CQI INDICATORS AS PER NABH 4th EDITION

Standard
S. No. Deptt. KPI Formula Frequency
Ref.

Sum of time taken for the assessment/Total no. of

1 CQI 3a ER Time for initial assessment of emergency patients Monthly
patients in ER

Sum of time taken for the assessment/Total no. of

2 CQI 3a Med Ops Time for initial assessment of indoor patients Monthly
indoor patients

No. of in-patient case records wherein the care plan

Percentage of cases (Inpatients) wherein care plan with desired
3 CQI 3a Med Ops with desired outcomes has been documented /Total Monthly
outcomes is documented and countersigned by Clinician
No. of patients * 100

No. of in-patient case records wherein the

Percentage of cases (inpatients) wherein screening for nutritional
4 CQI 3a Dietetics nutritional assessment has been documented /Total Monthly
needs has been done
No. of patients * 100

No. of inpatient case records wherein the nursing

Percentage of cases (inpatients) wherein the nursing care plan is
5 CQI 3a Nursing plan has been documented / Total No. of patients * Monthly
documented
100

No. of Reporting errors / No. of Tests performed *

6 CQI 3b Lab Number of reporting errors / 1000 investigations Monthly
1000

7 CQI 3b Lab Percentage of re-dos No. of Re-dos / No. of tests performed * 100 Monthly

Percentage of reports co-relating with clinical diagnosis No. of reports co-relating with clinical
8 CQI 3b Lab Monthly
(atleast Histopath) diagnosis/No. of tests performed * 100

Percentage of adherence to safety precautions by employees No. of employees adhering to safety

9 CQI 3b Lab Monthly
working in diagnostics precautions/No. of employees sampled * 100

No. of reporting errors / No of tests performed *

10 CQI 3b Radiology Number of reporting errors / 1000 investigations Monthly
1000

11 CQI 3b Radiology Percentage of re-dos No. of re-dos / No. of tests performed * 100 Monthly
 No. of reports co-relating with clinical
12 CQI 3b Radiology Percentage of reports co-relating with clinical diagnosis Monthly
diagnosis/No. of tests performed * 100

Percentage of adherence to safety precautions by employees No. of employees sampled / No of employees

13 CQI 3b Radiology Monthly
working in diagnostics adhering to safety precautions * 100

Nursing/ Total number of medication errors/No. of patient

14 CQI 3c Incidence of Medication error Monthly
Pharmacy days * 1000

Nursing/ No. of admissions developing ADR/No. of

15 CQI 3c Admissions with Adverse drug reactions Monthly
Pharmacy discharges and death

No. of medications charts with error prone

Nursing/
16 CQI 3c Percentage of medication charts with error prone abbreviations abbreviations/No. of medications charts reviewed Monthly
Pharmacy
*100

Number of patients receiving high risk medications

Nursing/ Percentage of patients receiving high risk medications
17 CQI 3c who have an adverse drug events/No. of patients Monthly
Pharmacy developing adverse drug events
receiving high risk medications*100

No. of patients in whom the anaesthesia plan was

18 CQI 3d Anaesthesia Percentage of modification of anaesthesia plan modified/No. of patients who underwent Monthly
anaesthesia* 100

No. of patients requiring unplanned ventilation

19 CQI 3d Anaesthesia Percentage of unplanned ventilation following anaesthesia/No.of patients who Monthly
underwent anaesthesia * 100

No. of patients who developed adverse anaesthesia

20 CQI 3d Anaesthesia Percentage of adverse anaesthesia events event/No. of patients who underwent anaesthesia* Monthly
100

No. of patients who died due to anaesthesia/No. of

21 CQI 3d Anaesthesia Anaesthesia related mortality rate Monthly
patients who underwent anaesthesia* 100

No. of unplanned return to OT/ No. of patients

22 CQI 3e OT Percentage of unplanned return to OT Monthly
operated*100

No. of cases rescheduled/ No. of surgeries planned*

23 CQI 3e OT Percentage of re-scheduling of surgeries Monthly
100

Percentage of cases where the organisations procedure to

No. of cases where the procedure was
24 CQI 3e OT prevent adverse events like wrong site, wrong patient and wrong Monthly
followed/No. of surgeries performed *100
surgery have been adhered to.
 No. of patients who did receive appropriate
Percentage of cases who received appropriate prophylactic
25 CQI 3e OT prophlactic antibiotic(s)/No. of surgeries Monthly
antibiotics within the specified time frame
performed* 100

No. of transfusion reactions/No. of units transfused*

26 CQI 3f Blood Bank Percentage of transfusion reactions Monthly
100

No. of blood and blood component units wasted

27 CQI 3f Blood Bank Percentage of wastage of blood and blood products among those issued/No. of blood and blood Monthly
products issued from the blood bank * 100

No. of components used/ No. of blood and blood

28 CQI 3f Blood Bank Percentage of blood component usage Monthly
products used * 100

Sum of time taken/Total number of blood and

29 CQI 3f Blood Bank TAT for issue of blood and blood components Monthly
blood components issued

Infection No. of urinary catheter associated UTIs in a month

30 CQI 3g Urinary Tract Infection Rate Monthly
Control / No. of urinary catheter days in that month * 1000

Infection No. of ventillator associted pneumonia in a month /

31 CQI 3g Pneumonia rate (Total episodes of VAP identified in Hospital) Monthly
Control No. of ventilator days in that month * 1000

Infection No. of central line associated BSI in a month / No.

32 CQI 3g Blood Stream Infection rate Monthly
Control of central line days in that month * 1000

Infection No. of surgical site infections in a given month / No.

33 CQI 3g Surgical Site Infection Rate Monthly
Control of surgeries performed in that month * 100

Total No. of hand hygiene missed

Infection
34 CQI 3j Hand Hygiene Compliance Rate (%) oppurtunities/Total no. of hand hygiene Monthly
Control
oppurunities * 100

35 CQI 3h MRD Mortality Rate No. of deaths / No. of discharges and deaths * 100 Monthly

No. of returns to ICU within 48hrs/No. of

36 CQI 3h Med. Ops Return to ICU within 48hours Monthly
discharges/transfers in the ICU*100

No. of returns to emergency within 72hrs with

Return to the emergency department within 72hrs with similar
37 CQI 3h ER similar presenting complaints/No. of patients who Monthly
presenting complaints
have come to the emergency* 100
 No. of re-intubations within 48hrs of extubation/No.
38 CQI 3h Nursing Re-intubation rate Monthly
of intubations* 100

No. of items purchased by local purchase/No. of

Pharmacy/
39 CQI 4a Percentage of drugs and consumables procured by local purchase drugs listed in hospital formulary and hospital Monthly
Stores
consumables list* 100

No. of stock outs/No. of drugs listed in hospital

40 CQI 4a Pharmacy Percentage of stock outs including emergency drugs Monthly
formulary and hospital consumables list*100

Pharmacy/ Percentage of drugs and consumables rejected before Total quantity rejected /Total quantity received
41 CQI 4a Monthly
Stores preparation of goods receipt note. before the preparation of GRN*100

Pharmacy/ Total no. of variations from the usual procurement

42 CQI 4a Percentage of variations from the procurement process Monthly
Stores process / Total no. of items procured * 100

Med
43 CQI 4b No. of variations observed in mock drills as defined in Hospital Total no. of variations observed in a mock drill Monthly
ops/Security

Med
44 CQI 4b Incidence of falls No. of falls/Total No. of patient days * 1000 Monthly
Ops/Nursing

No. of patients who develop new or worsening of

45 CQI 4b Nursing Incidence of bed sores after admission (HAPU) Monthly
pressure ulcer / No. of patient days* 1000
 Infection No. of employees who were due to be provided pre-
46 CQI 4b Control and Percentage of employees provided pre-exposure prophylaxis exposure prophylaxis/No. of employees who were Monthly
HR provided pre-exposure prophylaxis * 100

No. of inpatient days in a given month / No. of

47 CQI 4c MRD Bed Occupancy Rate Monthly
available bed days in that month * 100

Med Ops No. of inpatient days in a given month / No. of

48 CQI 4c ALOS Monthly
and MRD discharges and deaths in that month

49 CQI 4c OT OT utilisation rate OT utilisation time in hours / Resource hours * 100 Monthly

Sum of downtime for all critical equipments in

50 CQI 4c BME Critical equipment downtime Monthly
hours in a month

51 CQI 4c Nursing Nurse-Patient ratio for ICU's and Wards No. of staff per no. of shifts / No. of beds Monthly

Service
52 CQI 4d Out patient satisfaction Index Score achieved /Maximum possible score * 100 Monthly
Quality

Service
53 CQI 4d In patient satisfaction index Score achieved/Maximum possible score* 100 Monthly
Quality

Sum (Patient in time for consultation or procedure -

54 CQI 4d Front Office Waiting time for outpatient consultation Pt reporting time in OPD) / No. of patients reported Monthly
in OPD

Sum (Patient in time for procedure - Pt reporting

55 CQI 4d Front Office Waiting time for services including diagnostics time in diagnostics) / No. of patients reported in Monthly
diagnostics

Med Ops Sum of time taken for discharge/No. of patients

56 CQI 4d Time taken for discharge - Cash Monthly
and Billing discharged

Med Ops Sum of time taken for discharge/No. of patients

57 CQI 4d Time taken for discharge - TPA and Panel Monthly
and Billing discharged
58 CQI 4e HR Employee satisfaction index Score achieved/Maximum possible score* 100 Quarterly

No. of employees who have left during the

59 CQI 4e HR Employee attrition rate month/No. of employees at the beginning of month Monthly
+ newly joined staff*100

No. of employees who are on unauthorized

60 CQI 4e HR Employee absenteeism rate Monthly
absence/No. of employees *100

No. of employees who are aware of employee

Percentage of employees who are aware of employee rights,
61 CQI 4e HR rights, responsibilities and welfare schemes/No. fo Quarterly
responsibilities and welfare schemes
employees interviewed *100

Number of sentinel events analysed within the

Number of sentinel events reported, collected and analysed
62 CQI4f Quality defined timeframe/Number of sentinel events Monthly
within the defined timeframe
reported/collected * 100

Number of near misses reported/ Number of

63 CQI4f Quality Percentage of near misses Monthly
incidents reported*100

Infection No. of blood body fluid exposures/No. of inpatient

64 CQI 4f Incidence of blood body fluid exposures Monthly
Control days*1000

Infection No. of parenteral exposures / No. of in-patient days

65 CQI 4f Incidence of Needle Stick Injuries Monthly
Control * 1000

Med Ops No. of medical records not having discharge

66 CQI 4g Percentage of medical records not having discharge summary Monthly
and MRD summary / No. of discharges and death * 100

Med Ops Percentage of medical records not having codification as oer No. of medical records not having codification as
67 CQI 4g Monthly
and MRD International Classification of Diseases (ICD) per ICD / No. of discharges and deaths * 100

Med Ops Percentage of medical records having incomplete and/ or No. of medical records having incomplete and/or
68 CQI 4g Monthly
and MRD improper consent improper consent / No. of discharges * 100

Med Ops
69 CQI 4g Percentage of Missing Records No. of missing record / No. of records * 100 Monthly
and MRD

Med Ops Appropriate handovers during shift change (To be done Total no. of handovers done appropriately/Total no.
70 CQI 3j Monthly
and Nursing separately for doctors and nurses) - (per patient per shift). of handover oppurtunities *100
Med Ops No. of Patient Identification Errors/No. of
71 CQI 3j Incidence of Patient identification errors Monthly
and Nursing patients*100
Clinical Total No. of prescriptions in Capital Letters/Total
72 CQI 3j Complaince rate to Medication Prescription in Capitals Monthly
Pharmacist no. of prescriptions * 100