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No. of Pages : 13

Date Created : DD/MM/YYYY

Date of Implementation : DD/MM/YYYY

Prepared By : Signature :
Name :
Designation : NABH Coordinator

Approved By : Signature :
Name :
Designation : Medical Director
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AMENDMENT SHEET
SL. No. Section no & Details of the Reasons Signature of the Signature of
page no amendment preparatory the approval
authority authority
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CONTROL OF THE MANUAL

The holder of the copy of this manual is responsible for maintaining it in good and safe condition and in a readily
identifiable and retrievable.

The holder of the copy of this Manual shall maintain it in current status by inserting latest amendments as and when
the amended versions are received.

Accreditation coordinator is responsible for issuing the amended copies to the copyholders, the copyholder should
acknowledge the same and he /she should return the obsolete copies to the Accreditation coordinator.
The amendment sheet, to be updated (as and when amendments received) and referred for details of amendments
issued.

The manual is reviewed once a year and is updated as relevant to the hospital policies and procedures. Review and
amendment can happen also as corrective actions to the non-conformities raised during the self-assessment or
assessment audits by NABH.

The authority over control of this manual is as follows:

Preparation Approval Issue

Accreditation coordinator Medical Director Accreditation coordinator

The procedure manual with original signatures of the above on the title page is considered as ‘Master Copy’, and the
photocopies of the master copy for the distribution are considered as ‘Controlled Copy’.

Distribution List of the Manual:

S. No Designation

1 Medical Director
2 Accreditation Coordinator
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CONTENTS
S. No Topics Page Number

CQI 01 INDICATOR MONITORING SYSTEM 5

CQI 02 SENTINEL EVENTS 12

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CQI-01 Indicator Monitoring System

Purpose: This system is for the purpose of identifying, calculating and monitoring those indicators that
indicates the quality and safety levels of the hospital. The selection of indicators has been done in a manner so
that all parameters relevant to quality and safety factors in the hospital are comprehensively covered.

Scope of the document: This document specifies following

1. Parameters established for quality and safety

2. Indicators established for each parameters
3. Methodology related to indicator calculation
4. Roles and responsibilities

Policy: Quality and safety of the hospital shall be continually improved through structured system of
calculating indicators, monitoring the indicator values with respect to the set standards, identifying trends and
taking appropriate action based on the Indicator results. This system shall be considered as one of the most
important system for achieving the Quality Policy and Objective of the Hospital.

The parameters and indicators as described in this document shall be used for this purpose. Quality Assurance
Committee and team shall take the responsibility and coordinate to get the data and Indicators calculated as
per described frequency. Standardized formats described in this document shall be used for collection of data
and preparation of reports.

Important activities in Indicator Monitoring System:

1. Continual Quality Improvement Cycle

2. Parameters for Quality & Safety
3. Selection of Indicators
4. Deselect ion of Indicators
5. Standard value/Trend:
6. Quality & Safety Indicator report
7. Patient feedback and satisfaction analysis report
8. Medical Record Documentation Quality report
9. OT Utilization rates
10. OPD Utilization rates
11. Validation of reports
12. Mechanism to take action/decision on the basis of Indicator reports.
13. Formats

1. Continual Quality Improvement Cycle: The Continual Quality Improvement through Indicator Monitoring
System is represented graphically as given below:

2. Parameters for Quality & Safety: The parameters of Quality & Safety covers all parameters which
affects or is related to the Quality of services and safety of patient, staff and visitors. Following parameters
is defined for the Hospital:
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a. Patient satisfaction
b. Employee satisfaction
c. Managerial Quality
d. Hospital wide safety
e. Medical Quality

All activities under quality & safety programme and Indicator Monitoring System is directed towards
strengthening and improving the above mentioned parameters. Various indicators as described in further
section of this document is used for identifying the Quality level of each of these parameters.

3. Selection of Indicators: The indicator is selected for each of the above mentioned parameters. Selection
of indicator depends upon the need for monitoring that indicator, which is determined by the Quality
Assurance Committee.

The data required for monitoring and the formulae for calculating the indicator value shall be worked up by
Quality Assurance Department and approved by Quality Assurance Committee. The formulae shall be
feeded in appropriate excel sheet for the purpose of automating the calculation of indicator value.

Selection of indicator is a continuous activity and any indicator can be added or deleted on the basis of
necessity.

4. Deselection of Indicators: An indicator can be deselected after approval of Committee and on following
basis:

a. The indicator has achieved the standard value continuously for three months, and no need is felt for
escalating the standard value.
b. The trend of Indicator values has shown a continual improvement and has achieved stability for a
continuous period of three months.
c. If an indicator is felt to be unnecessary in meeting the objective

5. Standard value/Trend: Standard values shall be fixed for each indicator to standardize the quality
assurance programme. Standard values are set on the basis of Internal benchmarking and perception of
the Committee. Effort shall be directed to achieve/exceed this standard value. Trend shall be established
for all Indicator values and effort shall be made to achieve the improvement in trends.

6. Quality & Safety Indicator report: This is a comprehensive hospital wide indicator report on all the
parameters described above. Quality and safety Indicator report shall be generated on monthly basis.
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a. Indicators calculated in Quality and Safety Indicator Report

Standard
S. No. Indicators Formula Frequency
Value
A. Patient Satisfaction Indicators
A-1 Patient Feedback Indicators
Patient satisfaction in IP in
A-1.1 Overall score / Total score >~85% Half yearly
% received
Patient satisfaction in OP in
A-1.2 Overall score / Total score >~85% Half yearly
% received
A-2 Patient comments indicators
Number of patient (Total number of patient
A-2.1 complaints per 1000 patient complaints / Total patient <20 Monthly
days days) * 1000
B Employee Satisfaction Indicators
B-1 Employee Feedback indicators
B-1.1 Employee satisfaction in % Overall score / Total score >75% Annually
B-2 Attrition rate indicator
(Number of staff
resigned (on
B-2.1 % of staff resigned Roll)/Total staff Monthly
strength of the hospital
(on Roll))*100
C Managerial Quality Indicator
C-1 Facility utilization indicators
Average No of beds in IP
occupied in a month / Total
C-1.1 Bed Occupancy rate >75% Monthly
No of beds X No of days in
a month.
Average No of beds in ICU
occupied in a month / Total
C-1.2 ICU occupancy rate >75% Monthly
No of beds X No of days in
a month.
C–2 Other indicators
No. of stock out Number of stock out
C - 2.1 0 Monthly
situations in medicines situation in medicines
D Hospital Safety Indicators
D-1 Patient safety indicators
(Number of
Number of Medication
medication errors
D-1.1 errors per 1000 patient
reported/Total patient
Observe trend Monthly
days
days)*1000
D-2 Clinical safety indicators
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(Number of adverse drug

Adverse drug
reaction
D-2.1 reaction rate (per 1000
reported/Total patient
Observe trend Monthly
patient days)
days)*1000
D-3 Other safety indicators
Incidence of minor fire Incidence of minor fire
D-3.1 Situations situations
0 Monthly
E Medical Quality Indicator
E-1 Morbidity and Mortality
E-1.1 Average length of stay Average length of stay <5 days Monthly
(Number of
Net mortality rate (per
E-1.2 deaths/No. of patients <4% Monthly
100 discharges)
discharged)* 100

b. Indicators calculated in Quality and Safety Indicator Report

S. No. Procedural Steps Responsibility
Take the print of monthly data sheet of each department
1. Department in charge
from main data sheet of quality and safety indicators
Distribute the data sheet to respective department with a
2. Department in charge
note to submit the asked data within 3 days
Receive filled data sheet from departments. Check whether
3. Department in charge
the data sheet is completely filled and signed
Enter all the data values in main data sheet of quality and
4. Department in charge
safety indicators
The indicator sheet will automatically calculate the values on
5. Department in charge
the basis of filled data
On indicator sheet, enter previous month values in
6. appropriate column. Previous month values can be seen Department in charge
from previous months indicator report
7. Check the headings for appropriate month Department in charge
8. Take the print out of indicator sheet, as indicator report Department in charge
9. File the report in Quality and Safety Indicator file Department in charge
10. Send the file to chairperson of Quality Assurance Committee Department in charge
A copy of the report in soft copy shall be sent to Corporate Department in charge
11. Quality Team for validation

7. Patient feedback and satisfaction analysis report: Patient feedback is collected on regular basis and
analyzed every month to identify the patient satisfaction level with various services provided by the hospital. This
report is generated every month and reviewed in QA committee.
a. Indicators in patient feedback and analysis report
Following aspects / indicators are monitored through this system
 Satisfaction level with front desk services
 Satisfaction level with Medical staff
 Satisfaction level with Consultants
 Satisfaction level with support services
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 Satisfaction level with Billing

 Satisfaction level with discharge process
Analysis: Overall satisfaction of individual aspect shall be calculated by taking the average of sub-question of
each aspect. Level of satisfaction shall be grouped in 3 categories
 High – Feedback as excellent and Good shall be taken as high level of satisfaction
 Medium – Feedback as average shall be taken as medium level of satisfaction
 Low – Feedback as poor shall be taken as low level of satisfaction
Standards to be achieved:
 % of feedback collection shall be more than 50% of total discharged patients
 % of high level satisfaction in any of the aspects shall be 70% or above
 % of low level of satisfaction in any of the aspects shall be 19% or less

b. Procedure of patient feedback collection and satisfaction analysis

S. No. Procedural Step Responsibility

Patient feedback shall be collected in standardized
1. PRO
patient feedback form
At the time of discharge handover the patient feedback
2. PRO
form to the patient
Courteously request the patient to provide his / her
3. PRO
feedback
4. If patient do not wish don’t force him / her for feedback PRO
5. Help the patient in providing feedback if Required PRO
The filled feedback forms shall be collected for
6. PRO
complete month
Enter the data from feedback forms in to excel sheet
7. Training Manager
(for calculation)
The calculations are then entered in standardized
8. Training Manager
patient feedback report
The report shall be sent to Quality Improvement
9. Committee and to corporate quality team
One copy of the report shall be maintained in patient
10. feedback analysis file
At the end of 3 months trend of patient feedback shall
11. be drawn in graphical format
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8. OT utilization rates: Detailed utilization rates are calculated on monthly basis for Operation Theatres, to assess
the level of managerial quality and efficiency.

a. Mechanism to calculate OT utilization:

S. No. Procedural Steps Responsibility

On daily basis details of surgeries, type of surgery, OT
1. number, In time, Out time, Total OT hours, and OT coordinator
turnaround time shall be entered in the excel sheet
This excel sheet shall be send to unit quality team at the
2. OT coordinator
end of the month
From the data available in this excel sheet unit team OT coordinator
3.
shall generate a report for each OT
The report shall specify for each OT, daily number of
surgeries, time utilized in surgeries, total turnaround OT coordinator
4.
time, and total functional hours available shall be
entered in the standardized format of
Monthly utilization shall be mentioned in utilization report OT coordinator
5.
of each OT
These utilization rates reports shall be submitted to QAC OT coordinator
6. chairperson for discussion and action in committee
meeting
A copy of this report shall be sent to Corporate quality OT coordinator
7.
team for validation

9. Procedure of validation of Indicator reports: To ensure that data and indicators being used in hospital for
action and decisions are genuine and valid, a procedure of validation has been put in place. Validation of all
indicator reports shall be done either offsite or onsite as described in the procedure below

S. No. Procedural Steps Responsibility

Receive completed indicator reports along with main Department in charge
1.
data sheet from unit
2. Validation can be done offsite and / or onsite Department in charge
For offsite validation, check all entries against each Department in charge
3. indicator value and mark those which shows an obscure
or irrelevant values
Mark all those indicators for which value has not been Department in charge
4.
calculated
Check the data sheet thoroughly and identify those data Department in charge
5. values which shows obscure or irrelevant
values
Mark all those data values for which values has not Department in charge
6.
been entered
For indicators showing obscure values, check the Department in charge
7.
formulae feeded in cells
8. On the basis of these checks complete the offsite Department in charge
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validation report as per the format

9. If required onsite validation can be decided Department in charge
For onsite validation, cross check a randomly selected
10. data from the registers / records maintained in the Department in charge
department

10. Mechanism to take action / decision on the basis of indicator report: These indicator reports
are meant for quality assurance and continual improvement. Action shall be decided and taken on those
indicator values which are below standard limit or shows a downward trend. All indicators shall show a
progressive improvement and this shall be depicted in trend graphs. Responsibilities and target shall be
specified while taking action and all action shall be recorded in committee meeting minutes or RCA analysis
records

CQI-02 Sentinel Events

Definition: An expected incident related to system or process deficiencies, which leads to death or major and
enduring loss of function for a recipient or health care services

Major and ensuring loss of Functions refer to sensory, motor, physiological, or psychological impairment not
present at the time services were sought or begun. The impairment lasts for a minimum two weeks and is not
related to an underlying condition.

Description of event

1. Surgical Events

 Surgery perform on the wrong body part

 Surgery performed on the wrong patient
 Wrong surgical procedure performed on the wrong patient
 Retained instruments in patient discovered after surgery/ procedure
 Patient death during or immediately post surgical procedure
 Anesthesia-related event

2. Device or product events

 The use of the contaminated drugs, devices, products supplied by the organization
 The use of function of a device in a manner other than the device’s intended use
 The failure or breakdown of a device or medical equipment
 Intravascular air embolism

3. Patient protection events

 Discharge of an infant to the wrong person

 Patient death or serious disability associated with elopement from the healthcare facility
 Patient suicide, attempted suicide or deliberate self harm resulting in serious disability
 Intentional injury to a patient by a staff member, another patient, visitor, or other
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 Any incident in which a line designated for oxygen or other came to be delivered to a patient
and contains the wrong gas or is contaminated by toxic substances
 Nosocomial infection or disease causing patient death or serious disability

4. Environmental events

Patient death or serious disability while being cared for an a healthcare facility associated with
 A burn incurred from any source
 A slip, trip or fall
 An electric shock
 The use of restraints or bedrails
5. Care Management events
 Patient death or serious disability associated with a hemolytic reaction due to the administration
of ABO- incompatible blood or blood products
 Maternal death or serious disability associated with labor or delivery in a low risk pregnancy
 Medical error leading to the death or serious disability of patient due to incorrect administration
of drugs for example
 Omission error
 Dosage error
 Dose-preparation error
 Wrong time error
 Wrong rate of administration error
 Wrong administrative technique error
 Wrong patient error
 Patient death or serious disability associated with an avoidable delay in treatment or response
to abnormal test results

6. Criminal Events

 Any instances of care ordered by or provided by an individual impersonating a clinical member

of staff
 Abduction of a patient
 Sexual assault on a patient within or on the ground of the healthcare facility
 Death or significant injury of a patient or staff member resulting from a physical assault or other
crime that occurs within or on the grounds of the healthcare facility.

Any sentinel events listed above needs to be recorded and brought to the notice of the management and
ethical committee.