| Sr. No | INDICATOR |
| 1a | Time for initial assessment of indoor and emergency patients |
1b | Time for initial assessment of indoor and emergency patients |
| 2 | Percentage of cases (in-patients) Wherein care plan with desired outcomes is documented and counter-signed by the clinician. |
| 3 | Percentage of cases (in-patients) wherein screening for nutritional needs has been done. |
| 4 | Percentage of cases (in-patients) Wherein the nursing care plan is documented. |
5 | Number Reporting Error/1000investigations |
| i) Radiology | |
| ii) Pathology | |
6 | Percentage of re-dose. |
| i) Radiology | |
| ii) Pathology | |
7 | Percentage of reports co- relating with clinical diagnosis. |
| i) Radiology | |
| ii) Pathology | |
8 | Percentage of adherence to safety precautions by employees working in diagnostics. |
| i) Radiology | |
| ii) Pathology | |
| 9 | Incidence of medication errors |
| 10 | Percentage of admissions with adverse drug reaction (s) |
| 11 | Percentage of medication charts with error prone abbreviations |
| 12 | Percentage of patients receiving high risk medications developing drug event. |
| 13 | Percentage of modification of anaesthesia plan |
| 14 | Percentage of unplanned ventilation following anesthesia. |
| 15 | Percentage of adverse anaesthesia events |
| 16 | Anaesthesia related mortality rate |
| 17 | Percentage of unplanned return to OT |
| 18 | Percentage of re-scheduling of surgeries |
| 19 | Percentage of cases where the organization’s procedure to prevent adverse events like wrong site, wrong patient and wrong surgery have been adhered to |
| 20 | Percentage of received appropriate prophylactic antibiotics within the specified time frame. |
| 21 | Percentage of cases in which the planned surgery is changed itraoperatively |
| 22 | Re-exploration rate |
23 | Percentage of transfusion reactions |
| i) MT | |
| ii) OT | |
24 | Percentage of wastage of blood and blood products |
| i) MT | |
| ii) OT | |
25 | Percentage of blood component usage |
| i) MT | |
| ii) OT | |
26 | Turnaround time for issue of blood and components |
| i) MT | |
| ii) OT | |
| 27 | Catheter associated Urinary tract infection rate |
| 28 | Pneumonia rate |
| 29 | Bloodstream infection rate |
| 30 | Surgical site infection rate |
| 31 | Mortality rate |
| 32 | Return to ICU within 48 hours |
| 33 | Return to the emergency department within 72 hours with similar presenting complains |
| 34 | Re-intubation rate |
| 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 (which have occurred in the organization) reported to the ethics committee within the defined time frame. |
| 39 | Percentage of drugs and consumables procured by local purchase |
| 40 | Percentage of stock outs including emergency drugs |
| 41 | Percentage of drugs and consumables rejected before preparation of goods receipt note |
| 42 | Percentage of variations from the procurement process |
| 43 | Number of variation observed in mock drills |
| 44 | Incidence of falls |
| 45 | Incidence of bed sores after admission |
| 46 | Percentage of employees provide pre-exposure prophylaxis |
47 | Bed occupancy rate and A |
| average length of stay B | |
| 48 | OT and ICU utilization rate •ICU-NA |
| 49 | Critical equipment down time |
| 50 | Nurse- Patient ratio for ICUs and wards • ICU-NA |
| 51 | Out patient satisfaction index |
| 52 | In patient satisfaction index |
53 | Waiting time for including diagnostics and |
| Outpatient consolation | |
| 54 | Time taken for discharge |
| 55 | Employee satisfaction index |
| 56 | Employee attrition rate |
| 57 | Employee absenteeism rate |
| 58 | Percentage of employees who are aware of employee rights, responsibilities and welfare schemes |
| 59 | Number of sentinel events reported, collected and analyzed within the defined timeframe |
| 60 | Percentage of near misses |
61 | Incidence of blood body fluid exposures |
| Safety Officer | |
| MT | |
62 | Incidence of needle stick injuries. |
| Safety Officer | |
| ICN | |
| 63 | Percentage of medical records not having discharge summary |
| 64 | Percentage of medical records not having codification of Diseases(ICD) |
| 65 | Percentage of medical records having incomplete and/or improper consent |
| 66 | Percentage of missing records |
| 67 | Appropriate handovers during shift change (to be done separately for doctors and nurses )-( per patient per shift) |
| 68 | Incidence of Patient identification errors |
| 69 | Compliance to Hand Hygiene partactice |
| 70 | Compliance rate to medication Prescription in capitals |
| 71 | Depression status monitoring at the time of discharge |
| 72 | Adherence to antibiotic policy |
| 73 | Mobility status monitoring at the time of discharge |
| 74 | Time for initial assessment of indoor patients by paramedics |
| 75 | TAT for referral and transfer |
| 76 | TAT for dispatch of Medical Record at MRD post discharge |
| 77 | Response tiime for breakdown of critical equipment |
| 78 | Vocational establishment rate and mobility aid provision rate |