Number of patients who underwent blood or component transfusion) x 100

To get data for this indicator a transfusion administration form must be filled for each transfusion, which shall have a column for indicating reactions if any

25.    

Percentage of blood and blood components wasted

(Units of blood and blood components wasted or discarded in a period / Total units of blood and blood components under storage during that period) x 100

Blood and blood components being discarded because of unfit in lab tests, shall not be counted as wastage. Wastage shall be because of reasons of expiry, errors, poor storage conditions etc.

26.    

Percentage of blood component usage

(Total units of blood components transfused to patients / Total units of whole blood plus blood components transfused to patients) x 100

The percentage should be high

27.    

Turn-around time for the issue of blood and blood components

Sum of time taken for issuing blood and blood taken in each requisition / Total number of requisition received for blood and blood component

The time taken shall be considered from the time of receipt of requisition till the time of dispatch of blood or blood component

28.    

Percentage of blood and blood components issued within defined time frame

(Number of blood and blood component requisitions that were issued within defined time-frame / Total number of requisition received for blood and blood component) x 100

The time frame must be defined by the organization

29.    

Catheter associated Urinary Tract Infection (CA-UTI) rate

(Number of patients developing CA-UTI in a period / Total urinary catheterization days in that period) x 1000

CA-UTI shall be determined clinically (CDC guidelines must be followed)

The catheterization days shall be calculated as sum of number of days each patient spent with urinary catheter in the period of calculation

30.    

Ventilator associated pneumonia (VAP) rate

(Number of patients developing VAP in a period / Total ventilator days in that period) x 1000

VAP shall be determined clinically (CDC guidelines must be followed)

The ventilator days shall be calculated as sum of number of days each patient spent on ventilator in the period of calculation

31.    

Central line catheter associated blood stream infection (CA-BSI) rate

(Number of patients developing CA-BSI in a period / Total central line days in that period) x 1000

CA-BSI shall be determined clinically (CDC guidelines must be followed)

The central line days shall be calculated as sum of number of days each patient spent with central line catheter in the period of calculation

32.    

Surgical site infection (SSI) rate

(Number of patients developing SSI in a period / Total number of clean surgeries performed in that period) x 100

CA-BSI shall be determined clinically (CDC guidelines must be followed)

This can be further bifurcated in superficial, deep and organ/space infections due to surgeries

33.    

Gross mortality rate

(Total number of deaths happened in the hospital in a period / Total number of deaths discharges during that period) x 100

All deaths (including deaths in emergency and ICU) shall be counted.

In denominator all types of discharges shall be considered

34.    

Net mortality rate

(Total number of deaths that happened after 48 hours of admission of the patient / Total number of deaths and discharges during that period) x 100

Deaths happening within 48 hours of discharge should also be counted in numerator

35.    

ICU specific mortality rate

(Total number of deaths in ICU patients in a  period / Total number of patients discharged from ICU in that period) x 100

On similar lines, condition specific or speciality specific deaths rates can also be calculated

36.    

Return to ICU within 48 hours

(Number of patients who were re-admitted to ICU within 48 hours of being discharged from ICU / Total number of patients discharged from ICU) x 100

The patients who were discharged against medical advice from ICU should be ignored

37.    

Return to emergency within 72 hours with similar presenting complaints

(Number of patients who returned to emergency within 72 hours with similar presenting complaints / Total number of patients discharged from emergency) x 100

The patients who were discharged against medical advice from emergency should be ignored

38.    

Re-intubation rate

(Number of patients who has to be re-intubated after ex-tubation / Total number of ex-tubation done during the period) x 100

Data on re-intubation and ex-tubation shall be taken from individual medical record or a master register

39.    

Percentage of research activities approved by ethics committee

(Number of research activities approved by ethics committee / Number of research proposal submitted to ethics committee) x 100

Applicable to hospital undertaking clinical research

40.    

Percentage of patients withdrawing from clinical research

(Number of patients withdrawing from research study / Number of patients originally enrolled in the study) x 100

Applicable to hospital undertaking clinical research

41.    

Percentage of protocol violations/deviations in clinical research study

(Incidence of protocol violations/deviations observed in clinical research study / Number of observations made) x 100

Applicable to hospital undertaking clinical research

42.    

Percentage of serious events in clinical research study reported to ethics committee

(Number of serious adverse events reported to ethics committee / Number of serious adverse events identified) x 100

Applicable to hospital undertaking clinical research

43.    

Error rates during shift hand-overs

(Number of errors detected in patient handovers during shift changes / Number of hand over records reviewed) x 100

A handover checklist must be available against which errors can be detected

44.    

Percentage of medical error due to wrong identification of patient

(Number of medical errors reported that happened due to wrong identification of patient / Total number of medical errors reported) x 100

A robust system of medical error reporting must be in place to get appropriate data

45.    

Hand hygiene compliance rate

(Number of observations in which staff complied with hand hygiene guidelines / Total number of observations made) x 100

Hand hygiene guidelines must be specified.

Data shall be gathered through monitoring

46.    

Compliance rate to medication prescription in capitals

(Number of prescriptions in which medications are written in capital letters / Total number of prescriptions checked) x 100

Not applicable, if prescription is computerized

47.    

Percentage of procurement through local purchase

(Value of drugs and consumables purchased through local purchase / Total value of drugs and consumables purchased in that period) x 100

Local purchases are unplanned, emergency purchases which increase the cost of purchasing

48.    

Percentage of stockouts for emergency drugs

(Number of emergency drugs on the stock-out / Total number of emergency drugs) x 100

Stock out is a situation when the inventory level of the medicine has gone below the defined minimum level

49.    

Percentage of drugs and consumables rejected before preparation of goods receipt note

(Number of drugs and consumables rejected before preparation of goods receipt note / Total number of drugs and consumables received) x 100

The data can be taken through a random sample of items that were checked

50.    

Percentage of variation from procurement process

(Number of times standard procurement process was not followed / Total number of procurements done) x 100

A standard operating process for procurement must be in place to calculate this indicator

51.    

Percentage of variations observed in mock drills

(Number of variations observed in mock drills / Total number of observations made) x 100

This should be separately calculated for different mock drills such as code bluecode redcode pink, disaster handling etc.

52.    

Patient fall rate per 1000 patient days

(Number of patient fall reported in a period / Total patient days in that period) x 1000

Patient fall must be defined. Generally, all kind of fall (fall from bed, in washroom, on stairs, while walking etc.) must be counted

53.    

Hospital-associated pressure ulcer rate

(Number of patients developing hospital associated pressure ulcers / Number of bedridden patient days) x 1000

Criteria for determining pressure ulcers shall be specified.

Patients at risk of developing pressure ulcers must be identified

54.    

Percentage of staff provided pre-exposure prophylaxis

(Number of staff who received pre-exposure prophylaxis / Total healthcare staff) x 100

Pre-exposure prophylaxis can be given for different conditions such as Hepatitis, certain kinds of Pneumonia etc.

55.    

Bed Occupancy Rate

(Total patient days in a period / Total bed days available during that period) x 100

Total patient days is the sum of days spent by each admitted patient in hospital

Total bed days is the product of number of functional beds in hospital with the number of days in that period

56.    

Average Length of Stay (ALOS)

Sum of length of stay of individual patients / Total number of patients whose length of stay has been taken

ALOS must be separately calculated for different disease conditions, specialities and ICU/Non-ICU cases

57.    

OT utilization rate

(Total hours for which actual surgeries were performed in OT / Total OT hours available) x 100

Total hours of surgeries can be calculated by summing up the duration of each surgeries performed in the period

 

Total OT hours can be calculated by multiplying functional hours available for each OT with the number of OT

58.    

ICU utilization rate

(Total ICU patient days in a period / Total ICU bed days available in that period) x 100

This is similar to calculation bed occupancy rate, but only for ICU

59.    

Percentage of downtime of Critical equipment

Total duration (in days or hours) for which a critical equipment was down / Total duration (in days or hours) in that period

A list of critical equipment shall be made.

This indicator shall be calculated separately for each critical equipment

60.    

Nurse patient ratio for wards

Total number of nurse working in a shift / Total number of patient in that shift

An average ratio of the month can be taken. This should be separately calculated for each shift and each ward

61.    

Nurse patient ratio for ICU

Total number of nurse working in ICU in a shift / Total number of patient in that shift

An average ratio of the month can be taken. This should be separately calculated for each shift and each ICU

62.    

Out-patient satisfaction index

Average rating given by patient of OPD to the hospital

A standard patient satisfaction feedback form can be used for obtaining rating from patients. Number of feedback collected should be statistically significant

63.    

In-patient satisfaction index

Average rating given by patient of IPD to the hospital

A standard patient satisfaction feedback form can be used for obtaining rating from patients. Number of feedback collected should be statistically significant

64.    

Average waiting time for services

Total waiting time of all patients for a particular service / Total number of patients whose waiting time has been taken

Average waiting time shall be separately calculated for OPD consultation, Billing, Pharmacy and
diagnostics

65.    

Average discharge time

Sum of time taken for discharging patients / Total patients whose discharge time is taken

Time taken for discharge shall be taken from the time when the discharged was ordered by the doctor till the time when patient was relieved from room/bed

66.    

Employee satisfaction index

Average rating given by employee to the organization

An employee satisfaction study must be conducted for this.

The index can be calculated for different categories of employees

67.    

Employee attrition rate

(Number of employee who resigned during a period / Total number of employee on roll) x 100

This should be calculated overall as well as category wise

68.    

Employee absenteeism rate

(Total number of absenteeism of employee in a period / Total employee days) x 100

Absenteeism shall be considered as absent without information.

 

This indicator shall also be calculated category wise

69.    

Percentage of employee aware of employee rights

(Number of  employee aware of employee rights / Total number of employee) x 100

Category-wise calculation shall be done

70.    

Percentage of sentinel events analysed within a defined time frame

(Number of sentinel events analysed within defined time frame / Number of sentinel events reported) x 100

Timeframe and sentinel events must be defined

71.    

Percentage of near misses

(Number of near misses reported / Total number of errors and near-miss reported) x 100

A robust system of reporting errors and near misses must be in place

72.    

Needlestick injury rate

(Number of needle stick injury reported / Total patient days in that period) x 100

Needlestick injury reporting and data collection mechanism must be in place

73.    

Percentage of medical records not having discharge summary

(Number of medical records not having discharge summary / Total number of medical records screened) x 100

Sufficient sample size must be ensured

74.    

Percentage of medical records not having ICD codes

(Number of medical records not having ICD codes / Total number of medical records screened) x 100

Sufficient sample size must be ensured

75.    

Percentage of medical records having incomplete and improper consent

(Number of medical records having incomplete and improper consent / Total number of medical records where consent was applicable

Standard process of informed consent must be in place to determine what constitutes incomplete or improper consent

76.    

Percentage of missing records

(Number of medical records missing / Total number of medical records in MRD) x 100

A definition of missing shall be available. Generally, any medical record which has been able to be traced for last 3 days shall be considered missing. In case, a missing record has been found it shall be removed from the missing data

 

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Source:indianexpress