VISI - emshospital.org.in€¦ · QUALITY POLICY “AT EMS MEMORIAL CO-OPERATIVE HOSPITAL &...

VISION Healing eacH WitHin His ReacH

“We at EMS Memorial Co-operative Hospital & Research Centre are committed to provide need based patient care affordable to all through continuous innovation and improvements in our system, process and delivery’’

EMS MEMORIAL CO-OPERATIVE HOSPITAL AND RESEARCH CENTRE LTD

QUALITY POLICY

“AT EMS MEMORIAL CO-OPERATIVE HOSPITAL & RESEARCH CENTRE, PERINTHALMANNA, WE ARE

COMMITTED TO PROVIDE QUALITY MEDICAL CARE TO THE SOCIETY IRRESPECTIVE OF CAST, CREED,

FINANCIAL STATUS AT AN AFFORDABLE COST AND AIM FOR CONTINUAL IMPROVEMENT PROGRAMMES “

QUALITY OBJECTIVES

Quality Objectives of EMS Memorial Co-operative Hospital & Research Centre are:

To improve patient satisfaction

To improve training facilities to the staff on regular basis.

To introduce new services with a view of providing modern health care facilities to the patients.

QUALITY INDICATORS

Sl INDICATORSAUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

1. Time for initial assessment :Indoor patients (in minutes) Target – 60 minutes

40(245/511)

40(353/523)

39(345/521)

39(316/481)

37(281/456)

40(306/455)

b. Emergency patients Target – 10 minutes 4.93 1.38 1.78 1.54 1.08 1.48

0

5

10

15

20

25

30

35

40

45

1 2 3 4 5 6

Time for initial assessment :Indoor patients Time for initial assessment :Emeergency patientsLinear (Time for initial assessment :Indoor patients)

Sl

NoINDICATORS

AUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

2 Percentage of cases (IP) wherein care plan with desired outcomes is documented and counter signed by the clinician (%) Target – 100 %

96(490/511)

97(510/523)

96(501/521)

96(463/483)

95(432/456)

96(437/455)

96

97

96 96

95

96

94

94.5

95

95.5

96

96.5

97

97.5

AUG SEP OCT NOV DEC JAN

Sl

NoINDICATORS

AUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

3Percentage of cases (IP) wherein screening for nutritional needs has been done (%) Target – 100 %

ICU-100 % Ward-90 %

ICU-100 % Ward-92.1

%

ICU-100 % Ward-96.7

%

ICU-100 % Ward-98.75 %

ICU-100 % Ward-98 %

ICU-100 % Ward-91.8

%

84

86

88

90

92

94

96

98

100


Percentage of cases (IP) wherein screening for nutritional needs has been done (%)

Analysis Decision

screening of nutritional needs has increasing trend

Sl

NoINDICATORS

AUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

4 Percentage of cases (IP) wherein the nursing care plan is documented (%) Target – 100 %97

(497/511)99

(518/523)99

(516/521)99

(476/483)98

(448/456)99

(450/455)

97

99 99 99

98

99

96

96.5

97

97.5

98

98.5

99

99.5


Sl No INDICATORS AUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

5. Number of reporting errors / per 1000 investigations :

a. LabTarget

Sl No INDICATORS AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

5. Number of reporting errors / per 1000 investigations : b. RadiologyMRI

1.3(1/751)

2.6(2/763)

1.2(1/817)

2.6(2/762)

1.4(1/698)

1.2(1/780)

CT 1.57(1/636)0

(0/587)2.1

(1/472)1.8

(1/530)1.7

(1/559)0

(0/635

USG 0.6(1/1562)0.7

(1/1474)0.6

(1/1602)0.67

(1/1475)0

(0/1425)0.6

(1/1605)

Analysis Root cause

0

0.5

1

1.5

2

2.5

3


MRI

CT

USG


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

6. Percentage of re-dos(Lab) Target Zero

0.24(333/137603)

0.28(387/136281)

0.25(340/135950)

0.18(216/123328)

0.26(318/120654)

0.26(337/128963)

0

0.05

0.1

0.15

0.2

0.25

0.3


Percentage of re-dos(Lab) (%)

Analysis Root cause


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

7 Percentage of reports correlating with clinical diagnosis : Radiology

82(410/500)

91.4(457/500)

88.6(443/500)

88(441/500)

90(450/500)

92(464/500)

82

91.4

88.688

90

92

76

78

80

82

84

86

88

90

92

94


Analysis Root cause

INDICATORS AUG2019

SEP

2019

OCT

2019

NOV2019

DEC2019

JAN2020

b. Lab :

1. CLINICAL PATHOLOGY(%)80.64(50/62)

78.33(47/60)

75.81(47/62)

70(42/60)

69.35(43/62)

88.71(55/62)

2. HEMATOLOGY (%)

77.41(48/62)

80(48/60)

77.42(48/62)

80(48/60)

75.81(47/62)

79.03(49/62)

3. BIOCHEMISTRY(%) 82.26(51/62)81.66(49/60)

80.65(50/62)

73.33(44/60)

72.58(45/62)

62.9(39/62)

4. SEROLOGY(%) 80.64(50/62)75

(45/60)74.19(46/62)

71.66(43/60)

71.66(40/62)

64.51(40/62)

5. MICROBIOLOGY(%) 79.03(49/62)76.66(46/60)

72.58(45/62)

76.66(46/60)

69.35(43/62)

66.13(41/62)

6. HISTOPATHOLOGY(%) 64.76(68/105)72.41(84/116)

71.68(81/113)

66.17(88/133)

73.15(109/149)

79.59(117/147)

AVERAGE(%) 76.14(316/415)76.68

(319/416)74.94

(317/423)71.82

(311/433)71.24

(327/459)74.62

(341/457)

76.14

76.68

74.94

71.82

71.24

74.62

68

69

70

71

72

73

74

75

76

77


Percentage of reports correlating with clinical diagnosis : LAB

0102030405060708090


Reports correlating with clinical diagnosis

Clinical Pathology

73

74

75

76

77

78

79

80

81


Hematology

0

10

20

30

40

50

60

70

80

90


Biochemistry

0

10

20

30

40

50

60

70

80

90


Serology

55

60

65

70

75

80


Microbiology

0

10

20

30

40

50

60

70

80

90


Histopathology


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

8Percentage of adherence to safety precautions by employees working in diagnostics (%) Target – 100 %

77 90 85 83 70 100

77

9085 83

70

100

0

20

40

60

80

100

120


Analysis Root cause


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

9 Incidence of medication errors (per 1000) : Target – Zero a. Prescription Errors

0(0/10423) NIL NIL NIL NIL NIL

b. Dispensing Errors(Wrong drug, wrong strength, wrong dose, wrong patient, wrong route administering & Monitoring errors)

0.19(2/10423) NIL

0.095(1/10436) NIL NIL

0.215(2/9290)

0

0.05

0.1

0.15

0.2

0.25


Dispensing Errors Analysis Root cause


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

10Percentage of admissions with adverse drug reactionTarget – Zero

NIL NIL NIL 0.078(2/2537) NIL NIL

Analysis Root cause


2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

11 Percentage of medication charts with error prone abbreviations Target – Zero NIL NIL NIL NIL NIL0

(0/717)

12 Percentage of patients receiving high risk medications developing adverse drug event (Excludes asymptomatic hypoglycemia)

Target – Zero NIL NIL NIL NIL NIL NIL

13Percentage of modification of anesthesia plan

Target – ZeroNIL NIL NIL NIL NIL NIL

14Percentage of unplanned ventilation following anesthesia


15Percentage of adverse anesthesia events


16Anesthesia related mortality rate


17 Percentage of unplanned return to OT (%) NIL NIL NIL NIL NIL NIL

Sl No

INDICATORS

AUG

2019

SEP

2019

OCT

2019NOV

2019

DEC

2019

JAN

2019

18 Percentage of rescheduling of surgeries (%)

0.34(2/582)

0.17(1/559)

0.74(5/674)

0.53(3/562)

1.01(6/589)

0.64(4/625)

0

0.2

0.4

0.6

0.8

1

1.2


Analysis Root cause


SEP

2019

OCT

2019NOV

2019

DEC

2019

JAN

2019

19Percentage of cases where the organization's procedure to prevent adverse events like wrong site, wrong patient & wrong surgery have been adhered to (%)

100(863/863)

100(909/909)

100(1028/1028)

100(864/864)

100(947/947)

100(970/970)

20 Percentage of cases who received appropriate prophylactic antibiotics with in the specified time frame (%)

100(533/533)

100(545/545)

100(623/623)

100(559/559)

100(593/593)

100(633/633)

21 Percentage of cases in which the planned surgery is changed intraoperatively (%)

0.15(1/635) NIL

0.13(1/719)

0.15(1/639)

0.14(1/712)

NIL

0.15

0

0.13

0.150.14

00

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16


Percentage of cases in which the planned surgery is changed intraoperatively Analysis Root cause

Sl No INDICATORS

AUG

2019

SEP

2019

OCT

2019NOV2019

DEC2019

JAN2020

22 Re exploration rate (%) NIL NIL NIL NIL NIL NIL

23 Percentage of transfusion reactions Target 1% 0(0/521)

0(0/687)

0(0/737)

0.18(1/570)

0(0/685)

0(0/699)

24 Percentage of wastage of blood and blood productsTarget – Zero

0.19(1/521)

0.29 (2/687)

0.95(7/737)

0.18(1/570)

0.44(3/685)

0.28(2/699)

0.19

0.29

0.95

0.18

0.44

0.28

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9

1


Percentage of wastage of blood and blood products

Analysis Root cause

25 Percentage of blood component usage (%)

Packed cell 70.82(369/521)

55.7(383/687)

56(413/737)

72.1(411/570)

61.6(422/68

5)

55.22(386/69

9)

Whole blood NIL NIL 0.14(1/737)0.18

(1/570)0.73

(5/685)0.29

(2/699)

Plasma 20.72(108/521)

40.69(212/687)

31.4(232/737)

22.45(128/570)

29.19(200/68

5)

29.18(204/69

9)

Platelet 8.4(44/521)

12.5(86/687)

12.2(90/737)

6.49(37/570)

8.9(61/685)

15.3(107/69

9)

Cryoprecipitate NIL NIL NIL NIL NIL NIL

26Turn around time for issue of blood and blood components (Emergency) Target 30 minutes

30 30 30 30 30 30

Sl INDICATORSAUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

27 Catheter Associated Urinary Tract Infection rate/10002

(2/959)2.6

(2/746)0

(0/863)4.3

(4/923)1.2

(1/772)1.24

(1/805)

2

2.6

0

4.3

1.2 1.24

0

0.5

1

1.5

2

2.5

3

3.5

4

4.5

5


Analysis Root cause

Sl INDICATORSAUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

28 Ventilator Associated Event rate /1000 0(0/133)0

(0/138)0

(0/151)5.9

(1/167)0

(0/116)0

(0/187)

29 Blood Stream Infection rate /1000 0(0/166)0

(0/152)7.2

(1/138)7.9

(1/126)0

(0/86)6.3

(1/157)

0 0

7.2

7.9

0

6.3

0

1

2

3

4

5

6

7

8

9


Blood Stream Infection rate /1000

Analysis Root cause

Sl INDICATORSAUG

2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2020

30 Surgical Site Infection (%) 0.11(1/863)0

(0/909)0.79

(8/1009)0.1

(1/850)0.21

(2/933)0.4

(4/970)

0.11

0

0.79

0.1

0.21

0.4

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9


Analysis Root cause

Sl INDICATORS AUG2019

SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2019

31 a. Mortality rate (%) 3.6(92/2558)3.18

(83/2610)2.54

(66/2595)2.92

(72/2465)2.92

(67/2294)3.6

(81/2250)

b. Proportional Maternal Mortality rate (%) 0(0/92)0

(0/83)0

(0/66)0

(0/72)0

(0/83)0

(0/82)

c. Proportional infant mortality rate (%) 3.26(3/92)3.61(3/83)

9.09(6/66)

1.39(1/72)

4.48(3/67)

2.47(2/81)

3.6

3.18

2.54

2.92 2.92

3.6

0

0.5

1

1.5

2

2.5

3

3.5

4


Mortality rate

3.263.61

9.09

1.39

4.48

2.47

0

1

2

3

4

5

6

7

8

9

10


Proportional infant mortality rate


SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2019

32 Return to ICU within 48 hours (%) 0.81(11/1348)0.6

(9/1426)0.6

(9/1397)0.86

(11/1275)0.4

(6/1344)0.52

(7/1354)

0.81

0.6 0.6

0.86

0.4

0.52

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7

0.8

0.9


Analysis Root cause


SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2019

33 Return to emergency department within 72 hours with similar presenting complaints (%)0.11

(2/1753)0.4

(7/1720)0.37

(6/1611)0.59

(9/1541)0.48

(8/1660)0.46

(7/1526)

0.11

0.40.37

0.59

0.48 0.46

0

0.1

0.2

0.3

0.4

0.5

0.6

0.7


Analysis Root cause


SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2019

34 Re-intubation rate (%) 1.7(1/56)0

(0/56)1.4

(1/69)1.69(1/59)

0(0/53)

0(0/49)

1.7

0

1.4

1.69

0 00

0.2

0.4

0.6

0.8

1

1.2

1.4

1.6

1.8


Analysis Root cause


SEP

2019

OCT

2019

NOV

2019

DEC

2019

JAN

2019

35 Percentage of research activities approved by Ethics committee(%) - - - - - -

36 Percentage of patients withdrawing from the study (%) - - - - - -

37 Percentage of protocol violations/ deviations Reported (%) - - - - - -

38 Percentage of serious adverse events reported to the ethics committee with in the defined time frame (Recommended every three months) (%)

- - - - - -

Sl INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

39

Percentage of drugs and consumables procured by local purchase: (%) a. Drugs

0(0/4465)

0(0/4465)

0(0/4465)

0(0/4465)

0(0/4465)

0(0/4465)

b .Consumables 0.31(5/1605)0.37

(6/1605)0.31

(5/1605)0.37

(6/1605)0.31

(5/1605)0.31

(5/1605)

0.31

0.37

0.31

0.37

0.31 0.31

0.28

0.29

0.3

0.31

0.32

0.33

0.34

0.35

0.36

0.37

0.38


Consumables

Analysis Root cause

Sl INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

40

Percentage of stock out including emergency medicine : (%) a. Drugs

0.09(4/4465)

0.11(5/4465)

0.11(5/4465)

0.11(5/4465)

0.13(6/4465)

0.07(3/4465)

b .Consumables 0(0/1605)0

(0/1605)0

(0/1605)0

(0/1605)0

(0/1605)0

(0/1605)

0.09

0.11 0.11 0.11

0.13

0.07

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14


Drugs

Analysis Root cause


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

41 Percentage of drugs & consumables rejection before preparation of Goods (%) Receipts Note :

a. Drugs

0.016(2/12474)

0.022(3/13347)

0.025(4/15651)

0.015(2/13131)

0.022(3/13509)

0.021(3/14094)

b .Consumables 0.089(2/2247)0.01

(2/2002)0.12

(3/2492)0.15

(3/1960)0.08

(2/2625)0.08

(2/2345)

0.0160.022 0.025

0.0150.022 0.021

0.089

0.01

0.12

0.15

0.08 0.08

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14

0.16

1 2 3 4 5 6

Drugs Consumables Linear (Drugs ) Linear (Consumables )

Analysis Root cause


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

42 Percentage of variations from the procurement process (%)

a. Drugs

0(0/12474)

0(0/13347)

0(0/15651)

0(0/13131)

0(0/13509)

0(0/14094)

b .Consumables 0(0/2247)0

(0/2002)0

(0/2492)0

(0/1960)0

(0/2625)0

(0/2345)

43 Number of variations observed in mock drills (Recommended yearly twice) Target –zero variation

code- Grey-20%

code orange-10%

code Red-10%code orange-Nil

Code Grey-10%code Orange-20%

Code Red-NilCode Red-Nil

Code Blak-5%Code Amber-10%


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

44 Incidence of falls 0.09(1/10423)0

(0/10494)0

(0/10436)0.01

(1/9468)0

(0/8815)0.012

(1/9290)


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

45 Incidence of bed sores after admission(Rate)0.09

(1/10423)0

(0/10494)0

(0/10436)0.11

(1/9468)0.11

(1/8815)0.12

(1/9290)

0.09

0 0

0.11 0.11

0.12

0

0.02

0.04

0.06

0.08

0.1

0.12

0.14


Analysis Root cause


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

46 Percentage of employees provided pre-exposure prophylaxis (%) 100 100 100 100 100 100

47 a. Bed occupancy rate (%) 72(10423/11415)

75.22(10494/13950)

72.39(10436/14415)

67.87(9468/13950)

61.15(8815/14415)

64.45(9290/14415)

7275.22

72.3967.87

61.1564.45

0

10

20

30

40

50

60

70

80


Bed occupancy rate


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

47 b. Average length of stay (Days) 4(10423/2602)

4.02(104942610)

4.03(10436/2595)

3.84(9468/2465)

3.84(8815/2294)

4.13(9290/2250)

4 4.02 4.033.84 3.84

4.13

2

3

4

5


Average length of stay (Days)

Sl No INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

48 OT utilization rate (%) Target 80%

73.56(588.5/8)

78.31(626.5/8)

82.23(658/8)

70.06(560.4/8)

74.25(594/8)

77.66(621.33/

8)

73.56

78.31

82.23

70.06

74.25

77.66

65

70

75

80

85


Analysis Root cause

Sl No

INDICATORS AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

b. ICU bed utilization rate(%) 93.9(1126.8/12)

98.9(1187.46/12)

94.29(1131.48/1

2)

88.82(1065.84/1

2)

78.12(937.29/

12)

79.4(952.8/

12)

Analysis Root cause

93.998.9

94.2988.82

78.12 79.4

0

10

20

30

40

50

60

70

80

90

100


breakdown of ICU utilization

Sl No

INDICATORS AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

1. MICU 116.94% 120.83% 106.45% 109.16% 95.96% 108.06%

2. NSICU 91.12% 88.61% 76.95% 77.77% 65.86% 85.49%3. SICU 159.97% 167.38% 179.49% 174.76% 170.96% 140.78

%4. CTICU 52.68% 48.33% 60.75% 48.33% 54.8% 36.55%

5. NMICU 85.48% 96.66% 76.95% 79.28% 65.05% 86.55%6. CCU-I 139.9% 119.3% 139.9% 122.08% 126.2% 135.8%7. CCU-II 139.5% 130.3% 120.96% 124.16% 115.3% 118.58%

8. Nephro ICU 87.74% 89.33% 72.25% 73.33% 58.7% 78.06%

9. EDICU 22.58% 92.69% 10.7% 9.7% - 0.4%

10. PICU 103.76% 126.66% 129.56% 98.3% 48.9% 48.9%

11.NNICU I 86.2% 69.5% 93.9% 86.6% 90.7% 66.1%

12.NNICU II 40.96% 37.87% 51.6% 62.42% 44.86% 47.8%

Sl No

INDICATORS AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2019

C . ICU equipment utilization rate(%) 39.67(476.06/12)

46.67(560.11/12)

43.6(523.6/12)

40.13(481.6/12)

34.15(444/13)

36.13(469.76/13)

39.67

46.67

43.6

40.13

34.1536.13

0

5

10

15

20

25

30

35

40

45

50


Sl No INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2019

1. Ventilator 14.1% 15.45% 11.72% 12.92% 10.02% 10.72%2. Monitor 88.46% 91.23% 49.7% 80.04% 69.86% 74.1%3. Syringe pump 40.8% 38.49% 45.6% 42.64% 34.5% 38.3%

4. Infusion pump 19.6% 29.75% 24.7% 24.21% 31.4% 32.1%

5. Bi PAP 12.8% 18.2% 15.7% 13.8% 12.1% 14.2%

6. C PAP 4.3% 7.76% 20.38% 9.98% 3.2% 7.5%

7. High flow 8.5% 4.43% 19.4% 25.3% 26.83% 21.4%

8. TPI 19.3% 27% 9.8% 16.66% 3.22% 9.6%

9. ABG (nos) 750 590 599 378 550 456

Sl No INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2019

49 Critical equipment down time (Hours)

387 Hr

55 Min

99 Hr

5 min

675 Hr

55 Min

111 Hr

35 Min

68 Hr

40 Min

146 Hr

45 Min

0

100

200

300

400

500

600

700

800


Analysis Root cause


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

50

a. Nurse –patient ratio for ICU Day-1:2Night-1:2Day-1:2Night-1:2

Day-1:2Night-1:2

Day-1:2Night-1:3

Day-1:2Night-1:3

Day-1:2Night-1:3

b. Nurse –patient ratio for wards Target 1 : 6

Day-1:6Night-1:7

Day-1:5Night-1:6

Day-1:6Night-1:6

Day-1:9Night-1:11

Day-1:8Night-1:10

Day-1:7Night-1:11


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

51 Out patient satisfaction index Target 100%

97.88(3152/3220)

99.7(3008/3016)

96.6(3159/3270)

99.8(3353/3360)

99.6(3685/3700)

99.2(3224/3250)

52 Inpatient satisfaction index Target 100%

68.7(2550/3712)

67.3(2553/3792)

68.5(2568/3750)

68.14(1908/2800)

70.12(1424/2016)

72.66(1767/2432)

97.88 99.7 96.699.8 99.6 99.2

68.7 67.3 68.5 68.14 70.1272.66

0

20

40

60

80

100

120


Out patient satisfaction index Inpatient satisfaction index

Sl INDICATORS Target AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

53

a)Waiting time for services at diagnostics for OP cases (in minutes)

MRI60 Minutes

CT20 Minutes

USG45 minutes

X-ray20 minutes

41.4

20.2

45.1

20.3

50.1

20

45

20.2

48

20.3

45.2

20

50.25

20.1

42

20.4

49

20.6

40

20

51.5

20

40

20.1

0

10

20

30

40

50

60


MRI CT USG X-ray


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

b)Waiting time for out patient consultation (minutes) Target 60 ‘

99 98 102 93 85 98

9998

102

93

85

98

75

80

85

90

95

100

105


Analysis Root cause

Sl INDICATORS

AUG2019

SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

54 Time taken for discharge (minutes) Target 180 ‘ 223 220 218 214 209 207

195

200

205

210

215

220

225


Analysis Root cause


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

55 Employee satisfaction index (Once in six months) Target 100 %76 76 76 76 76 76

56 Employee attrition Rate (%) 1.3 1.05 1.05 1.09 0.5 1.2

57 Employee Absentism rate (%) Target Zero 0 0 0 0 0 0

58Percentage of employees who are aware of employee rights responsibilities and welfare schemes (Once in six months) Target 100 %

95 95 95 95 95 95

59 Number of sentinel events reported collected and analyzed with in the defined time frame NIL NIL NIL NIL 1 NIL

60 Percentage of near misses 1(1/14) NIL NIL NIL 1 1


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

61Incidence of blood body fluid exposure

OP 0(0/29526)0

(0/29218)0

(0/31947)0

(0/27817)0

(0/26486)0

(0/29480)

IP0.09

(1/10423)0

(1/10494)0

(1/10436)0

(0/9468)0

(0/8815)0

(0/8992)

62

Incidence of needle stick injuries (in 1000)

OP 0(0/29526)0

(0/29218)0

(0/31947)0

(0/27817)0

(0/26486)0

(0/29480)

IP 0.19(2/10423)0

(2/10494)0.9

(1/10436)0.1

(1/9468)0.1

(1/8815)0

(0/8992)

63 Percentage of medical records not having discharge summary Target 0 NIL NIL NIL NIL NIL NIL

64 Percentage of medical records not having codification as per ICDTarget0 NIL NIL NIL NIL NIL NIL

65 Percentage of medical records having incomplete / improper consent(%)0.47

(12/2602)0.54

(14/2610)0.23

(6/2596)0.21

(4/1891)0.24

(6/2523)0.27

(7/2617)

67 Percentage of missing records (IP) NIL NIL NIL NIL NIL NIL


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

68 Appropriate handovers during shift change (%) 92 93 95 96 95 96

69 Incidence of patient identification errors (%)0.62

(2/320)0

(0/320)0.31

(1/320)0

(0/320)0

(0/320)0

(0/320)


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

70 Compliance to hand hygiene practice (%) 82(184/224)86

(193/224)87.5

(196/224)88

(313/352)89

(316/352)90

(317/352)

a Compliance to hand hygiene practiceDoctors(%)71.4

(40/56)78

(44/56)82.1

(46/56)87

(77/88)93

(82/88)89

(79/88)

b Compliance to hand hygiene practice Nurses(%)87.5

(98/112)89

(100/112)89

(100/112)89

(11/112)89

(11/112)94

(166/176)

c Compliance to hand hygiene practice Others(%)82

(44/56)87

(49/56)91.151/56

88(78/88)

86(76/88)

85(75/88)

78

80

82

84

86

88

90

92


Compliance to hand hygiene practice

0102030405060708090100


hand hygiene practice breakdown Doctors, Nurses & Others

Doctors Nurses Others


SEP2019

OCT2019

NOV2019

DEC2019

JAN2020

71 Compliance rate to medication prescription in capitals (%)99.1

(332/335)99.07

(322/325)99.37

(320/322)99.35

(310/312)99.35

(308/310)99.6

(285/286)

99.199.07

99.3799.35 99.35

99.6

98.8

98.9

99

99.1

99.2

99.3

99.4

99.5

99.6

99.7


DEPARTMENT WISE QUALITY INDICATORS NOEMBER 2019 TO JANUARY 2020

• AAC• COP• MOM• PRE• HIC• FMS• HRM• IMS

VISI - emshospital.org.in€¦ · QUALITY POLICY “AT EMS MEMORIAL CO-OPERATIVE HOSPITAL &...

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