gap analysis of nabh 3rd and 4th edition

Quality indicators

Chapters Standards O/E

NABH 4th edition standard

70 10 105 683

NABH 3rd Edition standard

65 10 102 636

Gap analysis of 3rd to 4th edition NABH The key performance indicators expected to be monitored by Healthcare

organization

4th edition 3rd edition

Access, Assessment and Continuity of Care (AAC)

•Standard

•observation elements

14

96

•Standard

•O/E

14

86

Care of patients ( COP) •Standard

•O/E

22

151

•Standard

•O/E

20

136

Management of medication (MOM)

•Standard

•O/E

13

76

•Standard

•O/E

13

73

Patients rights and education (PRE)

•Standard

•O/E

8

54

•Standard

•O/E

7

46

Hospital Infection Control (HIC)

•Standard

•O/E

9

54

•Standard

•O/E

9

51


Continuous Quality Improvement (CQI)

•Standard

•O/E

9

59

•Standard

•O/E

8

57

Responsibilities of Management (ROM)

•Standard

•O/E

6

39

•Standard

•O/E

6

38

Facility Management & Safety (FMS)

•Standard

•O/E

7

56

•Standard

•O/E

8

54

Human Resource Management (HRM)

•Standard

•O/E

10

53

•Standard

•O/E

10

52

Information Management Systems (IMS)

•Standard

•O/E

7

45

•Standard

•O/E

7

43

Continuous Quality Improvement (CQI) 3(a)


Standard a .Time for initial assessment of indoor patients.b. Time taken for initial assessment of patients attending emergency services

a. Time for initial assessment of indoor and emergency patients

Definition a. The time shall begin from the time that the patient has arrived at the bed of the ward till the time that the initial assessment has been completed by a doctor

b. In case of emergency the time shall begin from the time the patient’s arrival at the emergency till the time that the initial assessment is completed by a doctor.

a. The time shall begin from the time that the patient has arrived at the bed of the ward till the time that the initial assessment has been completed by a doctor.

Formula Sum of time taken for the assessment. Total number of patients in indoor /emergency

Sum of time taken Total number of patients (sample size)

Frequency Periodic- At least monthly •NOT MENTIONED



Standard Same a. Percentage of cases (in-patients) wherein care plan with desired outcomes is documented and countersigned by the clinician.

Definition Same b. Desired outcome includes curative, preventive, rehabilitative etc.

Formula Number of in-patient case records wherein the care plan with desired outcomes has been documented x 100 Total number of patients.

Number of in-patient case records wherein the care plan with desired

outcomes has been documented x 100 Total Number of patients (sample size)

Frequency Periodic At least monthly. •NOT MENTIONED



Standard same • Percentage of cases (in-patients) wherein screening for nutritional needs has been done.

Definition same Same

Formula Number of in-patient case records wherein the nutritional assessment has been documented x 100 Total number of patients

Number of in-patient case records wherein the nutritional assessment

has been documented x 100Total number of patients (sample size)

Frequency Periodic- at least monthly



Standard same Percentage of cases (in-patients) wherein the nursing care plan is documented.

Definition same Nursing care plan shall be the outcome of the nursing assessment done at the time of admission

Formula Number of in-patient case records wherein the nursing care plan has been documented x 100 Total number of patients.

Number of in-patient case records wherein the nursing care plan Has been documented x 100Total number of patients (sample size)

Frequency Periodic at least monthly Not mentioned

Continuous Quality Improvement (CQI) 3(b)


Standard Same Number of reporting errors/1000 investigations

Definition Same Reporting errors include those picked up before and after dispatch. It shall include transcription errors.

Formula Same Number of reporting errors x 1000 Number of tests performed

Frequency Continuous •Not mentioned



Standard • Rate of re-dos •Percentage of re-dos

Definition same •This shall also include tests repeated before release of the result (to confirm the finding).

Formula same Number of re-dos x 1000Number of tests performed

Frequency of data collection/ monitoring

Refer sample size (continuous)

• Not mentioned

Screening Population Sample size50 44

100 79150 108200 132500 217

1000 2782000 3225000 357

10000 37020000 377



Standard same •Percentage of reports co-relating with clinical diagnosis

Definition :Co-relation means that the test results should match either the diagnosis or differential diagnosis written in the discharge summary.

• Co-relation means that the test results should match either the diagnosis or differential diagnosis written in the requisition form.

Formula Number of reports co-relating with clinical diagnosis x 100 Number of tests performed

Number of reports co-relating with clinical diagnosis x 100 Number of tests performed


Continuous Not Mentioned



Standard same Percentage of adherence to safety precautions by employees working in diagnostics.

Definition same same

Formula same Number of employees adhering to safety precautions x 100 Number of employees sampled


Periodic at least quarterly

Continuous Quality Improvement (CQI) 3(c)


Standard Incidence of medication errors (Medication errors per patient days)

• Incidence of medication errors

Definition In addition to 3 rd

Calculation or preparation of a) Prescription error b) Dispensing error.

A medication errors is any preventable event that may cause or lead to inappropriate medication use or harm to a patient (US-FDA) Examples include, but are not limited to:• Errors in the prescribing, transcribing, dispensing,

administering, and monitoring of medications; • Wrong drug, wrong strength or wrong close errors• Wrong patient errors;• Wrong route of administration errors; and • Calculation or preparation errors.

Formula Total number of medication errors x 1000 number of patient days

A) Total no of prescription errors x 1000 No. of patient days

B) Total no. of medication dispensing errors x 1000 NO. of patients days

Total number of medication errors x 100 Number of patient days


continuous monitoring and periodic at least monthly.

•Not mentioned



Standard Percentage of admissions with adverse drug reaction(s) (Adverse drug reactions per 100 separations)

•Percentage of admissions with adverse drug reaction (s)

Definition Refer to glossary •Refer to glossary

Formula same Number of adverse drug reactions x 100 Number of discharges and deaths


continuous •Not mentioned



Standard Same •Percentage of mediation charts with error prone abbreviations

Definition Same •Medication chart with illegible handwriting and un accepted error prone abbreviations

Formula same • Number of medication charts with errors prone abbreviations x100 Number of medication charts reviewed


Continuous monitoring and periodic at least monthly.

•Not mentioned



Standard Same •Percentage of patients receiving high risk medications developing adverse drug event.

Definition Same •High risk medications are medications involved in a high percentage of medication errors or sentinel events and medications that carry a high risk for abuse, error, or other adverse outcomes. A good reference for this is the “ISMP’s list of high Alert medications”

Formula same Number of patients receiving high risk medications who have an adverse drug event x 100 Number of patients receiving high risk medications


Continuous Not mentioned

Continuous Quality Improvement (CQI) 3(d)


Standard same •Percentage of modification of anaesthesia plan

Definition same •The anesthesia plan is the outcome of pre-anaestheisa assessment/ Any changes done after this shall be considered as modification of anaesthesia plan.

Formula same Number of patients in whom the anaesthesia plan was modified x 100 Number of patients who underwent anaesthesia





Standard same •Percentage of unplanned ventilation following anaesthesia.

Definition same •same

Formula same Number of patients requiring unplanned ventilation following anaesthesia x 100 Number of patients who underwent anaesthesia


Continous



Standard Same •Percentage of adverse anaestheisa events

Definition Same •Adverse anaesthesia event is any untoward medical occurrence that my present during treatment with an anaesthetic product but which does not necessarily have a causal relationship with this treatment.

Formula same Number of patients who developed adverse anaesthesia event x100Number of patients who underwent anaesthesia


Continuous



Standard Same • Anaesthesia related mortality rate

Definition Same •Any death where the cause is possible probable (likely) or certain to be due to anaesthesia shall be included.

Formula same Number of patients who died due to anaesthesiax100 Number of patients who underwent anaesthesia


Continuous

Continuous Quality Improvement (CQI) 3(e)


Standard Same •Percentage of unplanned return to OT

Definition Same •same

Formula Same Number of unplanned return to OT x100Number of patients who underwent anaesthesia


continuous



Standard same •Percentage of re-scheduling of surgeries

Definition same •Re-scheduling of patient s includes cancellation and postponement (beyond 4 hours) of the surgery.

Formula same Number of cases re-scheduled x100Number of surgeries performed


Continous



Standard Same •Percentage of cases where the organization procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to

Definition Same •same

Formula Same Number of cases where the procedure was followed x 100Number of surgeries performed


•Not mentined



Standard same •Percentage of cases who received appropriate prophylactic antibiotics within the specified time frame.

Definition same •same

Formula same Number of patients who did receive prophylactic antibiotic (s)x100 Number of surgeries performed


Continous •Not mentioned



Standard Percentage of cases in which the planned surgery is changed intraoperative.

------------------Formula No. of cases in which the planned

surgery is changed intraoperative x100 Total no. of surgeries performed.


Continuous and periodic monthly. ( Refer sample size )

Screening Population Sample size50 44

100 79150 108200 132500 217

1000 2782000 3225000 357

10000 37020000 377



Standard Re – exploration rate

…………………………….

Formula NO. of re-explorations done during same admission x 100 Total number of surgeries


Periodic monthly

Continuous Quality Improvement (CQI) 3(f)


Standard Percentage of transfusion reactions recipient. The causes include red blood cell incompatibility ,allergic sensitivity to the leukocytes, platelets, plasma protein components of the transfused blood; or potassium or citrate preservatives in the banked blood

Percentage of transfusion of transfusion reactions

Definition A systemic response by the body to the administration of blood incompatible with that of the recipient

A systemic response by the body to the administration of blood incompatible with that of the recipient. The causes include red blood cell incompatibility allergic sensitivity to the leukocytes, platelets, plasma protein components of the transfused blood; or potassium or citrate preservatives in the banked blood.

Formula Number of transfusion reactions x 100 Number of units transfused Number of transfusion reactions x 100

Number of transfusions





Standard Percentage of wastage of blood and blood components

Percentage of wastage of blood and blood products

Formula A) Number of blood and blood components units wasted among those issued x 100 Number of blood and blood components units issued from the blood bank.

B) Number of blood and blood components units wasted at blood bank/blood storage center x100 Number of blood and blood components units stored in the blood bank.

Number of blood and blood products used x100 Number of blood and blood products issued from the blood bank


Continuous. Not mentioned



Standard same •Percentage of blood component usage

Formula same Number of components used x 100Number of blood and blood products used


Continuous



Standard same •Turnaround time for issue of blood and blood components

Definition same •The time shall begin from the time that the order is raised to blood/blood component reaching the clinical unit.

Formula same Sum of time takenTotal number of blood and blood

components issued


Continuous

Continuous Quality Improvement (CQI) 3(g)


Standard •Catheter associated urinary tract infection rate

•Urinary tract infection rate

Definition •Same •As per the latest CDC/NHSN definition

Formula •Same • Number of urinary catheter associated UTIs in a month x 1000 Number of urinary catheter days in

that monthFrequency of data collection/ monitoring

•continuous •Not mentioned



Standard Ventilator associated Pneumonia rate.

•Pneumonia rate

Definition Same •As per the latest CDC/NHSN definition

Formula same Number of “ventilator Associated Pneumonias” in a month x 1000 Number of ventilator days in that month


Continuous •Not mentioned



Standard Central line associated Bloodstream infection rate.

•Bloodstream infection rate

Definition Same •As per the latest CDC/NHSN definition

Formula Same Number of central line associated blood stream infections in a month x1000Number of central line days in that month





Standard Same •Surgical site infection rate

Definition Same •As per the latest CDN/NHSN definition

Formula Same Number of surgical site infections in a given month x 100 Number of surgeries performed in that month


continuous

Continuous Quality Improvement (CQI) 3(h)


Standard same •Mortality rate

Formula a. Number of deaths x100 Number of discharges and deaths.b. Proportional maternal mortality rate= Total no. of maternal deaths x 100 Total no. of deathsc. Proportional infant mortality rate= Total no. of infant deaths x100 Total no. of deaths.

Number of deaths x 100 Number of discharges and deaths





Standard Same •Return to ICU within 48 hours

Formula same Number of returns to ICU within 48 hoursx100 Number of discharge/transfers and deaths in the ICU





Standard Same •Return to the emergency department within 72 hours with similar presenting complaints

Formula same Number of returns to emergency within 72 hours with similar presenting complaints x100Number of patients who have come to the emergency





Standard Same •Re-intubation rate.

Definition Same •This shall include re-intubation within 48 hours of extubation

Formula Same Number of re-intubations within 48 hours of extubation x100Number intubations



Continuous Quality Improvement (CQI) 3(i)


Standard Same •Percentage of research activities approved by Ethics committee

Formula Same Number of research activities approved by ethics committee x 100 Number of research protocols submitted to ethics committee





Standard Same •Percentage of patients withdrawing from the study

Formula Same Number of patients who have withdrawn from all on-going studiesx100Number of patients enrolled in all on-going studies.


continuous



Standard Same •Percentage of protocol violations/ deviations reported

Formula Same Number of protocol violations/ deviations reported x 100 Number of protocol violation/ deviations that have occurred





Standard Same •Percentage of serious adverse events (which have occurred in the organization) reported to the ethics committee within the defined timeframe.

Definition Same •The timeframe for reporting shall be as per ICMR guidelines or as laid down by the sponsor.

Formula same Number of serious adverse events reported within the defined timeframe x100Number of serious adverse events reported within and outside the defined timeframe.


continuous Not mentioned



Standard Same •Percentage of drugs and consumables procured by local purchase

Definition same •These include drugs Y consumables which are not include in the hospital formulary at the time of prescription, but are then arranged by hospital pharmacy itself for the patient with in a short time.

Formula a. Number of drug/items purchased by local purchase within formulary x 100 Number of drugs/items in hospital formulary list

B. Number of drugs/item purchased by local purchased outside formulary number of x 100 drugs/items procured in hospital within as well as

outside.

Number of items purchased by local purchase x 100

Number of drugs listed in hospital formulary and hospital consumables list





Standard Same •Percentage of stock outs including emergency drugs

Definition Same •A stock out is an event which occurs when an item in a pharmacy or consumable store is temporarily unable to provide for an intended patient.

Formula Same Number of stock outs x100 Number of drugs listed in hospital formulary and hospital consumables list





Standard Same •Percentage of drugs & consumables rejected before preparation of Goods Receipt Note

Definition Same •All materials received not in conformity with the specifications and requirements ordered for in the purchase order shall be rejected

Formula Same Total quantity rejected x 100Total quantity received before GRN





Standard Same •Percentage of variations from the procurement process.

Definition Same •Variations from the written standardized procurement process of acquiring supplies form licensed, authorized, agencies wholesales/distributors.

Formula Same Total number of variations from the usual procurement process x100Total number of items procured.





Standard Same •Number of variations observed in mock drills

Definition Same •Mock drill is a simulation exercise of preparedness of any type of event. It could be event or disaster. This is basically a dray run or preparedness drill. For example, fire mock drill, disaster drill, code blue drill.

Formula same Total number of variations in a mock drill





Standard Same •Incidence of falls

Definition same The US department of veteran affairs National Centre for Patient Safety defines fall as “Loss of upright position on the floor, ground or an object or furniture or a sudden, uncontrolled, unintentional, non-purposeful, downward displacement of the body to the floor/ground or hitting another object like a chair or stair.”It is an event that results in a person coming to rest inadvertently on the ground or floor or other lower level.

Formula Number of falls x 1000 Total number of patient days.

Number of falls x 100 Number of discharges and deaths.





Standard Incidence of hospital associated pressure ulcers after admission (Bedsore per 1000 patient days)

•Incidence of bed sores after admission

Definition same • A pressure ulcer is localized injury to the skin and/or underlying tissue usually over a bony prominence, as a result of pressure, or pressure in combination with shear and /or friction.

Formula (Number of patients who develop new/ worsening of pressure ulcer ) x 1000 Total no. of patient days.

Number of patients who develop new /worsening of pressure ulcer x 100 Number of discharges and deaths.





Standard same •Percentage of employees provided pre-exposure prophylaxis

Definition Same •Pre-exposure prophylaxis is any medical or public health procedure used before exposure to the disease causing agent, its purpose is to prevent, rather than treat or cure a disease. (wikipedia)

Formula Same Number of employees who were provided pre-exposure prophylaxis x 100 Number of employees who were due to be provided pre-exposure prophylaxis





Standard same •Bed occupancy rate and average length of stay

Definition Same The bed occupancy rate is the percentage of official beds occupied by hospital in-patinets for a given period of time- (Basic statistics for health information management technology by Carol E. Osborn)The occupancy rate is a calculation used to show the actual utilization of an inpatient health facility for a given time period.Length of stay (LOS) is a term used to measure the duration of a single episode of hospitalization. Inpatient days are calculated by subtracting day of admission from day of discharge. However, persons entering and leaving a hospital on the same day have a length of stay of one

Formula Same Number of inpatient days in a given monthx100 Number of available bed days in that month Number of inpatient days in a given month Number of discharges and deaths in that month





Standard Same •OT and ICU utilization rate

Definition Same OT utilization is defined as the quotient of hours of OT time actually used during elective resource hours and the total number of elective resource hours available for use.The degree of utilization depicts the average utilization of beds in per cent. The actual bed occupancy is set in relation to the maximum bed occupancy. The maximum bed capacity is the result of the product of installed beds and the number of calendar days in the reporting year. The actual bed occupancy is the sum of calculation days and occupancy days, because every patient occupies one bed per inpatient day in the facility.

Formula Same OT utilization rate = OT utilization time in hours x 100 Resource hoursICU Equipment utilization = Number of equipment utilized days x 100 Equipment days availableBed utilization =Number of bed utilized days x 100Bed days available





Standard Same •Critical equipment down time

Definition same •The term downtime is used to refer to periods when a system is unavailable. Downtime or outage duration refers to a period of time that a system fails to provide or perform its primary function.

Formula Sum of down time for all critical equipment in hours in a month.

•Sum of down time for all critical equipment in hours


continuous



Standard same •Nurse patient ratio for ICUs and wards

Formula Number of nursing staff Number of beds to be calculated for each shift separately

Number of staff Number of beds


continous •Not mentioned



Standard same •Out patient satisfaction index

Definition Patient satisfaction is defined in terms of the degree to which the patient’s expectations are fulfilled. It is an expression of the gap between the expected and perceived characteristics of a service.

Patient Satisfaction is defined in terms of the degree to which the patient’s expectations are fulfilled. It is an expression of the gap between the expected and perceived characteristics of a service (Lochoro, 2004) diagnostic service (requisition form has been presented to the counter ) till the time that the test is initiated.Waiting time for out-patinet consultation is the time from which the patient has come to the concerned out-patient department (it may or may not be the same time as registration) till the time that the concerned consultant (not the junior doctor/resident) begins the assessment.

Formula same Score achieved x100 Maximum possible score


Continuous monitoring and audits should be done at least.

•Not mentioned



Standard Same •In patient satisfaction index

Formula same •Average score achieved x 100 Maximum possible score


Continuous monitoring and audits should be done at least quarterly



Standard Waiting time for services including diagnostics and out-patient consultation

………………………………….

Definition A waiting time is a length of time which one must wait in order for a specific action to occur, after that action is requested or mandated. Waiting time for diagnostics is the time from which the patient has come to the diagnostic service (requisition form has been presented to the counter) till the time that the test is initiated. Waiting time for out-patient consultation is the time from which the patient has come to the concerned out- patient department ( It may or may not be the same time as registration ) till the time that the concerned consultant ( not the junior doctor/resident) begins the assessment.

Formula Sum (Patient- in Time for consultation/Procedure Patient Reporting Time in OPD/Diagnostics)Number of patients reported in OPD/Diagnostics


Periodic monitoring and audits should be done atleast quarterly



Standard Same •Time taken for discharge

Definition Same Discharge is the process by which a patient is shifted out from the hospital with all concerned medical summaries after ensuring stability.The discharge process is deemed to have started when the consultant formally approves discharge and ends with the patient leaving the clinical unit.

Formula same Sum of time taken for discharge Number of patients discharged


Periodic monthly and audits should be done at least quarterly.



Standard Same •Employee satisfaction index.

Definition Same •Employee satisfaction index is an index to measure satisfaction of employee in an organization

Formula Same Score achieved x100 Maximum possible score


Periodic Quarterly

Continuous Quality Improvement 57. CQI 4 e


Standard same Employee attrition rate

Definition same Attrition rate is the percentage of people leaving the organization.

Formula same Number of employees who have left x 100Number of employees at the beginning of month + newly joined





Standard same Employee absenteeism rate.

Definition same Absenteeism in employment law is the state of not being present that occurs when an employees is absent or not present at work during a normally scheduled work period

Formula same • Number of employees who are on unauthorized absence x 100

Number of employees.





Standard same Percentage of employees who are aware of employee rights, responsibilities and welfare schemes.

Definition same Employee awareness is the state or condition of being aware; having knowledge; consciousness about employee rights, responsibilities and welfare schemes.

Formula same Number of employees who are aware of employee rights, responsibilities and welfare schemes x 100Number of employees interviewed


Periodic monitoring and audits we should be done at least quarterly

Not mentioned

Continuous Quality Improvement 59. CQI 4 f


Standard Number of sentinel events reported, collected and analyzed within the defined timeframe.

Number of sentinel events reported, collected and analyzed within the defined timeframe.

Formula Number of sentinel events analyzed within the defined timeframe x100 Number of sentinel events reported / collected

Number of sentinel events reported, collected and analysed within the defined timeframex100Number of sentinel events reported, collected and analysed


Continuous -



Standard Same Percentage of near misses

Definition Same A near miss is an unplanned event that did not result in injury, illness, or damage- but had the potential to do so. Errors that did not result in patient harm, but could have, can be categorized as near misses.

Formula Same Number of near misses reported x100 Number of incidents reported


Continuous -



Standard Same Incidence of blood body fluid exposures

Definition Same An exposure is when blood, blood components or other potentially infectious materials come in contact with a staff’s eyes, mucous membranes, non-intact skin or mouth. (Adopted from Joan Viteri Memorial Clinic “PEP” Post Exposure Prophylaxis)

Formula a. In IPD areas: Number of blood body fluid exposures x1000 Number of in-patient days B. In OPD Areas: Number of blood body fluid exposures x1000 Number of OPD Patient visits

Number of blood body fluid exposures x100Number of in-patient days


Continuous -

Continuous Quality Improvement 64. CQI 4 g


Standard Same Incidence of needle stick injuries

Definition Same Needle stick injury is a penetrating stab wound from a needle ( or other sharp object) that may result in exposure to blood or other body fluids. Needle stick injuries are wounds caused by needles that accidentally puncture the skin. Needle stick injuries are a hazard for people who work with hypodermic syringes and other needle equipment. These injuries can occur at any time when people use, disassemble, or dispose of needles. When not disposed of properly., needles can become concealed in linen or garbage and injure other workers who encounter them unexpectedly. (canadi and centre for occupational Health and safety)

Formula In IPD Areas: Number of parenteral exposures x1000 Number of in-patient daysB. In OPD areas: Number of Parenteral exposures x1000 Number of OPD Patient visits.

Number of parenteral exposures x100Number of in-patient days


Continuous. -



Standard Same Percentage of medical records not having discharge

Definition Same A discharge summary is the part of a patient record that summarizes the reasons for admission, significant clinical findings, procedures performed, treatment rendered, patients condition on discharge and any specific instructions given to the patient or family (for example follow –up medications).It is a summary of the patient’s stay in hospital written by the attending doctor.

Formula Same Number of medical records not having discharge summary x100 Number of discharge and deaths.


- -



Standard Same Percentage of medical records not having codification as per International Classification of Diseases (ICD)

Definition Same The ICD is the international standard diagnostic classification for all general epidemiological, many health management purposes and clinical use. These include the analysis of the general health situation of population groups and monitoring of the incidence and prevalence of diseases and other health problems in relation to other variables such as the characteristics and circumstances of the individuals affected, reimbursement, resource allocation, quality and guidelines (WHO).

Formula Same Number of medical records not having codification as per International classification of Diseases (ICD) x100 Number of discharges and deaths.


Periodic monthly -



Standard Same Percentage of medical records having incomplete and/or improper consent.

Definition Same Consent is the willingness of a patient to undergo examination/procedure/treatment by a health care provider. Informed consent is a type of consent in which the health care provider has a duty to inform his/her patient about the procedure, its potential risk and benefits, alternative procedure with their risk and benefits so as to enable the patient to take an informed decision of his/her health care. If any of the essential element/requirement of consent is missing it shall be considered as incomplete. If any consent obtained is invalid/void (consent obtained from wrong person/consent obtained by wrong person etc. ) it is considered as improper.

Formula Same Number of medical records having incomplete and /or improper consent x100 Number of discharges and deaths.


Periodic monthly •Not mentioned



Standard Same Percentage of missing records

Definition Same A medical record is considered as missing when the record could not be found out from the MRD after the 72nd hours of the record request.

Formula Same Number of missing record x100 Number of records



Continuous Quality Improvement 67. CQI 3j


Standard Appropriate handovers during shift change (To be done separately for doctors and nurses) – (per patient per shift)

………………………………

Formula Total no. of handovers done appropriately x 100 Total no. of handover opportunities

Frequency of data collection/ monitoring Periodic monthly



Standard Incidence of patient identification errors

…………………………………..

Formula No. of patient identification errors x100 no. of patients


Periodic monthly.



Standard Compliance to hand hygiene practice

------------------------------------Formula Total no. of hand hygiene missed opportunities x100 Total no. of hand hygiene opportunities.


Periodic monthly.



Standard Compliance rate to medication prescription in capitals.

………………………..

Formula Total no. of prescriptions in capital letters x100 Total no. of prescriptions


Periodic monthly