Quality Indicator of NABH 6th Edition

Quality Indicator 1: Time for initial assessment of indoor patients

Formula: (Sum of time taken for assessment / Total no. of admissions)

Quality Indicator 2: Number of reporting errors / 1000 investigations

Formula: (No. of Reporting errors / No. of Tests performed) * 1000

Quality Indicator 3: Percentage of adherence to safety precautions by employees in diagnostics

Formula: (No. of employees adhering to safety precautions / No. of employees sampled) * 100

Quality Indicator 4: Medication Error Rate

Formula: (Total no. of medication errors / Total no. of opportunities for medication errors) * 100

Quality Indicator 5: Percentage of medication charts with error-prone abbreviations

Formula: (No. of medication charts with error-prone abbreviations / No. of medication charts reviewed) * 100

Quality Indicator 6: Percentage of inpatients developing adverse drug reactions (ADR)

Formula: (No. of patients developing ADR / No. of inpatients) * 100

Quality Indicator 7: Percentage of unplanned return to OT

Formula: (No. of unplanned returns to OT / No. of patients who underwent surgeries in OT) * 100

Quality Indicator 8: Adherence to procedure preventing wrong site/patient/surgery

Formula: (No. of cases where procedure followed / No. of surgeries performed) * 100

Quality Indicator 9: Percentage of transfusion reactions

Formula: (No. of transfusion reactions / No. of units transfused) * 100

Quality Indicator 10: Standard Mortality Ratio for ICU

Formula: (Actual deaths in ICU / Predicted deaths in ICU) * 100

Quality Indicator 11: Return to the emergency within 72 hours with similar complaints

Formula: (No. of returns within 72hrs with similar complaints / No. of emergency patients) * 100

Quality Indicator 12: Incidence of hospital-associated pressure ulcers

Formula: (No. of new or worsening pressure ulcers / No. of patient days) * 1000

Quality Indicator 13: Urinary Tract Infection (UTI) Rate

Formula: (No. of urinary catheter-associated UTIs in a month / No. of urinary catheter days) * 1000

Quality Indicator 14: Ventilator-Associated Pneumonia (VAP) Rate

Formula: (No. of ventilator-associated pneumonia cases in a month / No. of ventilator days) * 1000

Quality Indicator 15: Blood Stream Infection (BSI) Rate

Formula: (No. of central line-associated BSI in a month / No. of central line days) * 1000

Quality Indicator 16: Surgical Site Infection (SSI) Rate

Formula: (No. of surgical site infections in a month / No. of surgeries performed) * 100

Quality Indicator 17: Hand Hygiene Compliance Rate

Formula: (No. of missed hand hygiene opportunities / Total no. of hand hygiene opportunities) * 100

Quality Indicator 18: Prophylactic Antibiotic Compliance

Formula: (No. of patients receiving prophylactic antibiotics appropriately / No. of surgeries performed) * 100

Quality Indicator 19: Percentage of rescheduling of surgeries

Formula: (No. of surgeries rescheduled / No. of surgeries planned) * 100

Quality Indicator 20: Turnaround Time (TAT) for the issue of blood/blood components

Formula: Sum of time taken / Total no. of blood components cross-matched/reserved

Quality Indicator 21: Nurse-Patient Ratio (ICU & Wards)

Formula: No. of nursing staff / No. of occupied beds

Quality Indicator 22: Waiting time for outpatient consultation

Formula: (Sum of [Consultation/procedure in-time – OPD reporting time]) / No. of outpatients

Quality Indicator 23: Waiting time for diagnostic services

Formula: (Sum of patient reporting time in diagnostics) / No. of diagnostic patients

Quality Indicator 24: Time taken for discharge

Formula: Sum of time taken for discharge / No. of discharges

Quality Indicator 25: Incomplete/Improper Consent in Medical Records

Formula: (No. of incomplete/improper consents / No. of discharges) * 100

Quality Indicator 26: Stock Out Rate of Emergency Drugs

Formula: (No. of stock outs of ER drugs / No. of ER drugs listed in hospital formulary) * 100

Quality Indicator 27: Variations observed in Mock Drills

Formula: Total no. of variations observed in mock drill

Quality Indicator 28: Incidence of Patient Falls

Formula: (No. of patient falls / Total no. of patient days) * 1000

Quality Indicator 29: Percentage of Near Misses

Formula: (No. of near misses reported / Total incidents reported) * 100

Quality Indicator 30: Incidence of Needle Stick Injuries

Formula: (No. of parenteral exposures / No. of inpatient days) * 1000

Quality Indicator 31: Appropriate Handovers during Shift Change

Formula: (No. of appropriate handovers / Total handover opportunities) * 100

Quality Indicator 32: Compliance with Prescription in Capital Letters

Formula: (No. of prescriptions in capital letters / Total prescriptions) * 100

Quality Indicator 33: Percentage of Beta-blocker prescriptions with a diagnosis of CHF with reduced EF.

Formula: (Number of patients discharged with a diagnosis of CHF with reduced EF and prescribed a beta blocker at discharge/ Number of patients discharged with a diagnosis of CHF) * 100

Quality Indicator 34: Percentage of patients with myocardial infarction for whom the door-to-balloon time of 90 minutes is achieved

Formula: (Number of acute myocardial infarction (AMI) patients undergoing primary angioplasty for whom the door-to-balloon time of 90 minutes is achieved/ Total number of AMI patients undergoing primary angioplasty) * 100

Quality Indicator 35: Percentage of hospitalized patients with hypoglycemia who achieved the targeted blood glucose level.

Formula: (Number of patients with hypoglycemic events where the target glucose level was achieved post-treatment ÷ Number of patients with Hypoglycemic events ) * 100

Quality Indicator 36: Spontaneous Perineal Tear Rate

Formula: (Number of cases where a spontaneous perineal tear occurs ÷ Total number of Vaginal deliveries) * 100

Quality Indicator 37: Postoperative Endophthalmitis rate

Formula: (Number of cases of postoperative endophthalmitis ÷ Total no. of Ophthalmic surgeries) * 100

Quality Indicator 38: Percentage of patients undergoing Colonoscopy who are sedated

Formula: (No. of patients sedated for the colonoscopy procedure ÷ Total number of patients undergoing Colonoscopy) * 100

Quality Indicator 39: Bile Duct Injury Rate Requiring Operative Intervention During Laparoscopic Cholecystectomy

Formula: (Number of cases where bile duct injuries occurred during laparoscopic cholecystectomy and required subsequent operative intervention to repair the injury / Laparoscopic cholecystectomies performed) * 100

Quality Indicator 40: Percentage of POCT results that led to a clinical intervention

Formula: (Number of POCT tests which resulted in a clinical intervention where indicated / Number of POCT tests where clinical intervention was deemed necessary) * 100

Quality Indicator 41: Functional gain following rehabilitation

Formula: (The sum of the functional gain achieved before the discharge in patients undergoing neurorehabilitation /Total number of patients undergoing neurorehabilitation) * 100

Quality Indicator 42: Percentage of sepsis patients who receive care as per the Hour-1 sepsis bundle

Formula: (Number of sepsis patients who receive care as per the Hour-1 sepsis bundle / Total number of sepsis cases) * 100

Quality Indicator 43: Percentage of COPD patients receiving a COPD Action plan at the time of discharge

Formula: (Number of COPD patients provided with a COPD action plan at the time of discharge / Number of COPD patients discharged) * 100

Quality Indicator 44: Percentage of stroke patients in whom the Door-to-Needle Time (DTN) of 60 minutes is achieved.

Formula: (Number of stroke patients in whom the Door-to-Needle time of 60 minutes is achieved / Number of stroke patients who receive thrombolytic therapy) * 100

Quality Indicator 45: Percentage of bronchiolitis patients treated inappropriately

Formula: (Number of patients treated inappropriately / Total number of patients with bronchiolitis) * 100

Quality Indicator 46: Percentage of oncology patients who had treatment initiated following

Formula: (Number of new oncology patients who had treatment initiated following multidisciplinary meeting (tumour board) / Number of new oncology cases (all disciplines) treated in the month) * 100

Quality Indicator 47: Percentage of adverse reactions to radiopharmaceutical

Formula: (Total number of patients who developed adverse reaction(s) to radiopharmaceutical / Total number of patients receiving the radiopharmaceutical) * 100

Quality Indicator 49: Percentage of adverse reactions to radiopharmaceutical

Formula: (Total number of patients who developed adverse reaction(s) to radiopharmaceutical / Total number of patients receiving the radiopharmaceutical) * 100

Quality Indicator 50: Percentage of oncology patients who had treatment initiated following

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