Continuous Quality Improvement ( CQI)- 2018.pptx

HOSPITAL NAME & ADD.
Quality Indicators
Continuous Quality Improvement (CQI)
Oct to April -2017-18
By:-
Quality Manager

QUALITY INDICATORS
POLICY
o Quality Indicator data collected on monthly basis.
o The collected data is analyzed, reviewed& reported, and
discusses for corrective and preventive action.
o HAI surveillance is done by Quality Manager, Infection
Control Officer, Infection Control Nurse and nursing
Superintendent. Data matched with patients file. Patient
files are available in MRD department.

Key Performance Indicator
S.No KPI Name Department Responsible Person
1 Emergency Staff Nurse
2 No of reporting errors- Radiology &
Imaging
Radiology Technician
3 Rate of Re Dos- radiology & Imaging Radiology Technician
4 Waiting time –CT Radiology Technician
5 Waiting Time – X- Ray Radiology Technician
6 Medication Error IPD NS
7 Percentage of transfusion reaction IPD NS
8 Catheter Associated Urinary Tract
Infection
ICU & wards ICN
9 Ventilator Associated Pneumonia Rate ICU ICN
10 Central Line Blood Stream Infection ICU ICN

S.No KPI Name Department Responsible Person
11 Surgical Site Infection IPD & OPD ICN
12 Mortality Rate MRD MRD officer
13 Incidence of falls IPD NS
14 Bed Sore ( Incidence of Hospital
associated pressure ulcers after
Admission)
IPD ICN
15 Bed occupancy Rate Nursing NS
16 OPD-satisfaction Index HR HR Manager
17 IPD satisfaction Index HR HR Manager
18 Incidence of needle stick Injury IPD & OPD
19 Percentage of medical records not
having discharge summary
MRD MRD officer
20 Percentage of medical records having
incomplete & or Improper consent
MRD MRD Officer
21 Compliance to hand Hygiene Practice All dept. ICN
22 LAMA MRD MRD officer

Time for initial assessment of emergency patients (min)
Month Oct’ 17 Nov’ 17 Dec’ 18 Jan’18 Feb’18 Mar’18 APR’18
Total Time
Taken
364 330 367 237 291 293 447
Total No.
of patients
82 73 76 52 78 79 114
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
OCT NOV DEC JAN FEB MAR APR
4.4 4.5
4.8
4.6
3.7 3.7
4.2

 Source: Data collected from Emergency Inpatient register
 Sample Size: - 100%
 Benchmark: 30 min.
 Action Plan - Continuous monitoring
Analysis: The initial assessment will start within 05 minutes of arrival of patient by nursing
Staff and within 10 minutes by Duty Doctor. Root Cause analysis will done by Hospital
Administrator.
Remarks: After analysis the data and monthly report the initial assessment time of
emergency .Patients within prescribed time frame and in all the cases the assessment was
done within
define time frame.
Time of initial assessment for emergency patient:
Sum of time taken for the assessment / Total No. of patients in emergency department in that
month .
Findings/ Corrective Action/ Preventive Action

No. Of Reporting Errors/1000 Investigation –Radiology & Imaging
Month Oct-17 Nov -17 Dec-17 Jan-18 Feb-18 Mar-18 Apr-18
Total No. of
reporting
errors
0 0 0 0 0 0 0
Total No. of
test
performed
239 229 231 240 203 237 234
0.0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1.0
0.0 0.0 0.0 0.0 0.0 0.0 0.0

Remarks: There is no reporting error reported
Number of Reporting Errors:
No of reporting errors/Total no of test performed x 1000
 Source: Data collected from the Reporting Error file and their
daily investigation recording register
 Sample Size: All Patients
 Benchmark: 0
 Findings: there is no reporting error find.
 Action Plan: Continuous monitoring

Rate of Re Dos- Radiology & Imaging
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
0.0 0.0 0.0
12.5
4.9
0.0
8.5
Rate of Re Dos
No. of Re
Dos
0 0 0 3 1 0 2
No. of test
performed
239 229 231 240 203 237 234

 Source: Data collected from the Re-do Register and their daily
investigation recording register
 Benchmark: 0
 Findings: Orders given by Consultants sometimes to confirm
the results of some doubtful tests
 Action Plan: Close monitoring required to avoid re-dos
Number of Re Dos:
No of Re Dos/Total No of test performed x 1000

Waiting Time –CT Scan
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
29.9 30.5 30.6 31.6
28.0 27.5 27.8
Sum of
Time taken
2241 2320 2111 1990 2070 1981 2415
No. of test
performed
75 76 69 63 74 72 87

 Source: Data collected from the CT –Master Register
 Benchmark: 45 Min
 Findings: Average waiting time 28 minutes.
Waiting Time: Sum of time taken for discharge /Number
of patients visited Radiology (CT)

Waiting Time for x-Ray- Report
0.0
5.0
10.0
15.0
20.0
25.0
30.0
35.0
40.0
25.9 26.8 28.3
26.4 24.8 26.1 26.3
Sum of
time Taken
4247 4101 4584 4670 3205 4302 3859
No. of test
performed
164 153 162 177 129 165 147

 Source: Data collected from daily investigation
recording register
 Benchmark: 30 Min
 Findings: Average waiting time is 26 minutes.
Waiting Time: Sum of time taken for discharge /Number
of patients visited Radiology (CT)

Incidence of medication Errors
0.0
0.5
1.0
1.5
2.0
2.5
3.0
3.5
4.0
4.5
5.0
4.1
4.6
0.0
1.4 1.6
2.2
1.3
No. of
medication
Error
3 4 0 1 1 2 1
No of PT
days
740 869 761 718 631 902 766

 Source: From incident reporting
 Sample Size: All patients
 Benchmark: 0
 Findings: Dispensing error due to illegible hand writing and
documentation error
 Action Plan: Training of Nursing staff and duty Doctors
Analysis s: The medication error are due to wrong timing, illegible hand
writing, medicine prescribed in small letter ,spelling mistake , Documentation
error and also Patients family member has not provided medicines to nurse on
time . Out of all medication error medication prescribed in small letter is
most common.
Formula:- Total number of medication errors / Number of patient
days x 1000

Percentage of transfusion Reactions
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
No. of
transfusion
reaction
0 0 0 0 0 0 0
No of unit
transfused
25 19 41 28 52 21 14

 Source: Data collected from blood transfusion register and
incident reporting
 Sample Size: All patients who get transfused
 Benchmark: 0%
 Findings: Nil
 Action Plan: Continuous monitoring & training about incident
reporting
Remarks: There was no transfusion reaction.
Percentage of Blood Transfusion Reaction:
Total No of Reaction/Total units transfused x 100

Catheter Associated urinary tract infection Rate
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
No of CAUTIs
in a month
0 0 0 0 0 0 0
No of urinary
catheter days
99 180 232 111 194 181 185

Remarks:
• CAUTI: Number of urinary catheter associated UTIs in a
month / Number of urinary catheter days in that month X 1000
Source: Data collected from Surveillance forms and through
culture reports
Sample Size: All patients having urinary catheter
Benchmark: 0
Findings: There is no CAUTI infection reported .
Action Plan: Training of staff for Implementation of Bundle
care of catheterization.

Ventilator Associated Pneumonia Rate
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
No of CAUTIs
in a month
0 0 0 0 0 0 0
No of VAP
days
38 42 21 12 4 24 16

Remarks: There is no positive case of VAP is reported. The reason may
be less Ventilator days (average Ventilator day per patient is 4-6 days)
VAP: Number of ventilator associated pneumonia in a month / Number of
ventilator days in that month X 1000
Source: Data collected from Surveillance forms and through culture
reports
Sample Size: All patients who undergo ventilation
Benchmark: 0
Findings: Nil
Action Plan: Continuous monitoring and education about care
bundles

Central line related Blood Stream Infection Rate
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
No of CLBSI
in a month
0 0 0 0 0 0 0
No of Central
Line days
26 36 52 14 06 72 27

Remarks: There is no positive case of CLBSI is reported.
CLBSI: Number of central line related blood stream infection in
a month /
Number of central line days in that month X 1000
Source: Data collected through surveillance forms and culture
reports
Sample Size: All patients who were on central line
Benchmark: 0
Findings: Nil
Action Plan: Continuous monitoring and education about Care
Bundles

Surgical Site Infection Rate
No of SSI in a
month
0 0 1 0 0 0 0
No of surgery
performed in
that month
66 76 73 53 50 66 61
0
0.2
0.4
0.6
0.8
1
1.2
1.4
0 0.0
1.4
0 0 0 0

Remarks: Positive case is reported in the Dec 2018. In this cases the infection
was reported after discharge and was not visible at time of discharge and
was not visible during first dressing. There are the chances that the
infection was occurred in the post surgical case due to poor hygiene
condition and dressing was not change on time.
Surgical Site Infection: No of surgical site infections in a given month/No
of surgeries performed in that month (x) 100
Source: Data collected through surveillance forms and culture reports
Sample Size: All surgical patients
Benchmark: 0
Action Plan: Continuous monitoring and education about Hygiene .

Mortality Rate-2017-18
0.0
1.0
2.0
3.0
4.0
5.0
6.0
7.0
8.0
9.0
6.0
3.2
8.1
3.9
1.6
4.7
1.5
No of death 8 5 11 5 2 6 2
No. of
Discharge &
death
133 158 135 128 123 128 134

Remarks: Out of total death 74% of death was occurred within 48 hours of admission.24%
of death was in case of patient of age group 70 (+) and 20 % of death was in case of
patient of age group 60 (+).The national mortality rate for Madhya Pradesh is 8.2
[Source -(SRS bulletin 2011& NFHS- III Data)as per 2011 census].The hospital
mortality rate ( Avg.- 4.5 in 2017 ) is less than that (though there are various variables
contributing for death rate in case of Madhya Pradesh but as there is no benchmark
available, death rate Madhya Pradesh is consider as benchmark).
Mortality Rate: Number of death in a month/Total no of discharge including death X 100
Source: MRD Records
Sample Size: All discharged patients
Findings: Most are trauma cases and patients reach in critical/
very critical stage

Incidence of Falls
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
0
1.2
0
1.4
0 0 0
No of Falls in
a month
0 1 0 1 0 0 0
No. of Patient
days
740 869 761 714 644 902 766

Remarks : There was total 02 falls reported in November and January
month due to not locking the side rail ( bed) and other. In this case
there was no external injury. Through the patient ( in which the fall
was due to not Locking the bed rail) complaint regarding pain.
Training class for Housekeeping and Nursing Staff was conducted
regarding patient safety and regarding prevention of fall.
Incidence of Falls: Number of Falls/ Total number of patient
days*1000
Source: Incident Reporting
Sample Size: All patients
Benchmark: 0
Action Plan: Continuous monitoring and adherence to safety
precautions

Incidence of Hospital associated pressure ulcers after Admission
0.00
0.20
0.40
0.60
0.80
1.00
1.20
1.40
0.00
1.15
1.31
0.00 0.00 0.00 0.00
No. Pt who
develop new
pressure ulcer
0 1 0 1 0 0 0
No. of Patient
days
740 869 761 714 644 902 766

Remarks: Bed source was reported after admission , it was due to non-
movement of patients ,critical patient on ventilator, long length of
stay & old age. In all cases back care along with appropriate care
was provided. To create awareness regarding the same and the same
poster has been displayed in Inpatient care areas.
Incidence of Hospital associated pressure ulcers after Admission :
Number of patients who develop new / worsening of pressure ulcer/
total no. of patient days *1000
Source: Active Surveillance
Sample Size: All patients
Benchmark: 0
Findings: Nil
Action Plan: Continuous education and monitoring

Bed occupancy Rate
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
59.7
72.4
61.4 59.5 57.5
72.3
63.8
No. of
inpatient days
in a given
month
740 869 761 714 644 902 766
No. of
Available bed
days in that
month
1240 1200 1240 1200 1120 1240 1200

Remarks: The average bed occupancy rate is 64.1%.
Bed Occupancy Rate: Number of inpatient days in a given
month/ number of available bed days in that month*100
Source: Collected through daily census reporting
Sample Size: All In-patients

OPD-Satisfaction Rate
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
1 2 3 4 5 6 7
84.5
89.5
84.1 81.5
70.4
84.2 84.5
Average Score
Achieved
972 958 782 1630 1380 1700 1623
Maximum
possible score
1150 1070 930 2000 1960 2020 1920

Remarks : Detail reports are prepared month wise.
OPD-Satisfaction Rate : Score achieved / Maximum possible
score x 100
 Source: OPD patient satisfaction forms
 Findings: Patient generally refuse to give feedback because
most of the patients come from rural areas and they didn’t
understand the purpose of such forms
 Action Plan: Continuous education to all patients coming in
the hospital

IPD- Satisfaction Index
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
84.3 82.7
69.1
73.4
58.5
64.8 66.9
Average Score
Achieved
3225 1096 726 2835 2220 1565 2402
Maximum
possible score
3825 1325 1050 3864 3795 2415 3588

• Remarks: Detail reports are prepared month wise
• In patient satisfaction index: Score achieved / Maximum
possible score x 100
Source: IPD patient satisfaction forms
Sample Size: More than 50% of in-patients
Findings: Patient generally refuse to give feedback because
most of the patients come from rural areas and they didn’t
understand the purpose of such form
Action Plan: Continuous education to all patients coming in
the hospital

Incidence Needle Stick Injury
0
0.5
1
1.5
0
1.2
0.0 0.0 0.0 0.0
1.3
No of
Parenteral
Exposures In
a Month
0 1 0 0 0 0 1
no. of
Inpatients
days in that
Month
740 869 761 714 644 902 766

Remarks: There was total 2 needle stick injury due to recapping of needle . It was
decided that the awareness regarding Needle Stick Injury will be done among the
staff and regarding same a poster was designed and was placed in all Nursing
station, Emergency and O.T. It was also included in the Induction training and all
the staff were trained regarding same. Record was submitted to HR Department.
Incidence of Needle Stick Injury : Number of Pareneteral exposures / Number of in-
patient days x 100
Source: Incident reporting
Sample Size: Continuous
Benchmark: 0
Findings: Accidental injury while performing procedure
Action Plan: Adherence to standard precautions

Percentage of Medical Records Not having Discharge Summary
0.0
0.5
1.0
1.5
2.0
2.5
2.3
1.3
1.5 1.6
0.8 0.8
1.5
No of MR not
having discharge
summary
3 2 2 2 1 1 2
Number of
Discharge and
Death
133 158 135 128 123 128 136

Remarks : Monitoring of percentage of medical records not having discharge
summary starting from May 2017.There was percentage of MR not having
discharge summary [(Oct- 2.3) & (jan-1.6)] that is highest rate record in Oct and
Jan month was due to original copy of discharge summary given to patient and
copy of the same not attached by computer operator. The file having not discharge
summary checked & recorded by MRD officer. It is decided that the summary are
to be attached other wise it will be not acceptable by the MRD.
Percentage of medical record not having discharge summary : No of file not having
discharge summary/No of discharge and Deaths x 100
Source: Medical Record Department
Sample Size: All In-patient medical records
Benchmark: 0%
Action Plan: Continuous monitoring

Percentage of Medical record Having Incomplete & Improper Consent
0.0
0.2
0.4
0.6
0.8
1.0
1.2
1.4
1.6
1.8
1.5
0.6
1.5
1.6 1.6
0.8 0.7
No. of MR having
incomplete or
Improper consent
2 1 2 2 2 1 1
No. of discharge
and death
133 158 135 128 123 128 136

Source: Medical Record Department
Sample Size: All In-patient discharged files
Benchmark: 0%
Action Plan: Continuous Monitoring
Remarks: The incompleteness in the consent form was due to non availability
of signature, time and date in the consent form. It is decided that the forms
are to be complete other wise it will be not acceptable by the MRD
Percentage of medical records having incomplete and or improper consent
: Number of medical
records having incomplete and / or improper consent / Number of discharges
and deaths x 100

Compliance to hand Hygiene Practice
Total no of
action
performed
974 2281 490 165 154 153 140
Total no. of
Hand hygiene
opportunities
1210 2805 704 195 195 175 165
0.0
10.0
20.0
30.0
40.0
50.0
60.0
70.0
80.0
90.0
100.0
60.7
66.5 69.6 65.9
73.3 71.5
66.7

Compliance to hand hygiene : No of hand
hygiene missed opportunity/Total no of hand
hygiene opportunities x 100
Source: Data collected through hand hygiene observation form
Sample Size: Randomly monitoring in each department
Benchmark: 0%
Findings: Observed missing compliance due to lake of hand
hygiene practice .
Action Plan: Continuous training and monitoring

LAMA
0.0
2.0
4.0
6.0
8.0
10.0
12.0
14.0
16.0
18.0
9.0
10.1
8.9
10.2
11.4 10.9
16.2
Total No. of
LAMA in a
month
12 16 12 13 14 14 22
No. of patient
discharge &
death in that
Month
133 158 135 128 123 128 136

• Source: MRD Data
• Major problem – Financial problem
• Some patient are reefer to other hospital

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