NABH All 64 Indicators 3rd Edition To Be Measured For HRC

S
Std.
Indicators
Type
Definition/Interpretation
Source
Initiation/
generation of
data
Time for initial

assessment of
Indoor Patients
Formula
Sample size
Remarks
Process
The time shall begin from the

time that the patient has arrived
at the bed of the ward till the time Medical
that the initial assessment has
record
been completed by a doctor.
(Refer AAC 4 e-g.)
time will be put in

QA
MR by Either Ward
Face sheet &
Coordinator/Wa
nurse or attending
history sheet
rd Incharge
doctor
Sum of time taken

-----------------------------------------X100
Total no. of patients (sample)
The average time should be

reviewed by the hospital, to see if
1. For Hospitals with < 20 patients/day: 100%
this has impacted clinical care,
2. For Hospitals with 20-50
outcome, or has reduced the
patients/day: 50%
3. For Hospitals
efficiency. The outliers: Those
with > 50 patients/day: 20%
taking more than 20% of the
average time shall be audited.
Process
In case of emergency the time

shall begin from the time the
patient has come to the door of
the emergency till the time that
the initial assessment is
completed by a doctor. Wheel in
time in the emergency -time the
initial assessment was started by
the EMO
Wheel in register
time will be put in
(Bed no. time )
MR by Either Ward
& initial
QA Coordinator
nurse or attending
assessment
doctor
form (start
time )
Sum of time taken

------------------------------------------X100

patients/day: 50%
3. For Hospitals
with > 50 patients/day: 20%
CQI 3a
Time for initial

assessment of
Emergency
Patients
CQI 3a
Percentage of
cases (in-patients)
wherein care plan
with desired
Process
outcomes is
documented and
counter-signed by
the clinician
Percentage of
cases (in-patients)
wherein screening
Process
for Nutritional
needs has been
done
Percentage of
cases (in-patients)
wherein the
Process
Nursing care plan
is documented
Medical
record
Desired outcome includes

curative, preventive, rehabilitative Medical
etc.plan of care will be written by record
the doctor. (Refer AAC 4 h-j.)
Nutritional assessment can be

done by doctor/nurse/dietecian. It Medical
should be written in case sheet.
record
(Refer AAC 4 e-g).
Nursing care plan shall be the

outcome of the nursing
assessment done at the time of
Medical
admission. It should be written by record
the attendig nurse. (Refer AAC 4
d-e)
Record
sheet/ form
Patient Assessment
CQI 3a
Resp./
monitered
by
Plan of care to be
written by doctor
within a definite
time frame
doctor and nurse

who attends the
patient and there
after by dietecian
To be documented
by the ward nurse
in MR.
Care Plan
QA Coordinator sheet/In-patietn
case sheet
Nutritional
assessment
QA Coordinator form in Inpatient case
sheet
Nursing
administrator
Nursing
assessment
sheet
No. of in-patients case records

wherein the care plan with desired
outcome has been documented
---------------------------------------X100

wherein the nutritional has been
documented
---------------------------------------X100

wherein the nursing care plan
has been documented
---------------------------------------X100
The outliers: Those taking more

than 20% of the average time
shall be audited.
The indicator shall be captured

during the stay of the patient and
not from the medical record
1. For Hospitals with < 20 admissions/day: 100% department. It shall be collated
on a monthly basis. The sampling
admissions/day: 50%
base shall be patients who have
3. For Hospitals with > 50 completed 24 hours of stay in the
admissions/day: 20%
hospital. However, immediate
correction is to be initiated, when
gaps are seen on a real time
basis.
department. It shall be collated
1. For Hospitals with < 20 admissions/day: 100%
admissions/day: 50%
3. For Hospitals
completed 24 hours of stay in the
with > 50 admissions/day: 20%
basis.
department. It shall be collated
1. For Hospitals with < 20 admissions/day: 100%
admissions/day: 50%
3. For Hospitals with
completed 24 hours of stay in the
> 50 admissions/day: 20%
basis.
Safety/Quality for Diagnostics Services (Lab & Radiology)
CQI 3b
Number of
reporting
errors/1000
investigations
Process
Reporting errors include those

picked up before and after
dispatch. It shall include
transcription errors. This shall be
captured in laboratory and
radiology.(Refer AAC 6 g).
It should be
Lab/Radio reported by the
logy
Lab technician to
records
the HOD
Lab/Radiology.
Log book/
HOD Register/
Laboratory/Rad
Incident Report
iology
form
No. of reporting errors

(typing, wrong pt., wrong test)
---------------------------------------X1000
Total no. of tests performed
not applicable
It is better if the organisation

captures these errors as errors
picked up before dispatching the
reports & after the dispatch of
reports. Although indicator is to
be captured on a monthly basis,
an immediate action shall be
initiated when such instance
happen.
Re-dos include tests which

needed to be repeated in view of
poor sample or improper
Lab tech will
positioning and in case of
Lab/Radio document if there HOD radiology also includes film
logy
is re-do in any case Laboratory/Rad
wastage.. This shall also include
records
and maintain the
iology
tests repeated before release of
log.
the result (to confirm the finding).
(Refer AAC 6 g).
Percentage of Redo's
Pathologist and
Percentage of
Co-relation means that the test
Lab/Radio radiologist will
reports co-relating
results should match either the
logy
decide whether
Outcome
with clinical
diagnosis or differential diagnosis
records
reports are
diagnosis
written in the requisition form.
corelating
Process
Percentage of
adherence to
No. of Employees adhering to
safety precautions
Structure safety precautions e.g. PPE, Lead
by employees
aprons , TLD Badges, Gloves etc.
working in
diagnostics
Observati
on report
10
11
HOD Lab/Radiology
HOD Lab/Radiology
Log book/
Register/
Incident Report
form
Investigation
Slip
QI Register
No. of re-do's (hemolysed sample,

wrong sample)
---------------------------------------X100
in a month
No. of reports co-relating

clinical diagnosis
---------------------------------------X100
in a month (sample)
No. of employees adhering to

safety precautions
---------------------------------------X100
No. of employees (sample)
not applicable
1. For Hospitals with < 100 tests/month: 100%

tests/month: 50%
3. For Hospitals
with > 201-300 tests/month: 25%
4. For
Hospitals with > 301-500 tests/month: 20%
5. For Hospitals with > 500 tests/month: 15%
1. For Hospitals with < 25 employees working in
these areas: 100%
2. For
Hospitals with < 26-50 employees working in
these areas: 50%
3. For
Hospitals with > 51-100 employees working in
these areas: 30%
> 100 employees working in these areas: 20%
Shall be captured in the

laboratory (at least
histopathology) and radiology (at
least CT and MRI)
Shall be captured in the

laboratory (at least
histopathology) and radiology (at
least CT and MRI)
Even if the employees is not

adhering with any one of the
organisation's/statutory safety
precautions it shall be considered
as non-adherence.
Medication Management
Percentage of
medication errors
MANDATORY
INDICATOR 1
A medication error is any

preventable event that may cause
or lead to inappropriate
medication use or harm to a
patient (USFDA). Examples
include, but are not limited to:
Errors in the prescribing,

transcribing, dispensing,
Medical
Outcome
administering, and monitoring of records
medications;
Wrong drug, wrong strength, or
wrong dose errors;
Wrong patient errors; Wrong route

of administration errors; and
Calculation or
preparation errors.
QA Co
ordinator,
Nursing
superintendent
&
pharmacologist
or physician
Log book/
Register/
Incident Report
form
Percentage of
admissions with
adverse drug
reaction(s)
Adverse drug reaction: A

response to a drug which is
noxious and unintended and
which occurs at doses normally
used In man for prophylaxis,
Outcome
ADR form
diagnosis, or therapy of disease or
for the modification of physiologic
function. Therefore ADR
adverse event with a causal link
to a drug
QA Coordinator &
Nursing
administrator
Incident
Report/ADR form
Percentage of
medication charts
with error prone
abbreviations
Process
Medication chart with illegible

handwriting and unaccepted error Medical
prone abbreviations.(Refer MOM records
4g)
QA Coordinator &
Nursing
administrator
Medical records
Total no. of medication errors

---------------------------------------X100
Total no. of bed days
1. For Hospitals with average occupancy < 50

patients/day: 10% of patients/day.
average occupancy 51-100 patients/day: 5% of
patients/day.
3.
For Hospitals with average occupancy 101-300
4. For Hospitals with average
occupancy 301-500 patients/day: 2% of
patients/day.
5. For Hospitals with average occupancy 5011000 patients/day: 1% of patients/day.
average occupancy > 1000 patients/day: 0.5%
of patients/day.
Total no. of adverse

drug reactions
---------------------------------------X100
Total no. of discharges
and deaths
NA
Total no. of medication charts

with error prone abbreviations
---------------------------------------X100
Total no. of medication
charts reviewed
1. For Hospitals with average occupancy < 50

2. For Hospitals with average
occupancy 51-100 patients/day: 5% of
patients/day.
3. For Hospitals with average occupancy 101300 patients/day: 3% of patients/day.
average occupancy 301-500 patients/day: 2% of
patients/day.
5.
For Hospitals with average occupancy 501-1000
average occupancy > 1000 patients/day: 0.5%
of patients/day.
In addition to incident reporting,

to detect medication errors the
organization shall either adopt
medical record review or direct
observation. The sample size for
this shall be as per the preceding
column. The average occupancy
shall be of the preceding 3
months
12
Percentage of
patients receiving
high risk
Process
medications
developing adverse
drug event
High risk medications are

medications involved in a high
percentage of medication errors
or sentinel events and
Medical
medications that carry a high risk
records
for abuse, error, or other adverse
outcomes. A good reference for
this is the ISMPs List of HighAlert Medications.
QA Co
ordinator &
nursing
administrator
Medical records
Not applicable
The denominator can be

captured from the pharmacy for
those patients who have been
dispensed high risk medications.
Anaesthesia
Process
The anaesthesia plan is the

outcome of pre-anaesthesia
assessment. Any changes done
after this shall be considered as
modification of anaesthesia plan.
Medical
records
HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator
Total no. of patients in whom

anaesthesia plan was modified
---------------------------------------X100
Total no. of patients underwent
Anaesthesia
Not applicable
Modification in anesthesia plan

could be captured in a
register/system before the patient
is shifted out of the OT.
Process
Every anaesthesia plan shall

invariably mention if there is a
Medical
possibility of the patient requiring records
ventilation following anesthesia.
HOD
anesthesia, OT Anaesthesia
in charge & QA record sheet
coordinator
Total no. of patients requiring

unplanned ventilation
following anaesthsia
---------------------------------------X100
Total no. of patients
underwent Anaesthesia
not applicable
Every case wherein a patient

required ventilation but this was
not captured in the anesthesia
plan shall be a part of the
numerator.
HOD
anesthesia, OT
In-charge & QA
coordinator
Log book/
Register/
Incident Report
form
Total no. of patients develop

adverse anaesthsia event
---------------------------------------X100
Total no. of patients underwent
Anaesthesia
Not applicable
Adverse anesthesia events

include events, which happen
during the procedure like hypoxia,
arrhythmias, cardiac arrest etc.
HOD
anesthesia, OT
Medical records
In-charge & QA
coordinator
No. of patients who died

due to anaesthsia
----------------------------------------X100
No. of patients who underwent
anaesthesia
Not applicable
Self Explanatory
Unplanned return shall be

captured only during the same
admission.
13 CQI 3d
Percentage of
modification of
anaesthesia plan
14
Percentage of
unplanned
ventilation
following
anaesthesia
15
Adverse anaesthesia event is any

untoward medical occurrence that
Percentage of
may present during treatment
Medical
adverse
Outcome with an anaesthetic product but
records
anaesthesia events
which does not necessarily have a
causal relationship with this
treatment.
16
Anaesthesia
related mortality
rate
Any death where the cause is

possible, probable (likely) or
Outcome
certain to be due to anaesthesia
shall be included.
Medical
records
Surgical Services
Medical
records
(OT)
OT In-charge
Log book/
Register/
Incident Report
form
No. of unplanned
returns to OT
----------------------------------------X100
No. of patients operated
Not applicable
Re-scheduling of patients includes

cancellation and postponement
(beyond 4 hours) of the surgery
OT
because of poor communication, records
inadequate preparation or
inefficiency within the system.
In-Charge OT
Log book/Daily
OT Report
No. of cases re-scheduled

----------------------------------------X100
No. of surgeries performed
Not applicable
OT
records
OT In-charge
Log book/
Register/
Incident Report
form
Percentage of
It is equally important that the
cases who received
antibiotic should have been given
appropriate
not more than two hours prior to Medical
prophylactic
Outcome
the incision. This indicator could
Records
antibiotics within
be captured in a register/system
the specified time
before the patient enters the OT.
frame
Surgeon will order

and ward nurse will
OT In-charge
administer and
write it in MR.
17 CQI 3e
Percentage of
unplanned return
to OT
18
Percentage of rescheduling of
surgeries
19
Percentage of
cases where the
organisation's
procedure to
prevent adverse
Outcome
events like wrong
site, wrong patient
and wrong surgery
have been adhered
to
20
Total no. of patients recieving

high risk medications who
have an adverse drug event
---------------------------------------X100
Total no. of patients recieving
high risk medications
Outcome
Process
Medical records
No. of cases where

procedure was followed
-----------------------------------------X100
No. of patients who did not

recieve any prophylactic
antibiotics
-----------------------------------------X100
Use of Blood and Blood products
Not applicable
This could be checked in the postop/recovery room and

documented in a register/system.
Not applicable
This indicator could be captured

in a register/system before the
patient enters the OT.
Prophylactic antibiotics should be
administered ideally within 30-60
minutes but certainly within two
hours of the time of incision.
21 CQI 3f
Percentage of
transfusion
reactions
MANDATORY
INDICATOR 2
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 Medical
Outcome
sensitivity to the leukocytes,
records
platelets, plasma protein
components of the transfused
blood; or potassium or citrate
preservatives in the banked blood
22
Percentage of
wastage of blood
Process
and blood products
This also includes blood products

found unfit for use. In case the
organisation does not have a
blood bank of its own, the
denominator shall be the total
number of blood and blood
products collected/indented from
the blood bank
23
Percentage of
blood component
usage
Process
As per NACO Guidelines, the use

of blood products should be
encouraged rather than whole
blood usage.
Blood
Bank
records
24
Turnaround time
for issue of blood
and blood
components
Process
The time shall begin from the

time that the order is raised to
blood/blood component reaching
the clinical unit
Blood
Bank
records
Blood
Bank
records
ward sister,ward
in-charge / doctor
can report to blood
bank and will
document it in MR.
In charge
blood bank
will maintain
the record of
reactions
Blood bank
tecnician will
report to the
Incharge blood
bank
In-Charge
Blood Bank will Log Book blood
maintain the
bank
record.
Blood bank
tecnician will
report to the
Incharge blood
bank
blood bank
technician will put
down time of
requisistion & issue
and will document
it.
Trasnfusion
reaction form
In-Charge
Blood Bank
Log Book blood

bank
In-Charge
Blood Bank
Log Book blood

bank
No. of transfusion reactions

-----------------------------------------X100
Total no. of units transfused
No. of units wasted

-----------------------------------------X100
Total no. of units issued
from the blood bank
No. of components used

----------------------------------------X100
Total no. of blood and
blood products issued
Sum of time taken
-------------------------------X100
Total no. of blood and
components issued
Not applicable
Any adverse reaction to the

transfusion of blood or blood
components shall be considered
as transfusion reaction.It may
range from an allergic reaction to
a life threatening complication
like TRALI & Graft Versus Host
Disease.
not applicable
It is important that the

organisation capture the number
of blood and blood products used
and not just the number of
transfusions carried out. At times
more than one blood bag or
components may have been
given in a single transfusion
not applicable
NA
Not applicable
This will include blood outsourced

from other blood banks, for those
organisations not having in house
Blood Banks.
Not applicable
However NABH now recommends

Symptomatic UTI rate in which
the statement of treating doctor
is sufficient.
Not applicable
In VAP Culture report is must to

ascertain the case.
not applicable
CLABSI and transfusion reactions

are to be monitored differently.
not applicable
SSI is to be monitored for one

month in follow up.
Infection Control
25 CQI 3g
Urinary tract
infection rate (UTI/
As per Latest CDC/ NHSN
SUTI)
Outcome
Definition.
MANDATORY
INDICATOR 3
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
Culture report
26
Ventilator
associated
pneumonia rate
(VAP)
MANDATORY
INDICATOR 4
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
Culture report
27
Central line
associated
Bloodstream
infection
rate(CLABSI)
MANDATORY
INDICATOR 5

Definition.
Medical
records
Reporting will be
done by treating
doctor. Order for
culture report.
Microbiologist
& ICN
28
Surgical site
infection rate (SSI)
Outcome
MANDATORY
Definition.
INDICATOR 6
Medical
records
Reporting will be
done by treating
doctor/Surgeon.
Order for culture
report.
Microbiologist
& ICN
Outcome
Outcome

Definition.
Culture report
Culture report
No. of catheter associated UTI's

in a given month
-------------------------------------------X100
Total no. of urinary catheter days
in that month
No. of ventilator associated
pneumonia in a given month
-------------------------------------------X100
Total no. of ventilator days
in that month
No. of central line associated
blood stream infections in a month
-------------------------------------------X100
Total no. of central line days
in that month
No. of surgical site infctions

in a given month
-------------------------------------------X100
Total no. of surgeries
in that month
Mortality & Morbidity
29 CQI 3h
Mortality rate
30
Percentage of
return to ICU
within 48 hours
Medical
Hospital admission
records
discharge register
Technician
Outcome
HMIS
Outcome
ICU nursing staff

Admissio
will initiate
n/Transfer
followed by inRegister
charge ICU.
ICU Incharge
Medical records
No. of deaths
-------------------------------------------X100
and deaths
Not applicable
Medical records
No. of returns to ICU within

48 hrs.
-------------------------------------------X100
Total no. discharges, transfers
and deaths in the ICU
Not applicable
Higher value may repesent a

fairly higher HAI rate in the
hospital.
31
32
Rate of return to
the emergency
department within
72 hours with
similar presenting
complaints
Re-intubation rate
Emergen
cy Patient
Record
Register
Outcome
Process
This shall include the re-intubation Medical

withi 48 hrs. of extubation.
Records
nursing in-charge
will report to EMO
and put down in
MR.
ward incharge
ER Incharge
Medical records
Ward Incharge Medical records
No. of returns to Emergency within

72 hours with similar presenting
complaints
-------------------------------------------X100
Total no. patients who have
come to Emergency
No. of re-intubations within
48 hrs. of extubations
-------------------------------------------X100
Total no. of extubations
Not applicable
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.
No. of re-intubations within 48 hours of

extubations/No. of intubations
NA
Clinical Research
33 CQI 3i
Percentage of
research activities
CAPTURED ON A QUARTERLY
Outcome
approved by ethics
BASIS
committee
Clinical
Research MOM of ethics
Departme committee
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
No. of research activities approved

by ethics committee
-------------------------------------------X100
Total no. of research protocols
submitted to ethics committee
not applicable
This indicator shall be captured

on a quarterly basis.
34
Percentage of
patients
withdrawing from
the study
Clinical
Research MOM of ethics
Departme committee
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
No. of patients who have withdrawn

from all ongoing activites
-------------------------------------------X100
Total no. of patients enrolled
in all ongoing studies.
not applicable

not applicable
Any protocol violation/deviation

that gets reported based on an
internal/external assessment
finding shall be considered as
deemed to have happened but
not reported. Hence, even though
it gets reported it shall be
included to only calculate the
denominator and shall not be
included in the numerator.
not applicable

not applicable
To capture this, organization

should maintain a register in the
pharmacy and stores (and also if
necessary in the wards) wherein
all such events are captured
not applicable
Organisation should maintain a

register in the pharmacy and
stores wherein all such events are
captured.
Outcome
BASIS
35
Percentage of
protocol
violations/deviatio
ns reported
BASIS
Clinical
Research Clinical Research
Departme Coordinator
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
No. of protocol violations/

deviations
-------------------------------------------X100
in all ongoing studies
36
Percentage of
serious adverse
events (which have
occurred in the
organisation)
Outcome
BASIS
reported to the
Ethics committee
within the defined
time frame
Clinical
Research Clinical Research
Departme Coordinator
nt
Clinical
Research
Coordinator
research
documents of
the hospitals
Number of serious adverse events

reported
-------------------------------------------X100
in all ongoing studies
Outcome
10
Procurement of medication essential to meet patient needs
37 CQI 4a
Percentage of
drugs &
consumables
procured by local
purchase
38
Percentage of
stock outs
including
emergency drugs
Process
This includes medicines or

consumables which were used by
the patients before admission and Pharmacy
Incharge
Incharge Pharmacy
need to continue but it is not
records
Pharmacy
included in the hospital list
(generic).
Local Purchase
register
Process
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..
Stockout
Register
Pharmacy
Incharge
Incharge Pharmacy
records
Pharmacy
No. of items purchased by local

purchase
-------------------------------------------X100
no. of drugs listed in hospital
formulary & hospital consumables list
No. of stock outs

-------------------------------------------X100
no. of drugs listed in hospital
formulary & hospital consumables list
39
Percentage of
drugs &
consumables
Process
rejected before
preparation of
goods receipt note
All materials received not in

conformity with the specifications
Store
and requirements ordered for in
records
the purchase order shall be
rejected.
40
Percentage of
variations from the
Process
procurement
process
Variations from the written

standardized procurement
Chief Pharmacist
Purchase
process of acquiring supplies from
will notify the no.
records
licensed, authorized, agencies,
of such processes.
wholesalers/ distributors.
In-chrage stores
In-chrage
stores
Purchase
Store Incharge
records
11
not applicable
Denominator is total quantity and

not number. For eg.a single order
may have 30 items of "X"
consumable. Of the 30, 10 may
be rejected. In this case the
formula will be 10/30.
No. of variatiosn from the procurement

process
-------------------------------------------not applicable
X100
Total no. of items procured
Risk Management
Mock drill is a simulation exercise
of preparedness for any type of
event. It could be event or
Mock drill
disaster. This is basically a dry run
QA Coordinator
records
or preparedness drill. For
example, fire mock drill, disaster
drill, Code Blue Drill.
Number of
variations
observed in mock
drills
Process
42
Incidence of falls
MANDATORY
INDICATOR 7
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, nonIncidence ward nurse/ward
Outcome purposeful, downward
Report
boy/aya
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.
43
Incidence of bed
sores after
admission
MANDATORY
INDICATOR 8
A pressure ulcer is localized injury

to the skin and/or underlying
tissue usually over a bony
Nursing
Outcome prominence, as a result of
Records
pressure, or pressure in
combination with shear and/or
friction.
44
Percentage of
employees
provided preexposure
prophylaxis
Pre-exposure prophylaxis is any

medical or public health
procedure used before exposure
Personnel Office
Structure
to the disease causing agent, its
records
superintendent
purpose is to prevent, rather than
treat or cure a disease.
41 CQI 4b
ward nurse will

report it in MR.
12
Accreditation
Coordinator
Nursing
administrator
Nursing
administrator
Mock drill
records
not applicable
To capture the variation it is

suggested that every
organisation develop a checklist
to capture the events during a
mock drill.
not applicable
1. At different levels - i.e. from

one level to ground level. E.g.
from beds, wheelchairs or down
stairs.
2. On the same level
as a result of slipping, tripping or
stumbling from a colllision,
pushing or shoving by or with
another person.
3. Below
ground level i.e. into a hole or
other opening in surface. All
types of falls are to be included
whether they result from
physiological reasons (fainting) or
environmental reasons.
No. of patients who develop

new/worsening of pressure
ulcer after admission
-------------------------------------------X100
and deaths
not applicable
will be confirmed by the

attending doctor.
Number of employees who

were provided preexposure prophylaxis
-------------------------------------------X100
Number of employees who
were due to be provided
pre-exposure prophylaxis
No. of employees who were provided preexposure prophylaxis /no. of employees posted
in high risk areas like lab ,dialysis, ICUs, Blood
Bank etc
It shall include at a minimum

prophylaxis against Hepatitis B.
not applicable
Inpatient Days: A patient day is

the unit of measure denoting
lodging provided and services
rendered to inpatients between
the census taking hours (usually
at midnight) of two successive
days. A patient formally admitted
who is discharged or dies on the
same day is counted as one
patient day, regardless of the
number of hours the patient
occupies a hospital bed. For
patients switched from
observation to inpatient status,
the patient day count should
begin on the day the patient was
officially admitted as an inpatient.
Total no. of variations in a mock drill
No. of Falls
Incidence Report -------------------------------------------X100
and deaths
Incident Report
Office
Personnel
superintendent records
Utilization of Space, Manpower and Equipment
CQI 4c
45
GRN
No. of Drugs & consumables rejected

before the preparation of GRN
-------------------------------------------X100
Total no. of drugs & consumables
received
The bed occupancy rate is the

percentage of official beds
occupied by hospital inpatients for
Bed occupancy rate
a given period of time.For a bed
MANDATORY
Outcome
HIS
to be included in the official
INDICATOR 9
count, it must be set up, staffed,
equipped and available for patient
care.
ward incharge
QA Coordinator &
MRD
technician
admissiondischarge
register
No. of inpatient days in a

given month
-------------------------------------------X100
No. of available bed days in
that month
45
Average length of
stay MANDATORY
INDICATOR 9
46
OT utilization rate
Length of stay (LOS) is a term

used to measure the duration of a
single episode of hospitalization.
Inpatient days are calculated by
Outcome subtracting day of admission from HIS
day of discharge. However,
persons entering and leaving a
hospital on the same day have a
length of stay of one
OT utilisation is defined as the

quotient of hours of OT time
actually used during elective
Outcome
HIS
resource hours and the total
number of elective resource hours
available for use.
ICU utilization rate Outcome
HIS
Any equipment the failure of

which could impede patient care
shall be considered critical. e.g.
ventilators, cardiac monitors,
pulse oximeter etc.
47
Critical equipment
down time
48
The HCOs should calculate the

staffing patterns separately for
Nurse-patient ratio
ICUs and for the wards. The in
Structure
for ICUs & Wards
charge/supervisor of the area
shall not be included for
calculating the number of staff.
Process
ward incharge
QA Coordinator &
MRD
technician
OT register
ICU in-charge
QA Coordinator &
MRD
technician
HIS/Midnight
census register
ward incharge
chief
paharmacist
Matron
13
49 CQI 4d
admissiondischarge
register
OT incharge/ OT
matron
Complain concerned
t log
department
Records
QA Coordinator &
MRD
technician
Complaint log
Hospital Census
No. of inpatient days in a

given month
-------------------------------------------X100
No. of discharges and deaths in
that month
Actual no. of surgeries performed

-------------------------------------------X100
Max. no. of surgeries that
can be done
Actual no. of in -patient bed days

-------------------------------------------X100
Max. no. of available bed days
total no. of hours of downtime

-------------------------------------------X100
Max. no. of functional hours
of the equipme
No. of staff per no. of shifts

-------------------------------------------X100
No. of beds
not applicable
Available bed days-It is the

product of number of inpatient
beds and number of days in that
month.
Number of inpatient daysIt is a sum of daily inpatient
census. While calculating the
overall length of stay and
available number of inpatient
beds, emergency, rehabilitation
and day care beds should not be
considered.
not applicable
The degree of utilisation depicts

the average utilisation 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
Actual no. of in-patient bed days/max no. of

available bed days X 100
NA
not applicable
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
not applicable
For example, if in the ICU there

are a total of 15 nurses who work
in 3 shifts the numerator will 5
(15/3) and if there are 5 beds the
ratio is 1:1. Similarly for wards It
is preferable that in case of ICU
the organisation capture the ratio
for ventilated and non-ventilated
patients separately.

2. For Hospitals with 21-50 patients/day:
50%
patients/day: 20%
101-200 patients/day: 10%
5. For Hospitals
with 201-400 patients/day: 5%
6. For
Hospitals with > 400 patients/day: 2%
The sample shall be derived from

repeat patients. It is preferable
that patients who are coming to
the hospital for the first time not
be included as it is possible that
they would not be in a position to
give feedback on some aspects.
The organisation could also
capture satisfaction for various
individual parameters (as laid
down in its feedback form). In
case the organisation is not
capturing an overall feedback but
instead only for various
parameters, the index shall be
calculated by averaging the
satisfaction of various
parameters.
Patient Satisfaction
Out patient
satisfaction index
Patient Satisfaction is defined in

terms of the degree to which the
patients expectations are
Outcome fulfilled. It is an expression of the
gap between the expected and
perceived characteristics of a
service.
Survey
Hospital manager
Accreditaion
coordinator
Score Achieved
OPD pt
-----------------------------------------satisfaction form
X100
Maximum possible score
50
In patient
satisfaction index
Wating time for

services out
patient
consultation
Outcome
Process
Survey
A waiting time is a length of time

which one must wait in order for a
Records
specific action to occur, after that
action is requested or mandated.
Hospital manager
Hospital manager
1. For Hospitals with < 20 discharges/day: 100%

discharges/day: 50%
51-100 discharges/day: 20%
4. For Hospitals
with > 100 discharges/day: 10%
Accreditaion
coordinator
Score Achieved
-------------------------------------------IPD pt
satisfaction form X100
Accreditaion
coordinator
Registration
time &
Consulting time
(shall be noted
by the
consultant )
Sum( patient in time for

consultation-patient reporting
time in OPD
-------------------------------------------X100
No. of patients reported
in OPD
not applicable
NA
Accreditaion
coordinator
Registration
time & Sample
collection
time(shall be
noted by the
technician )
Sum( patient in time for

consultation-reporting
time in diagnostics
-------------------------------------------X100
No. of patients reported
in diagnostics
not applicable
waiting time for diagnostics is

applicable only for out-patients.
Accreditaion
coordinator
Discharge note
& time on
discharge slip or
register
Sum of time taken for discharge

-------------------------------------------X100
No. of patients discharge
not applicable
In case patients request

additional time to leave the
clinical unit that shall not be
added. The discharge is deemed
to have been complete when the
formalities for the same have
been completed.
51
Wating time for

Process
service diagnostics
52
Time taken for

discharge
Process
Records
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 Records
deemed to have started when the
consultant formally approves
discharge and ends with the
patient leaving the clinical unit.
Hospital manager
ward incharge
14
Employee Satisfaction
Hospital manager
Score Achieved
-------------------------------------------Employee
satisfaction form X100
Hospital manager
Accreditaion
coordinator
HR records
No. of employees who have left

-------------------------------------------X100
No. of employees at the beginning
of the month+newly joined staff
not applicable
HR records
No. of employees who are on unauthorised absence

-------------------------------------------X100
No. of employees
not applicable
53 CQI 4e
The satisfaction shall be captured

Outcome from all categories of staff
Survey
CAPTURED ONCE IN 6 MONTHS
54
Employee attrition
rate
Outcome
55
Employee
absenteeism rate
Absenteeism in employment law

is the state of not being present
that occurs when an employee is Personnel Office
Outcome
absent or not present at work
records
superintendent
during a normally scheduled work
period.
56
Percentage of
Employee awareness is the state
employees who are
or condition of being aware;
aware of employee
having knowledge; consciousness
rights,
Outcome
Survey
about employee rights,
responsibilities
responsibilities and welfare
and welfare
schemes.
schemes.
Attrition rate is the percentage of

people leaving the organisation.
Records
Hospital manager
15
57 CQI 4f
58
1. For Hospitals with < 100 staff: 100%

2. For Hospitals with 101-200 staff: 50%
3. For Hospitals with 201-500 staff:
20%
staff: 15%
5. For Hospitals with >
1000 staff: 10%
Accreditaion
coordinator
Employee
Satisfaction index
Accreditaion
coordinator
Accreditaion
coordinator
Personnel
interview
records
No. of employees who are aware

of their rights, responsibilities and
welfare schemes
-------------------------------------------X100
No. of employees interviewed
1. For Hospitals with < 100 staff: 30%

2. For Hospitals with 101-200 staff: 15%
3. For Hospitals with 201-500 staff:
8%
4. For Hospitals with 5011000 staff: 15%
501- 1000 staff: 4%
6. For hospitals
with > 1000 staff: 2%
Adverse events and near misses

Number of sentinel
events reported,
collected and
Process
analysed within
the defined time
frame
A relatively infrequent,
unexpected incident, related to
system or process deficiencies,
Data
which leads to death or major and
enduring loss of function for a
recipient of healthcare services
ward incharge
Accreditaion
coordinator
Log book/
Register/
Incident Report
form
Percentage of near
Process
misses
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 Data
not result in patient harm, but
could have, can be categorized as
near misses.
concerned
department
Accreditaion
coordinator
Log book/
Register/
Incident Report
form
No. of sentinal events reported,

collected and analysed within
the defined time frame
-------------------------------------------X100
No. of sentinal events reported
collected and analyzed
No. of near misses reported
-------------------------------------------X100
No. of incident reports
not applicable
If there is deviation in either

reporting/collecting/analysis it
shall not be included in the
numerator.
not applicable
Near miss reporters can describe

what they observed of the
beginning of the event, and the
factors that prevented loss from
occuring.
59
60
Incidence of blood
body fluid
exposures
Process
An exposure is when blood, blood

components or other potentially
infectious materials come in
Data
contact with a staffs eyes,
mucous membranes, non-intact
skin or mouth.
Needle stick injury is a

penetrating stab wound from a
Incidence of needle
needle (or other sharp object) that
stick injuries
may result in exposure to blood or
Outcome
Data
MANDATORY
other body fluids. Needle stick
INDICATOR 10
injuries are wounds caused by
needles that accidentally
puncture in the skin
ward incharge
ward incharge
Accreditaion
coordinator
Matron
16
61 CQI 4g
62
Log book/
Register/
Incident Report
form
Needle stick
injury form/
Incident Report
form
Number of blood body fluid exposures

in the given period
Incidence of needle stick injuries

reported during the given period
not applicable
not applicable
Parenteral exposure means injury

due to any sharp. All incidences
of needle stick injuries should be
assessed on a case-by-case basis.
Analyze needle stick and other
sharps related injuries in the
workplace to identify hazards and
injury trends. Data from injury
reporting should be compiled and
assessed to identify: (1) where,
how, with what devices, and
when injuries are occurring and
(2) the groups of health care
workers being injured.
not applicable
Every medical record that comes

to the MRD from the clinical unit
following the discharge of a
patient shall be immediately
checked for the presence of
discharge summary. If this is not
present at this stage it shall be
captured as a part of the
numerator.
1. For Hospitals with < 20 discharges/day: 100%

discharges/day: 50%
51-100 discharges/day: 20% 4. For Hospitals
with > 100 discharges/day: 10%
ICD codification shall be done by

the concerned staff within the
specified period following
discharge. After completion of
this specified period an audit
shall be done (using sample size
mentioned in the previous
column) by an independent
person to capture this
Medical Records
Percentage of
medical records
Process
not having
discharge summary
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 patients stay in
hospital written by the attending
doctor.
Percentage of
medical records
not having
codification as per
International
Classification of
Diseases (ICD)
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
Medical
incidence and prevalence of
record
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).
Process
Medical
record
MRD Technician
MRD Technician
Hospital
manager
Hospital
manager
MRD check list
MRD check list
No. of medical records not having

discharge summary
-------------------------------------------X100
No. of discharges & deaths

codification as per ICD
-------------------------------------------X100
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
Medical
to enable the patient to take an
record
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.
63
Percentage of
medical records
having incomplete
and/or improper
consent
Process
64
Percentage of
missing records
A medical record is considered as

missing when the record could not
Medical
Outcome be found out from the MRD after
record
the 72nd hour of the record
request.
Note
MRD Technician
Hospital
manager
MRD check list
MRD Technician
Hospital
manager
Log book/
Register/
Incident Report
form

complete consent(s)
-------------------------------------------X100
No. of missing medical records

-------------------------------------------X100
No. of records
Unless specified all indicators shall be captured on a monthly basis and the numerator and denominator shall be of that month.
not applicable
not applicable
Regular checks should be in place

to ensure that there are no
missing medical records or
medical records are filed in the
wrong place.

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S

Time for initial

The time shall begin from the

time will be put in

Sum of time taken

The average time should be

In case of emergency the time

Sum of time taken

1. For Hospitals with < 20 patients/day: 100%

Time for initial

Desired outcome includes

Nutritional assessment can be

Nursing care plan shall be the

doctor and nurse

No. of in-patients case records

No. of in-patients case records

No. of in-patients case records

The outliers: Those taking more

The indicator shall be captured

Safety/Quality for Diagnostics Services (Lab & Radiology)

Reporting errors include those

No. of reporting errors

It is better if the organisation

Re-dos include tests which

No. of re-do's (hemolysed sample,

No. of reports co-relating

No. of employees adhering to

1. For Hospitals with < 100 tests/month: 100%

Shall be captured in the

Shall be captured in the

Even if the employees is not

A medication error is any

Errors in the prescribing,

Wrong patient errors; Wrong route

Adverse drug reaction: A

Medication chart with illegible

Total no. of medication errors

1. For Hospitals with average occupancy < 50

Total no. of adverse

Total no. of medication charts

1. For Hospitals with average occupancy < 50

In addition to incident reporting,

High risk medications are

The denominator can be

The anaesthesia plan is the

Total no. of patients in whom

Modification in anesthesia plan

Every anaesthesia plan shall

Total no. of patients requiring

Every case wherein a patient

Total no. of patients develop

Adverse anesthesia events

No. of patients who died

Unplanned return shall be

Adverse anaesthesia event is any

Any death where the cause is

Re-scheduling of patients includes

No. of cases re-scheduled

Surgeon will order

Total no. of patients recieving

No. of cases where

No. of patients who did not

Use of Blood and Blood products