Key Performance Indicators expected to be monitored by the healthcare organizatio

Standard Indicator
Time for initial assessment of indoor patients

1 PSQ 3a

Number of reporting errors/1000 investigations

2 PSQ 3a

Percentage of adherence to safety precautions by

staff working in diagnostics.

3 PSQ 3a

Incidence of medication errors

4
PSQ 3a

Percentage of in- patients developing adverse drug

reaction(s).
5 PSQ 3a
 Percentage of unplanned return to OT

6 PSQ 3a

Percentage of surgeries where the organization’s

procedure to prevent adverse events like the wrong
site, wrong patient, and wrong surgery have been
adhered to.

7 PSQ 3a

Percentage of transfusion reactions

8 PSQ 3a

Standardized Mortality Ratio for ICU

9 PSQ 3a

Return to ICU within 48 hours

10 PSQ 3a
 Return to ICU within 48 hours

10 PSQ 3a

Return to the emergency department within 72 hours wit

11 PSQ 3a

Incidence of hospital- associated pressure ulcers

after admission

12 PSQ 3a

Catheter-associated Urinary tract infection rate

13 PSQ 3b

Ventilator-associated Pneumonia rate

14 PSQ 3b

Central line- associated bloodstream infection rate

15 PSQ 3b

Surgical site infection rate

16 PSQ 3a

Compliance to hand hygiene practices

17 PSQ 3b

Percentage of cases who receive appropriate

prophylactic antibiotics within the specified time frame
18 PSQ 3b
 Percentage of cases who receive appropriate
prophylactic antibiotics within the specified time frame
18 PSQ 3b

Percentage of rescheduling of surgeries

19 PSQ 3c

Turnaround time for the issue of blood and blood

components
20 PSQ 3c

Nurse-patient ratio for ICUs and wards

21 PSQ 3c

Waiting time for outpatient consultation

22 PSQ 3c

Waiting time for diagnostics

23 PSQ 3c

Time taken for discharge

24 PSQ 3c
Percentage of medical records having incomplete
and/or improper consent

25 PSQ 3c
 Number of stock-outs of emergency medications

26 PSQ 3c

Number of variations observed in mock drills

27 PSQ 3d

Incidence of patient falls

28 PSQ 3d

Percentage of near misses

29 PSQ 3d

Rate of needlestick injuries

30 PSQ 3d
Appropriate handovers during shift change
31 PSQ 3d
Percentage of safe and rational prescriptions
32 PSQ 3d
monitored by the healthcare organization
Definition
The time shall begin from the time that the patient has
arrived at the bed of the ward until the time that the
initial assessment has been completed and documented
by a doctor.

A medication error is any preventable event that may

cause or lead to inappropriate medication use or patient
harm while the medication is in the control of the
healthcare professional, patient, or consumer. (Ref: NCC-
MERP).

Adverse Drug reaction is a response to a drug which is

noxious and unintended, and which occurs at doses
normally used in man for prophylaxis, diagnosis, or
therapy of disease or for the modification of physiologic
function.
Unplanned return to the OT is defined as any secondary
procedure required for a complication resulting directly
from the index operation during the same admission. For
example, post-operative bleeding, debridement,
secondary suturing, embolectomy, evaluation under
anesthesia etc.

Any adverse reaction to the transfusion of blood or blood

components shall be considered as transfusion reaction. It
may range from a mild allergic reaction (including chills/rigors)
to a life-threatening complication like TRALI and Graft Versus
A pressure ulcer is a 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.

As per the latest CDC/NHSN definition

As per the latest CDC/NHSN definition

As per the latest CDC/NHSN

definition

As per the latest CDC/NHSN definition

Re-scheduling of surgeries includes cancellation and
postponement (beyond 4 hours) of the surgery.

Time taken is to be calculated from the time the request is

received in the blood bank till the blood is
cross-matched/reserved and available for transfusion.

Waiting time is the 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 outpatient
consultation is the time from which the patient has come
to the concerned outpatient department (it may or may
not be the
Waiting same
time for time as registration)
diagnostics tillfrom
is the time the time that
which thethe
patient has come to the diagnostic service (the
requisition form has been presented to the counter) until
the time that the test is initiated.

The discharge process is deemed to have started when

the consultant formally approves discharge and ends
with the patient leaving the clinical unit
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
procedures with their risk and
A stock-out is an event that occurs when an item listed as
an emergency medication by the organization is not
available in the organization.

A mock drill is a simulation exercise of preparedness for

any type of event. It could be an event or disaster. This is
basically a dry run or preparedness drill.
For example, Fire
-mock drill, disaster drill, Code Blue Drill.

The US Department of Veteran Affairs National Centre for

Patient Safety defines fall as “Loss of upright position that
results in landing 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.”
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.

Needlestick injury is a penetrating stab wound from a

needle (or other sharp objects) that may result in
exposure to blood or other body fluids.

Rational use of medicines requires that patients receive

medications appropriate to their clinical needs, in doses
that meet their own individual requirements, for an
 Formula Unit
Sum of time taken for the assessment (in minutes)

Minute

Total number of admissions

Number of reporting errors

X1000 /1000 tests

Number of tests performed

Number of staff adhering to safety precautions

X 100 Percentage

Total number of medication errors

X100 Percentage

Total. No of Opportunities
Number of adverse drug reaction
Number of inpatients
X100 Percentage
Number of unplanned returns to OT

X 100 Percentage

Number of surgeries where the WHO safe surgery

checklist was followed

X100 Percentage

Number of surgeries that were audited

Number of transfusion reactions

X100 Percentage

Number of units transfused

Actual deaths in ICU

Ratio

Predicted deaths in ICU

Number of returns to ICU within 48 hours

x100 Percentage
Number of discharges/transfers from the ICU x100 Percentage

Number of returns to emergency within 72 hours with

similar presenting complaints

Number of patients who have come to the emergency X100 Percentage

Number of patients who develop new/ worsening of

pressure ulcer

/1000
X1000
Percentage

Total number of inpatient days

Number of urinary catheter-associated UTIs in a month
X1000 /1000 urinary catheter- days
Number of urinary catheter days in that month
Number of “Ventilator- Associated Pneumonia” in a
month

X1000 /1000 ventilator- days

Number of ventilator days in that month

Number of central line- associated bloodstream
infections in a month
X1000 /1000 central line days

Number of central line days in that month

Number of surgical site infections in a given month
Number of surgeries performed in that month
X100 /100 procedures

Total number of actions performed

X100 Percentage
Total number of hand hygiene opportunities
Number of patients who did receive appropriate
prophylactic antibiotic(s)
X100 Percentage
 X100 Percentage
Number of patients who underwent surgeries
Number of cases re-scheduled
X100 Percentage
Number of surgeries planned
Sum of time taken (in minutes)
Total number of blood and blood components cross-
matched/reserved Minutes

Number of nursing staff

Ratio

Number of occuiped bed

Sum total time (in minutes) for consultation

Total Number of outpatients
Minutes

Sum total time (in minutes)

Minute

Number of out- patients reported in Diagnostics

Sum of time taken for discharge (in minutes)
Minute
Number of patients discharged
Number of medical records having incomplete and/ or
improper consent

X100 Percent age

Number of stock-outs of emergency drugs

Number

Total number of variations in a mock drill

Number

Number of patient falls

/1000
X1000
patient days
Total number of inpatient days
Number of near misses reported

Number of incidents reported X100 Percent- age

Number of needlestick injuries

X1000 Rate
Average occupied beds
Total number of handovers done appropriately
X100 Percent- age
Total number of handover opportunities
Total number of safe and rational prescriptions
X100 Percent age
Total number of prescriptions audited
Remark
This shall be captured either through the HIS or through an audit. In case of an audit,
the sample size shall be as specified in the sample size calculation table.
Daycare patients are not included.
Sampling: Yes
Sampling methodology: Stratified random
++
For data captured through HIS-
Sampling: No
The system should track the number of records for which the initial assessment time
could not be captured due to incomplete data.

This includes reporting errors picked up after dispatch.

This shall be captured in the laboratory and Radiology. Reporting errors include
transcription errors.
For better analysis, the organization could capture the data separately for different
laboratory departments (For example, Biochemistry/Microbiology/Pathology) and
imaging modalities (for example, X- Ray/USG/CT/MRI). If a report has more than one
error in it, the total number of errors should be counted. For example, 10 tests were
This shall be captured by doing an audit on a monthly basis. The audit should be
done by an individual outside of the department being audited.Even if the staff is not
adhering to any one of the organization’s/statutory safety requirements, it shall be
considered as non- adherence.
Sampling: Yes
Sampling methodology: Stratified random

The methodology to capture shall be as stated in NABH’s document on medication

errors.
The indicator shall be captured for admitted patients.
Sampling: Yes
Sampling methodology: Stratified random

The organization needs to have a mechanism in place to ensure that all adverse drug
reactions are captured and reported.
Sampling: No
The data shall be captured with a delay of 30 days. This ensures that the
organization has adequate time to capture complications that require an unplanned
return to the OT. For example, the data which is collated in early January (assuming
that the December data is being reported) would include surgeries done in the
month of November.
This also includes unplanned re-exploration. This shall not include surgeries under
LA. However, if any such patient requires an unplanned return to the OT, the same
shall be captured in the incident form.
Sampling: No

This should be done by a prospective audit. The audit shall be done when the surgery is
being performed. A person(s) working in the OT complex could be entrusted with this
responsibility. It is preferable that the identity of the person auditing is anonymized from the
operating team.
Sampling: Yes
Sampling methodology: Stratified random (distributed across various days and operating
surgeons).

The number of units includes whole blood and components. The denominator is the
number of units transfused and not the number of units issued from the blood bank.
Sampling: No

Predicted death shall be calculated from models such as APACHE, SOFA, SAPS, MPM etc.
Sampling: No

This shall include data from all ICUs within the organization, excluding HDUs.
Sampling: No
This shall include data from all ICUs within the organization, excluding HDUs.
Sampling: No

To capture this indicator, it may be a good practice to capture during the initial assessment
itself if the patient had come within 72 hours for similar complaints.
Sampling: No

The organization shall use The European and US National Pressure Ulcer Advisory Panels
(EPUAP and NPUAP) staging system to look for worsening pressure ulcers.
Sampling: No

Sampling: No

Sampling: No

Sampling: No

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 for
December would be reported. The denominator would be the number of surgeries
performed in December, and that would not change. With respect to the numerator, there
would be some data but it would not be complete data. Hence, whatever value the
organization gets at this stage would at best be a preliminary value. The organization will
Observation involves directly watching and recording the hand hygiene behavior of
healthcare workers and the physical environment. A good reference is the WHO hand
hygiene compliance monitoring tool. Please refer: http://www.who.int/gpsc/5may/tools/en/
The appropriate prophylactic antibiotic should be according to hospital policy. The
numerator shall include patients who received the appropriate drug (and dose) within the
appropriate time. A patient who was not given prophylactic antibiotic because it was not
indicated (for example clean surgery) shall be included in the numerator.A patient who is
given a prophylactic antibiotic even though it was not indicated, shall be considered as
having received it inappropriately.
The appropriate prophylactic antibiotic should be according to hospital policy. The
numerator shall include patients who received the appropriate drug (and dose) within the
appropriate time. A patient who was not given prophylactic antibiotic because it was not
indicated (for example clean surgery) shall be included in the numerator.A patient who is
given a prophylactic antibiotic even though it was not indicated, shall be considered as
having
Any received
case it inappropriately.
included in the OT list (including tentative/provisional) but rescheduled/canceled
shall be included in the numerator. The start time for calculation of any delay shall be the
first booked time for that particular case.
Sampling: No
This will include blood outsourced from other Blood Banks, for those organizations not
having in-house Blood Bank.
Sampling: No

The HCOs should calculate the staffing patterns separately for ICUs and the wards.
The in-charge/supervisor of the area shall not be included for calculating the number of
staff.
It is preferable that in the case of ICU, the organization captures the ratio for ventilated and
non-ventilated patients separately.
To be calculated for each shift separately.
Sampling: No

In the case of appointment patients, the time shall begin with the scheduled appointment
time and end when the concerned consultant (not the junior doctor/resident) begins the
assessment. In cases where the patient has been seen ahead of the appointment time, the
waiting time shall be taken as zero minutes.
Sampling: No
Waiting time for diagnostics is applicable only for outpatients and for laboratory and
imaging.
In the case of appointment patients, the time shall begin with the scheduled
appointment time and end when the diagnostic procedure begins. In cases where the
patient's diagnostic test commences ahead of the appointment time, the waiting
time shall be taken as zero minutes.
Sampling: No

In case patients request additional time to leave the clinical unit that shall not be
added. The discharge is deemed to have been completed when the formalities for
the same have been completed. Day care patients are not included.
If any of the essential elements/requirements of consent is missing, it shall be
considered incomplete.
If any consent obtained is invalid/void (consent obtained from the wrong
person/consent obtained by the wrong person, etc.), it is considered improper.
Sampling: No
To capture this, the organization should maintain a register in the pharmacy and
stores (and also, if necessary, in the wards) wherein all such events are captured. The
organization shall capture the number of instances. In one instance, it is possible that
there was a stock-out of more than one emergency drug. For example, if on the 7th
there was an instance of stock out of two emergency drugs and on 24th there was an
instance of stock out of one emergency drug, the value of the indicator would be
two.
Sampling: No

To capture the variation, it is suggested that every organization develop a checklist to

capture the events during a mock drill. This shall also include tabletop exercises.
Sampling: No

Falls may be:

• at different levels – i.e., from one level to ground level, for example from beds,
wheelchairs or downstairs
• on the same level as a result of slipping, tripping, or stumbling, or from a collision,
pushing, or shoving, by or with another person
• below ground level, i.e. into a hole or other opening in the surface
All types
A key of falls
to any nearare to be
miss included
report is thewhether they result
“lesson learned”. from
Near physiological
miss reasons
reporters can
(fainting)
describe what they observed at the beginning of the event, and the factors that to
or environmental reasons. Assisted falls (when another person attempts
minimize
preventedthelossimpact of the fall by assisting the patient's descent to the floor) should
from occurring.
be included.
Sampling: No (NDNQI, 2005).

The denominator is the average of the sum of the daily figures for the number of
beds occupied by patients.
The rate will be monitored on a monthly basis but reported cumulatively i.e. in the
Handover is an important communication tool used by healthcare workers.
The data can be collated together but it has to be captured separately for doctors
and nurses.
This includes only prescriptions for out-patients. This indicator shall be captured
through the prescription audit. The methodology for audit shall be as stated in
NABH's document on prescription audit.
HIS/EMR system Guide
The system generates a time stamp for the
start time (time of the arrival of patient at
the bed of the ward) and the end time
(completion and documentation of initial
assessment by doctor). The initial
assessment is deemed to be completed
when the data pertaining to chief complaint,
history, examination findings, and
provisional/ final diagnosis is captured. Any
edits done subsequently to any of these
fields shall not result in the alteration of the
time stamp of the endpoint of the initial
assessment.
The denominator shall include all admissions
except daycare.shall include any
The numerator
amendment or revision carried out after the
report has been signed, and approved by the
authorized signatory and the system has
released the same.
The numerator shall include any
amendment or revision carried out after the
Considering the challenges of data capture
for this indicator through the system, there
should be a provision for entering the
manual/ electronically collected (app/ online
forms) data.

It is preferred that the data is captured

through the system for all the sub-
components of medication errors. Wherever
there is a limitation in capturing the
information through the system, there
should be a provision for entering the
manual/ electronically collected (app/ online
forms) data.

The organization can use or download PvPI

software (Vigi Fow) to document and
analyze adverse drug reactions.
The numerator shall be captured through an
incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
The system shall count the total number of
unplanned surgeries done within 30 days.
Wherever there is a limitation in capturing
the information through the system, there
should be a provision for entering the
manual/ electronically collected (app/ online
forms) data.

Considering the challenges of data capture for

this indicator through the system, there should
be a provision for entering the manual/
electronically collected (app/ online forms) data.

The numerator shall be captured through an

incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
The denominator shall include the total number
of units transfused until midnight of the last day
of the calendar month.

The system shall calculate the total number of

deaths in all its ICUs until midnight of the last
day of the calendar month.
The denominator shall be captured through the
system.
Considering the challenges of data capture for
this indicator through the system, there should
be a provision for entering the manual/
electronically collected (app/ online forms) data
The system shall calculate the total number of
returns in all ICUs within 48 hours until midnight
of the last day of the calendar month.
The system shall calculate the total number of
discharges/transfers from all the ICUs until
midnight of the last day of the calendar month.
The system shall calculate the total number of
returns in all ICUs within 48 hours until midnight
of the last day of the calendar month.
The system shall calculate the total number of
discharges/transfers from all the ICUs until
midnight of the last day of the calendar month.

The system shall calculate the total number of

returns to an emergency within 72 hours with
similar presenting complaints until midnight of
the last day of the calendar month.

The numerator can be captured through an

incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
The denominator shall include the total number
of in-patient days until midnight
of the last day of the calendar month. To
calculate the number of in-patient days only
patients admitted in the wards and ICUs shall be
included. Day care patients including patients
undergoing dialysis, and emergency shall not be
a part of this count.

The numerator can be captured through an

incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
There should be endeavors to capture the
denominator
The numerator data
canthrough the system.
be captured through an
incident reporting module/software (stand-
alone or integrated with HIS/EMR system).

There should be endeavors to capture the

denominator data through the system.

The numerator can be captured through an

incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
There should be endeavors to capture the
denominator data through the system.
The numerator shall be captured through an
incident reporting module/software (stand-
alone or integrated with HIS/EMR system).
The system shall calculate the total number of
surgeries performed until midnight on the last
day of the calendar month.
Considering the challenges of data capture for
this indicator through the system, there should
be a provision for entering the manual/
The system shall calculate the number of
patients who did receive appropriate
prophylactic antibiotic(s)until midnight of the
last day of the calendar month.
The system shall calculate the total number of
patients who underwent surgeries until midnight
of the last day of the calendar month.
The system shall calculate the number of
patients who did receive appropriate
prophylactic antibiotic(s)until midnight of the
last day of the calendar month.
The system shall calculate the total number of
patients
The whoshall
system underwent
calculatesurgeries untilofmidnight
the number
of the last
patients day ofsurgery
whose the calendar month.or delayed
was canceled
beyond 4 hours from the planned time as per OT
list. The system shall calculate the total number
The system shall calculate the sum of time taken
for the issue of all blood and blood components.
The denominator shall include the total number
of blood and blood components cross-
matched/reserved until midnight of the last day
of the calendar month.
The system shall calculate the number of nursing
staff in each location, each shift, each day. This
data shall be used to calculate the average for a
particular category (ward beds/ ICU
ventilated/ICU non-ventilated) for each shift and
day. The final step of the calculation involves
capturing the average of all the categories of
beds for all shifts.

The system shall calculate the sum of the total

waiting time of all Outpatient consultations.
The denominator shall include the total number
of out-patient days until midnight of the last day
of the calendar month.
The system shall calculate the sum of total
waiting time for patients for laboratory and
imaging services.
The denominator shall include the total
number of out-patients who reported in
laboratory and imaging until midnight of the
last day of the calendar month.

The system shall calculate the sum of the

time taken for all the discharges.The
denominator shall include the total number
Considering the challenges of data capture
for this indicator through the system, there
should be a provision for entering the
manual/ electronically collected (app/ online
forms) data.
The system shall calculate the number of
stock outs of emergency medications. In
case the system does not capture this value,
there should be a provision for entering the
manually collected data

Considering the challenges of data capture

for this indicator through the system, there
should be a provision for entering the
manual/ electronically collected (app/ online
forms) data.

The numerator shall be captured through an

incident reporting module/software (stand-
alone or integrated with HIS).
The denominator shall include the total
number of in-patient days until midnight
of the last day of the calendar month. To
calculate
The number theof
number of in-patient
near misses can be days only
captured
patients admitted in the wards
through an incident reporting and ICUs
shall be included. (stand-
module/software Daycarealone
patients including
or integrated
with HIS/EMR system).
The number of incidents reported can be
captured through an incident reporting
module/software (stand- alone or integrated
with HIS/EMR system).

The number of needle stick injuries shall be

captured through an incident reporting
module/software (stand alone or integrated
The system shall calculate the total number
of handovers done appropriately.
Considering the challenges of data capture
There should be endeavors to capture data
through the system. Wherever there is a
limitation in capturing the information
Department Specific key performance Indicators
S. Standard Indicator
No.

1 PSQ 3a Percentage of Beta-blocker

prescription with a diagnosis of CHF
with reduced EF

PSQ 3a Percentage of patients with

myocardial infarction for whom
Door to balloon time of 90 minutes
is achieved

Percentage of Hospitalized patients

with hypoglycemia who achieved
targeted blood glucose level.

3 PSQ 3a
3 PSQ 3a

4 PSQ 3a Spontaneous Perineal Tear Rate

5 PSQ 3a Postoperative Endophthalmit is rate

Percentage of patients undergoing

6 PSQ 3a
Colonoscopy who are sedated
 Percentage of patients undergoing
6 PSQ 3a
Colonoscopy who are sedated

Bile Duct injury rate requiring

operative intervention during
Laparoscopic Cholecystecto my

7 PSQ 3a

Percentage of POCT results which

8 PSQ 3a
led to a clinical intervention.
 Functional gain following
9 PSQ 3a
rehabilitation

Percentage of sepsis patients who

receive care as per the Hour-1 sepsis
bundle.

10 PSQ 3a

Percentage of COPD patients

receiving COPD Action plan at the
time of discharge
11 PSQ 3a

Percentage of stroke patients in

whom the Door-to- Needle Time
(DTN) of 60
minutes is achieved.

12 PSQ 3a
 minutes is achieved.

12 PSQ 3a

Percentage of bronchiolitis patients

treated inappropriately

13 PSQ 3a

Percentage of oncology patients

who had treatment initiated
following Multidisciplinar y meeting
(Tumour board

14 PSQ 3a

Percentage of adverse reaction to

15 PSQ 3a
radio- pharmaceutical
 Percentage of Intravenous Contrast
Media Extravasation

16 PSQ 3a

17 PSQ 3a Time taken for triage

Percentage of patients undergoing

dialysis who are able to achieve
target hemoglobin levels

18 PSQ 3a
mance Indicators
Definition Formula

Cardiology

Proportion of patients with Congestive Heart Failure for whom it X100

is indicated beta blocker prescription at the time of discharge

Number of patients discharged with

a diagnosis of CHF with reduced EF
and prescribed a beta blocker at
discharge

Number of patients discharged with

a diagnosis of CHF

X100

Number of acute myocardial

infarction (AMI) patients undergoing
primary angioplasty for whom Door
to balloon time of 90 minutes is
achieved

Total number of AMI patients

undergoing primary angioplasty

Endocrinology

The definitions provided by the American diabetes association Number of patients with
(ADA) from time to time shall be used to define hypoglycemia. hypoglycemic events where the
The blood glucose level is detected by POCT as well as target glucose level was achieved
continuous glucose monitoring. post- treatment.

X100
 X100
Number of patients with
Hypoglycemic events

Obstetrics

A Perineal tear (Perineal laceration) is a tear in the tissue (skin

and muscle) around the patient's vagina and perineum
Number of cases where a
spontaneous perineal tear occurs

X100
Total number of Vaginal deliveries

Ophthalmology

Postoperative endophthalmitis is an inflammatory condition of Number of cases of postoperative

the eye, presumed to be due to an infectious process from endophthalmitis
bacteria, fungi, or, on rare occasions, parasites that enter the
eye during the perioperative period

X100
Total no of Ophthalmic surgeries

Gastroenterology

Minimal Sedation (Anxiolysis) - A drug- induced state during

which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired, No. of patients sedated for the
ventilatory and cardiovascular functions are unaffected. colonoscopy procedure
Moderate sedation (Analgesia) - Indicates a drug-induced
depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied
by light tactile stimulation.
No interventions are required to maintain a patent airway, and
spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. X100
Deep sedation/ Analgesia - A drug- induced depression of
consciousness during which patients cannot be easily aroused
but respond purposefully after repeated or painful stimulation.
The ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a
patent airway and spontaneous ventilation is inadequate.
Cardiovascular function is usually maintained.
General Anaesthesia - A drug induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
which patients respond normally to verbal commands. Although
cognitive function and coordination may be impaired,
ventilatory and cardiovascular functions are unaffected.
Moderate sedation (Analgesia) - Indicates a drug-induced
depression of consciousness during which patients respond
purposefully to verbal commands, either alone or accompanied Total number of patients undergoing
by light tactile stimulation. Colonoscopy
No interventions are required to maintain a patent airway, and
spontaneous ventilation is adequate.
Cardiovascular function is usually maintained. X100
Deep sedation/ Analgesia - A drug- induced depression of
consciousness during which patients cannot be easily aroused
but respond purposefully after repeated or painful stimulation.
The ability to independently maintain ventilatory function may
be impaired. Patients may require assistance in maintaining a
patent airway and spontaneous ventilation is inadequate.
Cardiovascular function is usually maintained.
General Anaesthesia - A drug induced loss of consciousness
during which patients are not arousable, even by painful
stimulation. The ability to independently maintain ventilatory
function is often impaired. Patients often require assistance in Surgery

Bile duct injury during a Laparoscopic Cholecystectomy is an Number of cases where bile duct
unintentional injury to the biliary tree that occurs during the injuries occurred during laparoscopic
operation. cholecystectomy and required
subsequent operative intervention to
repair the injury

X100

Laparoscopic cholecystectomies
performed

Biochemistry

Point of care testing is defined as laboratory testing conducted Number of POCT tests which
close to the site of patient care typically by non-lab personnel resulted in a clinical intervention
e.g. nurses, where indicated.
e.g. blood gases, electrolytes, troponin, and blood glucose.

Number of POCT tests where clinical

intervention was deemed necessary.

X100

Rehabilitation Medicine
 The sum of the functional gain
achieved before the discharge in
patients undergoing
neurorehabilitation.

Functional gain implies improvement in physical quality and

X100
activity.
Total number of patients undergoing
neurorehabilitation

Sepsis Management

Number of sepsis patients who

receive care as per the Hour-1 sepsis
bundle.

Sepsis is a life- threatening organ dysfunction caused by a

X100
dysregulated host response to infection
Total number of sepsis cases

Respiratory Medicine/Pulmonary Med

Number of COPD patients provided

with a COPD action plan at the time
of discharge
An action is a simple guide that helps patients to take care of
X100
patients their COPD.
Number of COPD patients
discharged.

Neurology

Number of Stroke patients in whom

the Door to needle time of 60
minutes is achieved.
Door-to-needle time is the time it takes for the stroke patient to
X100
receive thrombolytic.
Door-to-needle time is the time it takes for the stroke patient to
X100
receive thrombolytic.
Number of stroke patients who
receive thrombolytic therapy.

Paediatrics

In patients with bronchiolitis steroids, bronchodilators, and

antimicrobials are not recommended and hence would
constitute inappropriate treatment. Number of patients treated
inappropriately.

Total number of patients with X100

bronchiolitis

Oncology

A tumor board is a multidisciplinary team including a group of Number of new oncology patients
specialists and other medical professionals who meet on a who had treatment initiated
regular basis. following multidisciplinary meeting
The objective is to collectively choose the most effective course (tumour board)
of treatment for a patient

X100

Number of new oncology cases (all

disciplines) treated in the month

Nuclear medicine

In general, the most common adverse reactions to Total number of patients who
radiopharmaceuticals are the following: nausea, dyspnea, developed adverse reaction(s) to
bronchospasm, decrease in blood pressure, itching,f flushing, radiopharmaceutical
hives, chills, cough, bradycardia, muscle cramps, and dizziness.

X100
Total number of patients receiving
the radiopharmaceutical

Radiology
Contrast extravasation is a problem that occurs when contrast
dye leaks into the tissue around the vein where the IV is placed.

Number of Contrast extravasation

X100
Number of patients receiving
contrast

Emergency Medicine

Triage is a process of prioritizing patients based on the severity

of their condition so as to treat as many as possible when
resources are insufficient for all to be treated immediately. The
sorting of patients according to criteria which ensures that the
most seriously ill or injured patient is treated before patients Sum of time taken (in minutes) for
with less serious problems. triage

Total number of patients coming to

the emergency

Nephrology

Number of patients undergoing

dialysis who are able to achieve
target hemoglobin levels

X100
Total number of patients undergoing
dialysis
 Unit Frequency of data Remarks
collation/ Monitoring

Cardiology

Percentage Monthly Mandatory if specialty is in the scope and this is applicable only
for admitted patients. The data has to be captured from the
discharge summary.
The 2022 AHA/ ACC/
HFSA Guidance for the Management of Heart Failure.
1. ACE/ ARB
2. Beta Blocker
3. Mineralocorticoid (MRA) receptor antagonist.
4. SGLT Inhibitor Step Ladder therapy guidelines

Percentage Monthly Mandatory if specialty is in the scope. The start time shall be
when the patient is diagnosed with AMI (STEMI at first ECG
after arrival at the hospital) and the clinician decides to
perform primary angioplasty as the first choice of treatment.
The end time shall be the time of the first device activation.
Reference: AHA Cardiac outcome assessment program (COAP)

ndocrinology

Mandatory if the specialty is in the scope.

As per the current ADA definition, the blood glucose level
below 54 mg/dl requires immediate action. Hence for the
purpose of this indicator only admitted patients experiencing
an episode of blood glucose level below 54 mg/dl shall be
included. The target glucose level is resolution of hypoglycemia
namely glucose level greater than or equal to 70 mg/dl.

Percentage Monthly
 namely glucose level greater than or equal to 70 mg/dl.

Percentage Monthly

Obstetrics

Mandatory if the specialty is in the scope. All four degrees of

perineal tear should be included.
An episiotomy may help to prevent a severe perineum tear
during childbirth.

Rate (per
hundred
Monthly
vaginal
deliveries)

phthalmology

Rate (per
hundred
Monthly Mandatory if the specialty is in the scope
ophthalmic
surgeries

stroenterology

Optional
Implementing sedation in GI Endoscopy will be considered
good practice, However, the indicator pertains to Colonoscopy
only as advised by the American Association of
Gastroenterology.
This includes all patients including out-patient and daycare.

Percentage Monthly
 Implementing sedation in GI Endoscopy will be considered
good practice, However, the indicator pertains to Colonoscopy
only as advised by the American Association of
Gastroenterology.
This includes all patients including out-patient and daycare.

Percentage Monthly

Surgery

Optional. The injury may be detected intra-operative or in the

postoperative period. All injuries requiring operative
intervention shall be included for calculation of the indicator
irrespective of the severity.

Rate Monthly

Biochemistry

Optional
The organization should have a mechanism to ensure that all
POCT results are documented.
Based on these results, it is preferable that the organization
identifies results which require clinical intervention and
documents the same.

Percentage Monthly

bilitation Medicine
 Optional. This is applicable only to admitted patients
undergoing neurorehabilitation (For example Stroke, Trauma,
Spinal injuries, post- neurosurgery etc.).
The organization shall use the Functional Independence
Measure (FIM) scale. This assesses physical and cognitive
disability.
Ranges from 18 to
126. Higher scores indicate more freedom for patients.
Further, this is a measure of disability for a variety of
Rate (per populations and is not specific to any diagnosis.
hundred
neurorehabil Monthly
it ation
patients)

sis Management

Mandatory if specialty (ICU) is in the scope

The start time of the timeframe of one hour is when the
patient reaches ER or ICU. In case the patient is shifted to the
ICU from the ER, the start time is when the patient arrives at
the ER.
Percentage Monthly The components of the Hour-1 bundle include measuring
lactate obtaining blood culture before administering
antibiotics, administering broad- spectrum antibiotics,
beginning rapid administration of appropriate fluid, and
applying vasopressors where appropriate. For the patient to be
included in the numerator all the 5 components have to be
dicine/Pulmonary Medicine met. Only if the organization does not have capabilities to

Mandatory if specialty is in the scope.

As recommended by GOLD standards.
Percentage Monthly Some of the components of the action plan could include
medications, advice regarding smoking cessation and
vaccination where appropriate.

Neurology

Mandatory if the specialty is in the scope. The start time shall

be when the patient arrives at the emergency and the end time
is initiation of thrombolytic therapy.

Percentage Monthly
 Percentage Monthly

Paediatrics

Mandatory if specialty is in the scope

American Academy of Pediatrics.
This would be applicable mostly to children less than 24
months.

Percentage Monthly

Oncology

Mandatory if specialty is in the

Percentage Monthly
scope

clear medicine

Percentage Monthly Mandatory if specialty is in the scope

Radiology
 Mandatory if CT and/or MRI is in the scope.
All patients undergoing intravenous contrast administration
during CT or MRI are included in the calculation of this indicator

Percentage Monthly

rgency Medicine

Mandatory
The start time is when the patient arrives at the emergency and
the end time is when the triage is completed.

Minutes Monthly

Nephrology

Mandatory if dialysis is in the scope. The target hemoglobin

Percentage Monthly level in patients undergoing dialysis shall be between 11- 12
gm/dl.
HIS/EMR system Guide

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.
If it is possible to retrieve data from HIS/EMR, the data
shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.
shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.
If it is possible to retrieve data from HIS/EMR, the data
shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for Entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from his/emr, the data

shall be captured through the system. However,
considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

If it is possible to retrieve data from his/emr, the data

shall be captured through the system. However,
considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.
If it is possible to retrieve data from HIS/EMR, the data
shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data.

The system generates a time stamp for the start time

(time of the arrival of patient at the emergency) and the
end time (completion of triage).
The denominator shall include all patients coming to the
emergency.

If it is possible to retrieve data from HIS/EMR, the data

shall be captured through the system. However,
Considering the challenges of data capture for this
indicator through the system, there should be a
provision for entering the manual/ electronically
collected (app/ online forms) data