NABH Key Performance Indicators

The Key performance Indicators expected to be monitored by healthcare organisation:

S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
1 This shall be captured either through the
The time shall begin from Sum of time HIS, or through audit in case of audit, the
Time for the time that the patient taken for the sample size shall be as specified in the
initial has arrived at the bed of assessment sample size calculation table. Day care
PSQ 3a assessment of the ward till time that the patients are not included
Indoor initial assessment has been Total number Minutes Monthly Sampling: Yes
patients completed and of admissions Sampling
documented by a doctor. (sample size) methodology: Stratified random

This includes reporting errors picked up

after dispatch. This shall be captured in
the laboratory and radiology. Reporting
Number of errors include transcription errors. For
reporting better analysis, the organisation could
errors capture the data separately for different
laboratory departments (For example,
Number of Biochemistry/ Microbiology/Pathology)
reporting and Imaging modalities (for example, X-
2 PSQ 3a errors per /1000 Ray/USG/CT/MRI). Further, the
1000 x1000 tests Monthly organisation could consider capturing
investigations data pertaining to reporting errors that
were Identified and rectified before
Number of dispatch of the reports. This would enable
tests the organisation to improve on its
performed process. Although the indicator is
collated on a monthly basis, immediate
correction is to be initiated when such
instances happen. Sampling: No
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
This shall be captured in the laboratory
Number of and radiology. This shall be captured by
staff adhering doing an audit on a monthly basis. The
Percentage of to safety audit should be done by the competent
adherence to precautions individual outside of the department
safety Perce being audited. Even if the staff is not
3 PS03a precautions X100 ntage Monthly adhering to anyone of the organisation's/
by staff statutory safety requirements, it shall be
working in Number of considered as non- adherence.
diagnostics staff audited Sampling: Yes
Sampling methodology: Stratified
random

A medication error is any

preventable event that may
cause or lead to Total number The methodology for capture shall be as
inappropriate medication of medication stated in NABH's document on
Incidence of use or patient harm while errors medication errors. The indicator shall be
4 PS03a medication the medication is in the Perce Monthly captured for admitted patients
errors control of the healthcare X100 ntage Sampling: Yes
Total number
professional, patient or of Sampling methodology: Stratified
consumer. (Ref: NCC- opportunities random
MERP)

Adverse Drug reaction is a Number of

response to a drug which patients
Percentage of is noxious and unintended developing The organisation needs to have a
in-patients and which occurs at doses, adverse drug mechanism in place to ensure that all
5 PS03a developing normally used in man for reactions Perce Monthly adverse drug reactions are captured and
adverse drug prophylaxis, diagnosis, or X100 ntage reported.
reaction(s). therapy of disease or for Sampling: No
the modification of Number of
physiologic function. In-patients
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Unplanned return to the Number of The data shall be captured with a delay of
OT is defined as any unplanned 30 days. This ensures that the
secondary procedure return to OT organisation has adequate time to capture
required for a complication complications that require unplanned
resulting directly from the return to the OT. For example, the data
index operation during which is collated In January would
Percentage of same admission. For Number of X 100 include surgeries done in the month of
6 PS03a unplanned example, post-operative patients who Perce Monthly November. This also includes unplanned
return to OT bleeding, debridement, underwent ntage re-exploration. This shall not include
secondary suturing, surgeries in surgeries under LA. However if any such
Embolectomy, evaluation the OT patient required unplanned return to the
under anaesthesia etc. OT, the same shall be captured in the
Incident Form.
Sampling: No

Number of This should be done by prospective audit.

Percentage of surgeries The audit shall be done when the surgery
surgeries where the Monthly is being performed A person(s) working
where the procedure in the OT complex could be entrusted
organisation's followed with this responsibility. It is preferable
7 PS03a procedure to that the identity of the person auditing is
prevent Number of X 100 Perce anonymised from the operating team
adverse surgeries that ntage Sampling: Yes Sampling methodology:
events like were audited Stratified random (distributed across
wrong site, various days and operating surgeons)
wrong patient
and wrong
surgery have
been adhered
to.
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Any adverse reaction to
the transfusion of blood or Number of
Percentage of blood components shall be transfusion
8 PS03a transfusion considered as transfusion reactions
reactions reaction. It may range X 100 Perce Monthly Number of units includes whole blood
from a mild allergic ntage and components. Sampling: No
reaction (including Number of
chills/rigors) to life- units
threatening complications transfused
like TRALI and Graft-
Versus-Host Disease.
Actual deaths Predicted death shall be calculated from
ICU models such as APACHE, SOFA SAPS,
Standardised Ratio Monthly MPM etc.
9 PSQ3a Mortality Predicted Sampling: No
Ratio for ICU deaths in ICU

Number of
Returns to return to ICU
PSQ3a ICU within within 48
10 48 hours hours This shall include data from all ICUs
X100 Perce Monthly within the organisation, excluding HOUs
Number of ntage Sampling: No
discharges/tra
nsfers from
the ICU
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Number of
returns to
emergency
Return to the within 72
emergency hours with
department similar
within 72 presenting To capture this indicator it may be a good
11 PSQ3a hours with complaints Perce practice to capture during the initial
similar Number of X 100 ntage Monthly assessment itself if the patient had come
presenting patients who within72 hours for similar complaints,
complaints have come to Sampling: No
the
emergency

Incidence of A pressure ulcer is Number of

hospital localized injury to the skin patients who
12 PSQ3a associated and/or underlying tissue develop new/ The organisation shall use The European
pressure usually over a bony worsening of and US National Pressure Ulcer Advisory
ulcers after prominence, as a result of pressure ulcer /1000 panels (EPUAP and NPUAP) staging
admission pressure, or pressure in X1000 patien Monthly system to look for worsening pressure
(Bed sore per combination with shear Total no of t days ulcers.
1000 patient and/or friction. patient days Sampling: No
days)

Number of
urinary
Catheter catheter /1000
associated As per the latest associated urinar
13 PS03b Urinary tract CDC/NHSN definition UTIs in a y Monthly Sampling: No
infection rate month X1000 cathet
Number of er-
urinary days
catheter days
In that month
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Number of
"Ventilator
Associated
Ventilator As per the latest Pneumonia In /1000
14 PS03b associated CDC/NHSN definition a month X 1000 ventil Monthly Sampling: No
Pneumonia Number of ator-
rate ventilator days
days In that
month

Central line- Number of /1000

associated As per the latest central line- centra
Blood stream CDC/NHSN definition. associated l line
PS03b infection rate blood stream days
15 infections in Monthly
a month X 1000 Sampling: No
No. of central
days in that
month
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Keeping in mind the definition of SSI,
the numbers would have to be updated on
a continual basis until such time that the
monitoring period is over For example, in
January, the data of December would be
reported. The denominator would be the
number of surgeries performed in
Number of December and that would not change.
surgical site With respect to the numerator, there
Infections in would be some data but it would not be
a given complete data. Hence whatever value the
month organisation gets at this stage would at
16 PS03b Surgical site As per the latest best be a preliminary value. The
infection rate COC/NHSN definition X-100 /100 Monthly organisation will continue to monitor the
proce patients and by end of January, would
dures have got complete data with respect to
procedures which have a 30-day
surveillance period At this point in time,
based on the data that the organisation
Number of has collated the numerator may change
surgeries and hence, the SSI rate. However this
performed in again would not be the final data. The
that month organisation will continue to monitor
procedures which have a 90- day
surveillance period, and If there are new
SSIs, it would get added to the numerator
and thus the rate would change. The
surveillance period for surgeries which
are done in December and have a 90- day
surveillance period would end on March
30m (give or take a few days). It is only
at this point in time that the organisation
can have the final 551 rata for December
Sampling: No
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Total number Observation involves directly watching
Compliance of actions and recording the hand hygiene
to Hand performed Perce behaviour of health care workers and the
17 PSQ3b hygiene X 100 ntage Monthly physical environment. Good reference is
practice. Total number WHO hand hygiene compliance
of hand monitoring tool Please refer
hygiene http://www.who.int/apsc/5may/tools/en/
opportunities http://www.who.int/entity/gpsc/may/Obs
ervation_Form.doc2ua=1
Sampling: Yes
Sampling methodology: Stratified
random

Number of Appropriate prophylactic antibiotic

patients who should be according to hospital policy.
Percentage of did receive The numerator shall include patients who
cases who appropriate received the appropriate drug (and dose)
received prophylactic within the appropriate time. A patient
appropriate antibiotic(s) X100 Perce Monthly who was not given prophylactic antibiotic
18 PSQ3b prophylactic ntage because it was not indicated (e.g. clean
antibiotics Number of surgery) shall be included in the
within the patients who numerator A patient, who is given
specified underwent prophylactic antibiotic even though it was
timeframe surgeries in not indicated, shall be considered as
the OT having received it Inappropriately.
Sampling: No

Percentage of Re-scheduling of surgeries Number of

re-scheduling includes cancellation and cases re- Perce Any case included in the OT list
of surgeries postponement (beyond 4 scheduled X100 ntages Monthly (including tentative/provisional) but
19 hours) of the surgery. Number of rescheduled shall be included in the
surgeries numerator.
planned Sampling: No
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Turnaround Time taken is to be Sum of time This will include blood outsourced from
time for issue calculated from the time taken other Blood Banks, for those
PS03c of blood and the request is) received in Total number organisations not having In-house Blood
20 blood the blood bank till the of blood and Banks
components blood is cross blood Sampling: No
matched/reserved and Components Minut
available for transfusion. cross- es
matched/
reserved
Nurse-patient Number of The HCOs should calculate the staffing
ratio for ICUs nursing staff patterns separately for ICUs and for the
and wards wards. The in-charge/supervisor of the
Number of area shall not be included for calculating
21 PS03c occupied Ratio Continuous the number of staff. It is preferable that in
beds case of ICU the organisation capture the
ratio for ventilated and non-ventilated
patients separately. To be calculated for
each shift separately. Sampling: No
Waiting time is a length of In case of appointment patients, the time
time which one must wait shall begin with scheduled appointment
in order for a specific Sum total time and end when the concerned
action to occur, after that time for consultant (not the junior doctor/resident)
action is requested or consultation begins the assessment. In cases where the
mandated. Waiting time patient has been seen ahead of the
22 PS03c Waiting time for out- patient appointment time, the waiting time shall
for out- consultation is the time Minut be taken as zero minutes.
patient from which the patient has es Sampling: No
consultation come to the concerned out- Total
patient department (it may Number of
or may not be the same out-patients
time as registration) till the
time that the concerned
consultant (not the junior
doctor/resident) begins the
assessment.
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Waiting time for Sum total Waiting time for diagnostics is applicable
diagnostics is the time time only for out- patients and for laboratory
from which the patient has and Imaging. In case of appointment
23 Waiting time come to the diagnostic Number of patients, the time shall begin with the
PSQ 3c for service (requisition form patients Minut Monthly scheduled appointment time and end
diagnostics has been presented to the reported in es when the diagnostic procedure begins, In
counter) till the time that Diagnostics cases where the patient's diagnostic test
the test is Initiated. commences ahead of the appointment
time the waiting time shall be taken as
zero minutes.
Sampling: No
The discharge process is Sum of time
deemed to have! started taken for In case patients request additional time to
when the consultant discharge leave the clinical unit that shall not be
24 PSQ 3c Time taken formally approves Minut Monthly added. The discharge is deemed to have
for discharge discharge and ends with Number of es been complete when the formalities for
the patient leaving the patients the same have been completed.
clinical unit discharged Sampling: No

Informed consent is a type Number of

of consent in which the medical
Percentage of healthcare provider has a records
medical duty to inform his/her having If any of the essential
records patient about the incomplete element/requirement of consent is
having procedure, its potential and/or missing it shall be considered as
25 PSQ 3c Incomplete risks and benefits, improper Perce incomplete. If any consent obtained is
and/or alternative procedure or consent X100 ntage Monthly invalid/void (consent obtained from
improper treatment with their risks wrong person/consent obtained by wrong

Number of
discharges
and deaths
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
To capture this, organisation should
maintain a register in the pharmacy and
stores (and also if necessary in the wards)
A stock out is an event wherein all such events are captured. The
which occurs when an organisation shall capture the number of
Number of item listed as an Number of instances. In one instance, it is possible
26 PSQ 3c stock-outs of emergency medication by stock-outs of that there was stock out of more than one
emergency the organisation is not emergency Numb Monthly emergency drug. For example, if on the
medications available upon the drugs er 7th there was an instance of stock out of
requested need date in the two emergency drugs and on 24th there
organisation. was an instance of stock out of one
emergency drug, the value of the
indicator would be two.
Sampling: No

A mock drill is a
simulation exercise of
Number of preparedness for any type To capture the variation it is suggested
variations of event. It could be an Total number that every organisation develop a
27 PSQ 3d observed in event or disaster. This is of variations Numb Monthly checklist to capture the events during a
mock drills basically a dry run or observed in a er mock drill. This shall also include table
preparedness drill. For mock drill top exercises.
example, fire mock drill, Sampling: No
disaster drill, Code Blue
Drill
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
The US Department of Number of Falls may be:
Veteran Affairs National patient falls  at different levels- i.e. from one
Centre for Patient Safety level to ground level e.g. from
defines fall as "Loss of beds, wheelchairs or down stairs
upright position that  on the same level as a result of
results in landing on the slipping. tripping, or stumbling, or
Incidence of floor, ground or an object from a collision, pushing, or
28 PSQ 3d patient falls. or furniture or a sudden, shaving, by or with another
uncontrolled, person
unintentional, non- /1000 Monthly  below ground level, i.e. Into a
purposeful, downward X1000 patien hole or other opening in surface
Total number
displacement of the body t days
of patient
to the food/ground or All types of falls are to be included
days
hitting another object like whether they result from physiological
a chair or stair”. reasons (fainting) or environmental
reasons Assisted falls (when another
It is an event that results in person attempts to minimize the impact
a person coming to rest of the fall by assisting the patient's
inadvertently on the descent to the floor) should be. Included
ground or floor or other (NDNOI, 2005),
lower level. Sampling: No

A near miss is an Number of

unplanned event that did near misses
not result in injury, illness, reported A key to any near miss report is the
or damage-but had the "lesson learned” Near miss reporters can
Percentage of potential to do so. describe what they observed of the
29 PSQ 3d near misses Number of X 100 Perce Monthly beginning of the event, and the factors
Errors that did not result in Incidents ntage that prevented loss from occurring
patient harm, but could reported Sampling: No
have, can be categorized as
near misses.
S. Standar Indicator Definition Formula Unit Frequency Remarks
No. ds of Data
Collation/
Monitoring
Needle stick injury is a Number Number of occupied beds is the average
penetrating stab wound needle stick of the sum of the daily figures for the
from a needle (or other Injuries number of beds occupied by patients. The
sharp object) that may rate will be monitored on a monthly basis
result in exposure to blood but reported cumulatively i.e. in the form
Rate of or other body fluids. /100 Monthly on of year to date. For example, in January It
30 PSQ 3d needle stick Needle stick injuries are X100 occup a would be January data but in February it
injuries wounds caused by needles Number of ied cumulative would be January February data, in July
that accidentally puncture occupied beds basis it would be data from January to July and
the skin. beds so on so that by the end of the year the
(Canadian Centre for annual rate is obtained.
Occupational Health and Sampling: No
Safety)

Total number Handover is an important communication

of handovers tool used by healthcare workers. The data
Appropriate done can be collated together but it has to be
31 PSQ 3d handovers appropriately Perce Monthly captured separately for doctors and
during shift X100 ntage nurses. Handover documentation by each
change Total number shift can be used as a guide to capturing
of handover the Information.
opportunities Sampling: No

Total no. of
prescriptions
in capital
Compliance letters X100 Perce Monthly This includes only prescriptions for out-
rate to ntage patients.
32 PSQ 3d Medication Sampling: Yes
Prescription Total number Sampling methodology: Stratified
in capitals of sampled random
prescriptions
 Sample size calculation (Monthly)

Screening Population Sample Size

50 44
100 79
150 108
200 132
500 217
1000 278
2000 322
5000 357
10000 370
20000 377

 Screening population is the 'base' from which the samples would be selected. The base shall be the average of the previous three months. For
example, in the case of time for initial assessment of patients, this would be the average number of patients admitted per month in the preceding
three months. Assuming that the average is 200, this would constitute the screening population and the organisation would have to sample 132
patients over the entire month.

 For the recommended sample size, all the samples should be taken on a continuous basis.