CQE-7-Nursing-Quality-indicators 5.3.25 ppt.pptx

health care quality indicator are more than 76 indicator to view the patient excellence in care

1. © All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published in any form by any means, nor should the material be disclosed to third parties without the consent of IHH. Quality Indicators for health care organization DR.ANJALATCHI MUTHUKUMARAN PROFESSOR CUM VICE PRINCIPAL ERA COLLEGE OF NURSING ERA UNIVERSITY , LUCKNOW 226003

2. NATIONAL ACCREDITATION BOARD OF HEALTH CARE (NABH) National Accreditation Board for Hospitals and Healthcare Providers (NABH) is a constituent board of Quality Council of India (QCI), set up to establish and operate accreditation programme for healthcare organizations . NABH accreditation NABH accredits healthcare organizations, including hospitals, blood banks, dental clinics, and more. NABH accreditation is internationally recognized, which helps boost medical tourism in India

3. Purpose of NABH NABH standards are guidelines that healthcare organizations must follow to improve patient safety and quality of care. The National Accreditation Board for Hospitals and Healthcare Providers (NABH) is responsible for setting these standards.  Purpose of NABH standards   To improve patient safety, To improve healthcare quality, To promote continuous quality improvement, To set benchmarks for health industry progress, and s To build a quality culture

4. Need of quality indicator

5. STANDARD :SETS

6. NABH STANARD AND CHAPTER

7. KEY FEATURE OF NABH ACCREDITATION

8. Benefit of nabh for staff/organization

9. 2 The Beginning of Evaluating the quality of nursing practice - When Florence Nightingale began to measure patient outcomes . Reflection for today: She used statistical methods to generate reports correlating patient outcomes to environmental conditions ( Dossey, 2005 ; Nightingale, 1859/1946 ). Over the years, quality measurement in health care has evolved – Quality Assurance - Continuous Quality Improvement, Quality Movement & Campaign, Accreditation Awards and Recognition ……… Moving beyond Accreditation …… India – QCI, NABH, CAHO, JCI, NABH NE etc.… We learn from advanced countries: The work done in the 1970s by the American Nurses Association (ANA), the wide dissemination of the Quality Assurance (QA) model ( Rantz, 1995 ), and the introduction of Donabedian's structure, process, and outcomes model ( Donabedian, 1988, 1992 ) have offered a comprehensive method for evaluating health care quality specifically in Nursing. History of Nursing Quality Indicators (NQI)

10. 3 QUALITY INDICATORS – Familiar NQIs Medication Errors Hospital Associated Pressure Ulcer CAUTI VAP Rate CLABSI SSI Hand Hygiene Compliance Rate Incidence of Needle Stick Injuries Inpatient Fall Rate Nursing Attrition Rate

11. 4 What is Nursing Quality Indicator? The Nursing Quality Indicators are measures of Nursing care quality that use readily available hospital inpatient administrative data. What is Continuous Nursing quality improvement (CNQI)? Continuous Nursing quality improvement (CNQI) is the key to care excellence to match with the paradigm shift in roles of health care professionals, expectations from consumers and technological advancements in Health care. Safety and quality are integral aspects of Nursing Care Continuum. ∞ More than What, Why and How is significant when it comes to NQI

12. 5 For patients, what helps make their hospital stay a much better experience & how nursing care impacts? ………………A smart competent people friendly health care provider at their bedside. Who else other than Nurses can be fitting into this … What helps these providers perform better especially “The Nurses”? ..………….. An environment that encourages/ nourishes proactive & predictive behaviors directed toward prioritizing patient care. How to evaluate the quality of care? …..………...Right and Appropriate Quality Indicators Where? Destination How? Values Who? Team Let us Reflect

13. 6 Why NQI ? It remains a critical element in the nursing professional tool kit to ensure accountability, transparency, and quality improvement. Why monito r QI ? To carry out interdisciplinary processes to meet organizational QI goals and to measure, improve, and control nursing- sensitive indicators (NSI) affecting patient outcomes specific to nursing practices. Monitor for early recognition of adverse events, complications and errors. Initiating deployment of appropriate and timely nursing care to aid patients in speedy recovery. To ensure TAT in clinical process. For assessing the provided care & improving the quality of care For defining strategies to achieve goals & redefining patient care.

14. 7 How do we identify QI for Nursing Service? – Its Nursing Domain Decision Scope/ Center of Excellence General Medical and Surgical Superspecialist – Transplantation Obstetrics Orthopedics Neurology Pediatrics Oncology Depth/Limit No specified size and limit for the number of QI that can be monitored. How ever critical NQIs are significant. Eg: Medication Error Incidence of Medication Error Incidence of prescription error Incidence of transcription error Incidence of dispensing error Incidence of administration error Percentage of admissions with ADR Percentage of medication charts with error prone abbreviations Compliance rate to Medication Prescription in capitals Percentage of patients receiving high risk medications developing adverse drug event. Percentage of contrast allergic reaction Number of patients on NG tube receiving Non- enteric coated drugs. Key Principle: Appropriate & Relevant Eg: Initiation of Breast feeding – Obstetrics Nursing Simple to Complex – Eg. Pressure Injury (PI) to PI Healing pattern Common / Routine to uncommon/ Rare

15. 8 Nursing Indicator – Safe Staffing For Example Missed breaks Nursing overtime Planned, required and available nurses for each shift High levels and/or ongoing reliance on temporary nursing Compliance with any mandatory training Nursing staff unable to take scheduled breaks Nursing staff working extra hours The number of planned, required and available nursing hours on hospital inpatient wards in relation to bed utilization. Temporary- pull in & pull out nursing staff on hospital inpatient wards. Compliance of ward nursing staff with any mandatory training in accordance with local policy

16. 9 Importance of NQI in NABH & JCI Ref: NABH NE NABH NE Ref: JCI Standards

17. Nursing Sensitive Indicators- Structure Process & Outcome Model Includes the supply of nursing staff, the skill level of nursing staff, equipment, education and certification levels of nursing staff. Structural Indicators Measure methods of patient assessment and nursing interventions and competency assessment. Nurses job satisfaction is also considered a process indicator. Process Indicators Reflect patient outcomes that are determined to be nursing- sensitive because they depend on the quantity or quality of nursing care outcome. These include pressure ulcers and falls. Outcome Indicators 10 Ref: https:// www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality-indicators-anyway/

18. 11 *Nurse Staffing Characteristics Number of Nursing Staff Number Staffing Ratio Nurse Staffing Levels Nurse Staffing Qualifications Nurse Experience Nurse Education *Hospital Characteristics Work Schedule Patient Safety Patient turnover Work environment Nurse autonomy Case Mix Treatment and Procedures Pain Management Maintenance of skin integrity Patient Education Nurses Job satisfaction Nurse reported quality of care Nurse burnout Nurse turnover Nosocomial Infection Mortality Pressure ulcer Patient Satisfaction Patient falls Patient falls with injury LOS DVT/Pulmonary Embolism Physical restrain use Shock/Cardiac arrest Organizational- Focused Structural Indicators Nursing Focused Process/Intervention Indicators Nurse Focused outcome Indicators Patient Focused Outcome Indicators STRUCTURE PROCESS OUTCOME Structure Process Outcome Model

19. 12 How are Nursing- Sensitive Indicators Developed ? Identification of potential Indicator Literature Review Nursing Panel review’s the validity of the Indicator Conduct Pilot study **Once the potential indicator has been empirically supported to be meaningful in clinical practice and it has been determined that no undue burden would be placed on participating facilities/ team. A pilot study is performed in willing facilities/unit/area . It shall be an inclusive approach. QI is basis for BSC

20. 13 INDICATOR SUB- INDICATOR MEASURE Nursing Hours per Patient Day Registered Nurses (RN) Structure Patient Falls with Injury Injury Level Process & Outcome Pressure Ulcer Prevalence Community Acquired Hospital Acquired Unit Acquired Process & Outcome Nosocomial Infections Urinary catheter- associated urinary tract infection (UTI) Central line catheter associated blood stream infection (CABSI) Ventilator- associated pneumonia (VAP) Community Acquired Hospital Acquired Unit Acquired Process & Outcome Nursing Sensitive Indicators - Classification

21. 14 This is not enough we need to move to next level to impact outcome

22. 15 Benchmarking - A continuous process comparing an organization's performance against that of the best in the industry considering critical consumer needs and determining what should be improved. Benchmarking Encompasses: Regularly comparing indicators (structure, activities, processes and outcomes) against best practitioners Identifying differences in outcomes through inter-organizational visits Seeking out new approaches in order to make improvements that will have the greatest impact on outcomes; and Monitoring Indicators. Here comes Ideation, Innovation & Enovation Benchmarking can be done at Department level, hospital level, National level or international level. Benchmarking QI for Nursing – Where do we position our Nursing Care

23. 16 Select the object of the benchmarking (the service or activity to be improved). Identify benchmarking partners (reference points). Collect and organize data internally. Identify the competitive gap by comparing against external data. Set future performance targets (objectives). Communicate the benchmarking results. Develop action plans. Take concrete action (project management). Monitor progress. Steps of Benchmarking Ref: Pitarelli and Monnier (2000)

24. 17 Linking NQI to Performance of an Organization Better outcomes for participant & population Better professional development (competence, pride, joy) Everyone Better program performance (Quality & Value) Change does not necessarily result in improvement, but improvement always brings change

25. 18 To carry out interdisciplinary processes to meet organizational QI goals and to measure, improve, and control nursing- sensitive indicators (NSI) affecting patient outcomes specific to nursing practices. All levels of nurses, from the direct care bedside nurse to the chief nursing officer (CNO), play a part in promoting QI within the healthcare provider organization. Monitor for early recognition of adverse events, complications and errors. Initiating deployment of appropriate and timely nursing care to aid patients hastens speedy recovery. Sharpen Nurses EQ/CQ & Empower them to Express without fear while at Bedside or in Boardroom Role of Nurse in Quality Improvement

26. 19 Involvement of Nurses at Various level in monitoring QI CNOs set the tone for the nursing department's participation in QI. As a member of administrative leadership, the CNO must integrate nursing practices into the organizational goals for excellence in patient outcomes through communication of strategic goals to all levels of staff. The direct care bedside nurse is the key to quality patient outcomes, carrying out the protocols and standards of care shown by evidence to improve patient care. The NM is responsible for communicating and operationalizing the organization's QI goals and processes to the bedside nurse, identifying specific NSIs that need improvement according to his or her particular patient population, and coordinating QI processes to improve these at the unit level The nurse manager (NM) The CNO The direct care nurse/Bed side RN Not an additional task, but a frame of mind Creating A Mindset for the Context is very significant Data Originator? Data Validation?

27. 20 Other Factors Related to Quality Competent nurses Independent and autonomous practice (micro- management is frowned upon, even in other professions) Management support (recognitions, team building, and other activities or programs are present) Patient- centered culture (patients over revenue) Collaborative working environment (particularly between nurses and doctors) Availability of continuing education and training options ( engagement of team & newer approaches ) Nurses directly affect the quality of hospital care - All efforts to train them and maintain their value should be addressed. Nurses will – in turn – pass the same value and care along to their patients.

28. 21 The difficulties encountered by RNs while implementing QI Lack of time Inadequate number of professionals Lack of knowledge on the subject. Lack of understanding of how to use these instruments CRITICAL FACTOR - Available level of nurse staffing

29. 22 Relationship between Quality of care and Staff Empowerment Staff Empowerment Increased Job Satisfaction, Lower Job Turnover Increased Patient satisfaction & Perception of care Higher Quality of care Nursing Quality of Care- Measured through NQI What Builds Staff Empowerment? Leader support and teams. Communication and information sharing. Positive reinforcement. Confidence. Just Culture Barriers for Staff Empowerment? Lack of senior leader support. Lack of resources. Poor teamwork and support. Stagnation and loss of momentum for change. Staff turnover. Punitive response to error.

30. In-patient wards checklist and Quality Indicators for NABH  E . Quality Indicators for wards:  These QIs can be calculated in each ward and then combined for hospital wide QI Average time for initial assessment of admitted patient and % outliers  Incidence of  medication errors Percentage of admissions with adverse drug reactions Percentage of patients receiving high risk medicines and developing adverse drug reaction Percentage of transfusion reaction Percentage of near miss events Incidence of patient falls Incidence of bed sores after admissions Incidence of patient rights violations Incidence of needle stick injuries Incidence of missing medical records Percentage of non-compliance observed related to infection control practices Patient satisfaction rate of the ward ( Checout a sample form ) Time taken for discharge Average nurse patient ratio in each shift Percentage of current medical records that are incomplete as per hospital’s policy

31. Checklist for CSSD for NABH preparation and its quality indicators Quality Indicators for CSSD       ·         % of HAI happening due to instrument/devices used on patients       ·         Number of times of sterilization failure       ·         % re-sterilization required due to improper storage       ·         % of non-compliance to sterilization practices

32. Checklist of Hospital’s Food services (Kitchen) for NABH accreditation preparation F. Quality Indicators % of time food was not delivered within the time-frame % of food wastage (raw material and cooked food) Diet distribution error per 1000 patient days Patient satisfaction  rating to quality of food

33. ICU checklist and quality indicators for NABH  Quality Indicators specific to ICU:  All quality indicators mentioned in  ‘ In-patient wards checklist and Quality Indicators ’ are also applicable to ICU. In addition, following quality indicators can be used for ICU ICU specific HAI rates (VAP, CA-UTI, CA-BSI, SSI) Standardized mortality rate Incidence of accidental removal of tubes Average length of stay Compliance percentage to admission-discharge criteria ICU re-admission rate Re-intubation rate

34. Checklist of Pathology Laboratory and its quality indicators for NABH Quality Indicators:  Following quality indicators must be used in imaging as a part of quality assurance program. Each doctor and staff should be aware of these indicator % of test result delayed from standard turn-around time % compliance to laboratory safety practices (done through sample monitoring) % of critical results reported to concerned consultant within the given timeframe % of variation in internal quality checks % of variation in external quality checks % of repeat samples required to be taken % of re-testing done

35. Checklist of Blood Bank and Quality Indicators for NABH Quality Indicators for blood bank and transfusion services      1.       Percentage of blood wastage (whole blood and component-wise)      2.       Adverse transfusion reaction rate      3.       Turn-around time for blood issuance      4.       Percentage of component quality control failure (for each component)      5.       Adverse reaction rate with donors      6.       Percentage of components in blood bank

36. Code blue policy indicators 9.       Quality indicators:  Few indicators that can be used for evaluating whether or not the code blue system is working efficiently and effectively, are given below a.       Average time to respond –  The time from activation of code blue till the time when the 1 st  member of code blue team reach on spot b.      Outcome percentage –  Percentage of patients’ survived out of total who went under cardiac arrest c.       Non- compliance rate –  Percentage of non-compliance to standard process of code blue system d.      Failure to activate –  Percentage of times when code blue was not activated, when required

37. Example of Quality Indicator for various department Quality Indicators are the backbone on which quality assurance programme of a hospital relies. NABH accreditation expects hospitals to calculate several quality indicators and use it for monitoring the quality of care. These are the list of quality indicators, which a hospital preparing for accreditation must necessarily monitor. (Also check -  Performance measures for hospital business )

38. List of indicator in health care setting S. N. Indicator Formula Remark 1.           Average time taken for initial assessment of patients admitted in IPD Sum of time taken for initial assessment of all admitted patients in a period / total number of patients admitted in that period The time taken can be taken from time when patient was registered for admission till the time at which initial assessment was completed and documented 2.           Percentage of IPD patients for whom the initial assessment was completed within defined timeframe (Number of patients for whom the initial assessment was completed within a defined time frame / total number of patients admitted) x 100 Timeframe for initial assessment of patient getting admitted must be defined by the hospital 3.           Average time taken for initial assessment of patients coming to emergency Sum of time taken for initial assessment of all patients who accessed emergency services in a period / total number of patients who accessed emergency services in that period The time taken can be taken from time at which patient arrived at emergency department till the time at which initial assessment was completed and documented. 4.           Percentage of emergency patients for whom the initial assessment was completed within defined timeframe (Number of patients in emergency for whom the initial assessment was completed within a defined time frame / total number of patients admitted) x 100 Timeframe for initial assessment of emergency patients must be defined by the hospital

39. 5.           Percentage of in-patients wherein the plan of care with desired outcomes is documented and countersigned by the clinicians (Number of case records in which plan of care with desired outcomes is documented and countersigned by the clinicians / Total number of case records checked) x 100 This can be further broken down into subcomponents such as case records with documented plan of care, documented desired outcomes and countersigned 6.           Percentage of in-patients wherein  screening for nutritional needs  has been done (Number of admitted patients who has been screened for nutritional requirements / Total number of patients admitted) x 100 Nutritional screening format   can be used and is required for all admitted patients 7.           Reporting error rates (per 1000) in laboratory (Number of lab reports in which errors detected / Number of lab reports checked) x 1000 The error rates can be separately calculated for each unit of laboratory 8.           Percentage of re-dos in laboratory (Number of lab tests which has to be repeated in a period/ Total lab tests conducted in that period) x 100 Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues 9.           Percentage of lab reports co-relating with clinical diagnosis (Number of lab reports in which the diagnosis matches with the clinical diagnosis of the doctor / Total lab tests conducted) x 100 While higher correlation shall be expected, it may not necessarily be 100% 10.       Percentage of adherence to safety precautions by employees working in labs (Number of observations that indicates adherence to safety precautions in a period / Total number of observations made in that period) x 100 Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be related safety from infection, bio-medical waste and safety from chemicals.

40. 11.       Reporting error rates (per 1000) in Imaging (Number of lab reports in which errors detected / Number of lab reports checked) x 1000 The error rates can be separately calculated for each imaging modality 12.       Percentage of re-dos in Imaging (Number of Imaging tests that has to be repeated in a period / Total Imaging tests conducted in that period) x 100 Only those repeat test shall be considered in calculation, where the reason of repeating is related to errors, mistake or quality issues 13.       Percentage of Imaging reports co-relating with clinical diagnosis (Number of Imaging reports in which the diagnosis matches with the clinical diagnosis of the doctor / Total Imaging tests conducted) x 100 While higher correlation shall be expected, it may not necessarily be 100% 14.       Percentage of adherence to safety precautions by employees working in Imaging (Number of observations that indicates adherence to safety precautions in a period / Total number of observations made in that period) x 100 Safety precautions must be clearly defined. Data must be gathered through random monitoring of practices followed by staff. Most safety precautions shall be radiation safety and infection control 15.       Medication error  rate OR Medication error per 1000 patient days (Number of medication errors reported in a period / Total number of medication administration events) x 100 OR (Number of medication errors reported in a period / Total patient days in that period) x 1000 For data on medication error a strong medication error reporting system must be in place. This indicator can further be divided into various types of medication errors, such as administration error, dispensing error, error of route, error of dose etc.

41. 16.       s Percentage of adverse drug reactions (Number of patients who suffered adverse drug reactions in a period / Number of admitted patients in that period) x 100 Adverse drug reaction and medication error shall be defined and should not overlap with each other 17.       Percentage of adverse drug reaction due to high-risk medicine (Number of patients developing adverse drug reaction from high-risk medicines in a period / Number of patients given high-risk medicine in that period) x 100 List of high-risk medicines shall be specified by the hospital and any adverse reaction happening due to these medicines shall be counted for this indicator 18.       Percentage of medical records with error-prone abbreviations (Number of medical records which contains error-prone abbreviations / Number of medical records screened) x 100 List of accepted abbreviations shall be determined by the hospital and any abbreviation other than that shall be considered as error prone 19.       Percentage of modification of anaesthesia plan (Number of patients in whom anaesthesia plan was modified immediately before induction of anaesthesia / Number of patients that have undergone anaesthesia) x 100 Each patient must undergo pre- anaesthesia check-up in which anaesthesia plan (type of anaesthesia and anaesthetic agent) is determined. Any change in this plan shall be considered as a modification 20.       Percentage of unplanned ventilation following anaesthesia (Number of patients who required unplanned ventilator support following anaesthesia / Number of patients who were given anaesthesia) x 100 Unplanned ventilation is the situation in which patient has to be put on the ventilator after surgery, due to complications resulting from anaesthesia

42. 21.       Percentage of re-scheduling of surgeries (Number of planned surgeries re-scheduled or cancelled / Number of surgeries planned) x 100 This indicator can further be classified as per causes of re-scheduling for the management to take appropriate corrective and preventive measures 22.       Compliance rate to surgical safety practices (Number of surgical patients in which all surgical safety practices where adhered / Number of surgical patients’ cases reviewed) x 100 For surgical safety practices, ‘ WHO surgical safety checklist   can serve as a good reference material’. The compliance rate of individual practices can also be calculated for detailed analysis 23.       Percentage of cases who received prophylactic antibiotic within specified time-frame (Number of surgical patients who has received prophylactic antibiotic / Total number of patient undergone surgery) x 100 The hospital must define the time-frame for giving prophylactic antibiotic. The documentation of administration of antibiotics and the time shall be done for getting data 24.       Percentage of transfusion reactions (Number of patients who developed blood or blood component transfusion reaction / Number of patients who underwent blood or component transfusion) x 100 To get data for this indicator a transfusion administration form must be filled for each transfusion, which shall have a column for indicating reactions if any 25.       Percentage of blood and blood components wasted (Units of blood and blood components wasted or discarded in a period / Total units of blood and blood components under storage during that period) x 100 Blood and blood components being discarded because of unfit in lab tests, shall not be counted as wastage. Wastage shall be because of reasons of expiry, errors, poor storage conditions etc.

43. 26.       Percentage of blood component usage (Total units of blood components transfused to patients / Total units of whole blood plus blood components transfused to patients) x 100 The percentage should be high 27.       Turn-around time for the issue of blood and blood components Sum of time taken for issuing blood and blood taken in each requisition / Total number of requisition received for blood and blood component The time taken shall be considered from the time of receipt of requisition till the time of dispatch of blood or blood component 28.       Percentage of blood and blood components issued within defined time frame (Number of blood and blood component requisitions that were issued within defined time-frame / Total number of requisition received for blood and blood component) x 100 The time frame must be defined by the organization 29.       Catheter associated Urinary Tract Infection (CA-UTI) rate (Number of patients developing CA-UTI in a period / Total urinary catheterization days in that period) x 1000 CA-UTI shall be determined clinically (CDC guidelines must be followed) The catheterization days shall be calculated as sum of number of days each patient spent with urinary catheter in the period of calculation 30.       Ventilator associated pneumonia (VAP) rate (Number of patients developing VAP in a period / Total ventilator days in that period) x 1000 VAP shall be determined clinically (CDC guidelines must be followed) The ventilator days shall be calculated as sum of number of days each patient spent on ventilator in the period of calculation

44. 30.       Ventilator associated pneumonia (VAP) rate (Number of patients developing VAP in a period / Total ventilator days in that period) x 1000 VAP shall be determined clinically (CDC guidelines must be followed) The ventilator days shall be calculated as sum of number of days each patient spent on ventilator in the period of calculation 31.       Central line catheter associated blood stream infection (CA-BSI) rate (Number of patients developing CA-BSI in a period / Total central line days in that period) x 1000 CA-BSI shall be determined clinically (CDC guidelines must be followed) The central line days shall be calculated as sum of number of days each patient spent with central line catheter in the period of calculation 32.       Surgical site infection (SSI) rate (Number of patients developing SSI in a period / Total number of clean surgeries performed in that period) x 100 CA-BSI shall be determined clinically (CDC guidelines must be followed) This can be further bifurcated in superficial, deep and organ/space infections due to surgeries 33.       Gross mortality rate (Total number of deaths happened in the hospital in a period / Total number of deaths discharges during that period) x 100 All deaths (including deaths in emergency and ICU) shall be counted. In denominator all types of discharges shall be considered 34.       Net mortality rate (Total number of deaths that happened after 48 hours of admission of the patient / Total number of deaths and discharges during that period) x 100 Deaths happening within 48 hours of discharge should also be counted in numerator 35.       ICU specific mortality rate (Total number of deaths in ICU patients in a  period / Total number of patients discharged from ICU in that period) x 100 On similar lines, condition specific or speciality specific deaths rates can also be calculated

45. 36.       Return to ICU within 48 hours (Number of patients who were re-admitted to ICU within 48 hours of being discharged from ICU / Total number of patients discharged from ICU) x 100 The patients who were discharged against medical advice from ICU should be ignored 37.       Return to emergency within 72 hours with similar presenting complaints (Number of patients who returned to emergency within 72 hours with similar presenting complaints / Total number of patients discharged from emergency) x 100 The patients who were discharged against medical advice from emergency should be ignored 38.       Re-intubation rate (Number of patients who has to be re-intubated after ex- tubation / Total number of ex- tubation done during the period) x 100 Data on re-intubation and ex- tubation shall be taken from individual medical record or a master register 39.       Percentage of research activities approved by ethics committee (Number of research activities approved by ethics committee / Number of research proposal submitted to ethics committee) x 100 Applicable to hospital undertaking clinical research 40.       Percentage of patients withdrawing from clinical research (Number of patients withdrawing from research study / Number of patients originally enrolled in the study) x 100 Applicable to hospital undertaking clinical research

46. 41.       Percentage of protocol violations/deviations in clinical research study (Incidence of protocol violations/deviations observed in clinical research study / Number of observations made) x 100 Applicable to hospital undertaking clinical research 42.       Percentage of serious events in clinical research study reported to ethics committee (Number of serious adverse events reported to ethics committee / Number of serious adverse events identified) x 100 Applicable to hospital undertaking clinical research 43.       Error rates during shift hand-overs (Number of errors detected in patient handovers during shift changes / Number of hand over records reviewed) x 100 A handover checklist must be available against which errors can be detected 44.       Percentage of  medical error  due to wrong  identification of patient (Number of medical errors reported that happened due to wrong identification of patient / Total number of medical errors reported) x 100 A robust system of  medical error  reporting must be in place to get appropriate data 45.       Hand hygiene compliance rate (Number of observations in which staff complied with hand hygiene guidelines / Total number of observations made) x 100 Hand hygiene guidelines must be specified. Data shall be gathered through monitoring

47. 46.       Compliance rate to medication prescription in capitals (Number of prescriptions in which medications are written in capital letters / Total number of prescriptions checked) x 100 Not applicable, if prescription is computerized 47.       Percentage of procurement through local purchase (Value of drugs and consumables purchased through local purchase / Total value of drugs and consumables purchased in that period) x 100 Local purchases are unplanned, emergency purchases which increase the cost of purchasing 48.       Percentage of stockouts for emergency drugs (Number of emergency drugs on the stock-out / Total number of emergency drugs) x 100 Stock out is a situation when the inventory level of the medicine has gone below the defined minimum level 49.       Percentage of drugs and consumables rejected before preparation of goods receipt note (Number of drugs and consumables rejected before preparation of goods receipt note / Total number of drugs and consumables received) x 100 The data can be taken through a random sample of items that were checked 50.       Percentage of variation from procurement process (Number of times standard procurement process was not followed / Total number of procurements done) x 100 A standard operating process for procurement must be in place to calculate this indicator

48. 51.       Percentage of variations observed in mock drills (Number of variations observed in mock drills / Total number of observations made) x 100 This should be separately calculated for different mock drills such as  code blue ,  code red ,  code pink , disaster handling etc. 52.       Patient  fall  rate per 1000 patient days (Number of patient fall reported in a period / Total patient days in that period) x 1000 Patient fall must be defined. Generally, all kind of fall (fall from bed, in washroom, on stairs, while walking etc.) must be counted 53.       Hospital-associated pressure ulcer rate (Number of patients developing hospital associated pressure ulcers / Number of bedridden patient days) x 1000 Criteria for determining pressure ulcers shall be specified. Patients at risk of developing pressure ulcers must be identified 54.       Percentage of staff provided pre-exposure prophylaxis (Number of staff who received pre-exposure prophylaxis / Total healthcare staff) x 100 Pre-exposure prophylaxis can be given for different conditions such as Hepatitis, certain kinds of Pneumonia etc. 55.       Bed Occupancy Rate (Total patient days in a period / Total bed days available during that period) x 100 Total patient days is the sum of days spent by each admitted patient in hospital Total bed days is the product of number of functional beds in hospital with the number of days in that period

49. 56.       Average Length of Stay (ALOS) Sum of length of stay of individual patients / Total number of patients whose length of stay has been taken ALOS must be separately calculated for different disease conditions, specialities and ICU/Non-ICU cases 57.       OT utilization rate (Total hours for which actual surgeries were performed in OT / Total OT hours available) x 100 Total hours of surgeries can be calculated by summing up the duration of each surgeries performed in the period Total OT hours can be calculated by multiplying functional hours available for each OT with the number of OT 58.       ICU utilization rate (Total ICU patient days in a period / Total ICU bed days available in that period) x 100 This is similar to calculation bed occupancy rate, but only for ICU 59.       Percentage of downtime of Critical equipment Total duration (in days or hours) for which a critical equipment was down / Total duration (in days or hours) in that period A list of critical equipment shall be made. This indicator shall be calculated separately for each critical equipment 60.       Nurse patient ratio for wards Total number of nurse working in a shift / Total number of patient in that shift An average ratio of the month can be taken. This should be separately calculated for each shift and each ward

50. 61.       Nurse patient ratio for ICU Total number of nurse working in ICU in a shift / Total number of patient in that shift An average ratio of the month can be taken. This should be separately calculated for each shift and each ICU 62.       Out-patient satisfaction index Average rating given by patient of OPD to the hospital A standard  patient satisfaction feedback form  can be used for obtaining rating from patients. Number of feedback collected should be statistically significant 63.       In-patient satisfaction index Average rating given by patient of IPD to the hospital A standard  patient satisfaction feedback form  can be used for obtaining rating from patients. Number of feedback collected should be statistically significant 64.       Average waiting time for services Total waiting time of all patients for a particular service / Total number of patients whose waiting time has been taken Average waiting time shall be separately calculated for OPD consultation, Billing, Pharmacy and diagnostics 65.       Average discharge time Sum of time taken for discharging patients / Total patients whose discharge time is taken Time taken for discharge shall be taken from the time when the discharged was ordered by the doctor till the time when patient was relieved from room/bed

51. 66.       Employee satisfaction index Average rating given by employee to the organization An employee satisfaction study must be conducted for this. The index can be calculated for different categories of employees 67.       Employee attrition rate (Number of employee who resigned during a period / Total number of employee on roll) x 100 This should be calculated overall as well as category wise 68.       Employee absenteeism rate (Total number of absenteeism of employee in a period / Total employee days) x 100 Absenteeism shall be considered as absent without information. This indicator shall also be calculated category wise 69.       Percentage of employee aware of  employee rights (Number of  employee aware of employee rights / Total number of employee) x 100 Category-wise calculation shall be done 70.       Percentage of sentinel events analysed within a defined time frame (Number of sentinel events analysed within defined time frame / Number of sentinel events reported) x 100 Timeframe and sentinel events must be defined

52. 71.       Percentage of near misses (Number of near misses reported / Total number of errors and near-miss reported) x 100 A robust system of reporting errors and near misses must be in place 72.       Needlestick injury rate (Number of needle stick injury reported / Total patient days in that period) x 100 Needlestick injury reporting and data collection mechanism must be in place 73.       Percentage of medical records not having discharge summary (Number of medical records not having discharge summary / Total number of medical records screened) x 100 Sufficient sample size must be ensured 74.       Percentage of medical records not having ICD codes (Number of medical records not having ICD codes / Total number of medical records screened) x 100 Sufficient sample size must be ensured 75.       Percentage of medical records having incomplete and improper consent (Number of medical records having incomplete and improper consent / Total number of medical records where consent was applicable Standard process of informed consent must be in place to determine what constitutes incomplete or improper consent 76.       Percentage of missing records (Number of medical records missing / Total number of medical records in MRD) x 100 A definition of missing shall be available. Generally, any medical record which has been able to be traced for last 3 days shall be considered missing. In case, a missing record has been found it shall be removed from the missing data

53. 23 https://www.nice.org.uk/guidance/sg1/chapter/9-safe-nursing-indicators https://ojin.nursingworld.org/MainMenuCategories/ANAMarketplace/ANAPeriodicals/OJIN/Tabl eofContents/Volume122007/No3Sept07/NursingQualityIndicators.aspx https://www.hcpro.com/NRS-248978-868/Ask-the-expert-Understanding-nursing-roles- in- quality-improvement.html https://www.americansentinel.edu/blog/2011/11/02/what-are-nursing-sensitive-quality- indicators-anyway/ NQI - https://www.qualityindicators.ahrq.gov/ NABH Standards & JCI Standards Books References

54. © All Rights Reserved. This material is confidential and property of IHH Healthcare Berhad. No part of this material should be reproduced or published in any form by any means, nor should the material be disclosed to third parties without the consent of IHH. Thank You Nurse you are a Patient Advocate & Express without fear while at Bedside or in Boardroom.