CQI Presentation KUNAL HOSPITAL- 2018.pptx

CQI PRESENTATION’18
Analysis From January,2018

1a) Time taken for initial assessment of IPD patients
SLNO MONTH QI NUMERATOR
(A)
DENOMINATOR
(B)
VALUE
Time taken for
initial assessment
of IPD patient
Total time taken for
initial assessment for
entire month
Total number of
In- patients A/B
1 January 2018 IPD assessment 1843 168 10.97 min
Emergency
assessment
230 12 19.16 min

Graphical Presentation
10.97
19.65
0
5
10
15
20
25
Jan/18
TIME
IN
Minutes
MONTH
Time taken for initial assessment of IPD patients

Root cause analysis
Time taken for
initial
assessment of
IPD patients
Lack of training
on good
documentation
inconsistency
in supervision
Lack
awareness in
new RMO’s

Corrective action/preventive action
Sr.No Corrective Action Taken Sr.No Preventive Action Taken
1 Involvement of the Nursing Incharges 1 Maintained reordering level
2 In emergency cases involvement of the
Nursing In charges .
2 Training on good documentation.
3 Initiation of team work. 3 Daily audits.

(2) % of cases where in care plan is countersigned by Clinician
SL.NO MONTH QI NUMERATOR
(A)
DENOMINATOR (B) VALUE
Percentage of cases
(inpatients) wherein
care plan with desired
outcomes is
documented & counter
signed by the clinician
No. of in patient case
record wherein care plan
with desired outcomes has
been documented &
counter signed by the
clinician
Total no of Patients
A/B*100
1 January 2018 48 108 44.44%

44%
0%
5%
10%
15%
20%
25%
30%
35%
40%
45%
50%
Jan/18
Percentage
Month
% of cases where in care plan is countersigned by Clinician

Root cause analysis
% of patients with care
plan documentation is
counter signed by
Clinicians
Lack of Awareness
inadequate
knowledge of
NABH process
inconsistency in
supervision
Inadequate
Training

1
Started Record Maintaining
1 Supervision started in uniform manner
2
Started Analysis of Files
2 Ward Checklist Implemented for proper
documentation
3
Deficiency Checklist Implemented
3 Training on Good documentation practices
4
Training Given for Employees
4 Maintaining re ordering level of stock
5
Started daily audits
5 Active file audit on daily basis

(3) % of Cases(Inpatients) wherein screening of Nutritional needs has
been done
(A)
DENOMINATOR
(B)
VALUE
% of
cases(Inpatients)
wherein screening
of Nutritional needs
has been done
No of In patients case
record wherein the
Nutritional assessment
has been documented
Total no of Patients
a/b*100
1 January 2018 108 108 100%

100.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Jan/18
Percentage
Month
% of Cases(Inpatients) wherein screening of Nutritional needs has been done

(4) % of cases (In Patients) wherein the nursing care plan is documented
SL.NO MONTH QI NUMERATOR (A) DENOMINATOR (B) VALUE
% of cases (In
Patients) wherein
the nursing care
plan is documented
No of in patients case
record wherein the
nursing care plan has
been documented
Total no of patient
A/b*100
1 January 2018 108 108 100%

100.00%
0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Jan/18
Percentage
Month
% of cases (In Patients) wherein the nursing care plan is
documented

5 No.of reporting errors per 1000 Investigations (Laboratory)
(A)
No.of reporting
errors per 1000
Investigations
( CQI 3b)
No.of reporting
errors
No.of test performs A/b*1000
1 June 2017 1 2196
0.45
2 July 2017 0 2696 0
3 August 2017 1 2994 0.33
4 September 2017 0 3313
0
5 October 2017 0 2876 0
6 November 2017 2 2471 0.08

0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
0.5
Jun/17 Jul/17 Aug/17 Sep/17 Oct/17 Nov/17
No. of reporting errors per 1000 Investigations

Root cause analysis
REPORTING
ERRORS
CLERICAL ERROR
WHILE TYPING
THE FIGURES
IN EMERGENCY, PROCESSING
OF SAMPLE IS DONE URGENTLY
BEFORE ENTRY OF THE PATIENT SO
LIS NOT DONE
IN HAEMATOLOGY, WBC DLC &
PLATELETS COUNT HAS TO BE
EDITED AFTER LIS
(LAB INFORMATION SYSTEM)
IN SOME TEST, NUMERATOR &
DENOMINATOR VALUES GET
PRINTED REVERSED
Eg.UACR

1 Correction of print error done . 1 Asked the technician to be more vigilant & careful
while typing the reports.
2 Report reprinted. 2 Every technician asked to check the report before
printing.
3 Technician made aware of the correct
reports.
3 In case of hematology total DLC should be 100 &
correct platelets & WBC count because CBC
reports are edited after this.
4 Counselling of the technician . 4 Given warning to have action against him / her in
case of repeated errors.

6 % of Re do`s (Laboratory)
(A)
DENOMINATOR
(B)
VALUE
% of Re do`s No.of Re do`s No.of Tests Performed a/b*1000
1 June 2017 2 2196
0.91
2 July 2017 6 2696 2.22
3 August 2017 2 2994 0.66
4 September 2017 3 3313
0.90
5 October 2017 0 2876 0
6 November 2017 1 2471 0.40

0.91
2.22
0.66
0.9
0
0.4
0
0.5
1
1.5
2
2.5
PERCENTAGE
MONTH
% of Re do`s (Laboratory)

Root cause analysis
Re do`s
Heamatology – sample
not
Mixed properly & run
(Technical error)
Hemolysis of sample due to
improper handling
Sample taken from
Cetral line in which
Iv fluids given to
patient
Insufficient
Sample while
Collection due to non
cooperative patient

1 Shake EDTA sample immediately after
collection
1 Counselling of the technician
2 Asked the technician to take sample from
peripheral line
2 Not to take the sample from central line
3 Take repeat sample if EDTA / citrate sample
found clotted
3 Asked always check for clot in sample before
processing
4 Ask to take sufficient sample in sample cup
before processing
4 Always check for the sufficient quantity of
sample before processing

Blood Transfusion Reaction
SL.NO MONTH Total no of blood Transfusion
Reaction (A)
No of blood Transfusion
(B)
VALUE (A/B)
1 June 2017 0 97 0%
2 July 2017 10 141 0%
3 August 2017 0 154 0%
4 September 2017 0 145 0%
5 October 2017 0 117 0%
6 November 2017 0 45 0%

Graphical Representation
Blood Transfusion Reaction
Total no of blood Transfusion Reaction *100
No of blood Transfusion
Std-less than -1%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1

S.No Preventive Action Taken
1 Blood requisition and sample collection is done after proper identification of patient.
2 Blood transfusion is monitored with blood monitoring chart.
3 All standard precautions followed and all protocols are adhered.

Blood Component Usage
SL.NO MONTH No. of components
used
No. of blood and
blood product used
VALUE (A/B
*100)
1 January 2018 62 66 93.93%

Blood Component Usage
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan/18

Root cause analysis
Blood Component
Usage
Immunocompromised patients
RTA cases Surgical procedures

Sr.No Corrective Action Taken
1 Surgical Patients
2 Immunocompromised patients

(26) Turn around Time of Issue of Blood and Blood Components
(A)
Turn around Time of
Issue of Blood and
Blood Components
Sum of time
taken
Total number of
Blood and Blood
components issued
A/B
1 January 2018 3540 66 53.63 min

Jan/18
TIME
IN
MINS
MONTH
Turn around Time of Issue of Blood and Blood Components

Sr.No Preventive Action Taken
1 Requisition send on the priority basis.
2 Cross matching sample send on time.

(13) % of Modification of Anesthesia plan
(A)
DENOMINATOR
(B)
VALUE
% of
Modification of
Anesthesia plan
( CQI 3d)
No. of patients in whom
the anesthesia plan was
modified
No.of patients who
underwent
anesthesia
a/b*100
1 January 2018 0 58 0

0.00%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan/18
PERCENTAGE
MONTH
% of Modification of Anesthesia plan

(14) % of Unplanned ventilation following anesthesia
(A)
DENOMINATOR
(B)
VALUE
% of Unplanned
ventilation
following
anesthesia
No.of patients requiring
unplanned ventilation
following anesthesia
No.of patients who
underwent
anesthesia
a/b*100
1 January 2018 0 58 0

0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
% of Unplanned ventilation following anesthesia

(15) % of adverse anesthesia events
(A)
DENOMINATOR
(B)
VALUE
% of adverse
anesthesia events
No.of patents who
developed adverse
anesthesia events
No.of patients who
underwent
anesthesia
a/b*100
1 January 2018 0 58 0

0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
% of adverse anesthesia events

(16) % Anesthesia related mortality rate
(A)
DENOMINATOR
(B)
VALUE
% Anesthesia
related mortality
rate
No. of Patients who
died due to anesthesia
No.of patients who
underwent anesthesia a/b*100
1 January 2018 0 58 0

0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
% Anesthesia related mortality rate

(17) % of unplanned return to OT
It is defined as any secondary procedure required for a complication resulting directly or indirectly
from the index operation.
(A)
% of unplanned
return to OT
(CQI 3e)
No.of unplanned
return to OT
No.of Patients
Operated
a/b*100
1 January 2018 1 58 0

Root Cause Analysis
• The patient Mr. XYZ , was posted for ORIF with mandible plating and
IMF. Post surgery on day 11 ,

0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
PERCENTAGE
MONTH
% of unplanned return to OT

(18) % of Rescheduling of Surgeries
Re- scheduling of patients includes cancellation and post postponement (beyond 4 hours) of
the surgery.
(A)
DENOMINATOR
(B)
VALUE
% of Rescheduling of
Surgeries
No. of cases Rescheduled No.of Surgeries
performed a/b*100
1 January 2018 3 58 5.17%

0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
Jan/18
PERCENTAGE
MONTH
% of Rescheduling of Surgeries

Root cause analysis
Rescheduling
of Surgeries
Clinically
unfit on OT
day
OT not
available
unfitness of
patient for
anaesthesia
Anaesthetic
not available
ptatient not
admitted
insurance
approval not
received

1 pre anesthesia evaluation 1 Pre evaluation of case one day before
2 Ensure about time of surgery & availability
of surgeon and anaesthetic.
2 Making update OT list as soon as possible
3 Booking of OT and reconfirming it before
shifting the patient.
3 Cross checking of all the needed documents
before shifting the patient from the ward.

(19) % of cases where the organizations procedure to prevent wrong
site, wrong patient, wrong surgery have been adhered to
SLNO MONTH QI NUMERATOR (A)
(A)
DENOMINATOR
(B)
VALUE
% of cases where the
organizations procedure to
prevent wrong site, wrong
patient, wrong surgery have been
adhered to
No. of cases where
the procedures was
followed
No.of Surgeries
performed.
a/b*100
1 January 2018 58 58 100%

0%
20%
40%
60%
80%
100%
120%
Jan/18
PERCENTAGE
MONTH
% of cases where the organizations procedure to
prevent wrong site, wrong patient, wrong surgery
have been adhered to

(20) % of cases who received appropriate prophylactic antibiotics
within the specified time frame
(A)
DENOMINATOR
(B)
VALUE
% of cases who received
appropriate
prophylactic antibiotics
within the specified
time frame
No.of patients who
did received
prophylactic
antibiotic
No.of Surgeries
performed
a/b*100
1 January 2018 58 58 100%

0.00%
20.00%
40.00%
60.00%
80.00%
100.00%
120.00%
Jun/18
PERCENTAGE
MONTH
% of cases who received appropriate prophylactic antibiotics within the
specified time frame

(21) % of cases in which the planned surgery is changed
intraoperatively
(A)
DENOMINATOR
(B)
VALUE
% of cases in which
the planned surgery
is changed
intraoperatively
(CQI 3e)
Number of cases
in which the
planned surgery is
changed
intraoperatively
Total no. of surgeries
performed
a/b*100
1 January 2018
0 58
0

0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
%% of cases in which the planned surgery is changed
intraoperatively

(22)Re –exploration rate
(A)
DENOMINATOR
(B)
VALUE
Re –exploration
rate(CQI 3e)
Number of re-
explorations done
during same
admission
Total no. of
surgeries
performed
a/b*100
1 January 2018 0 58 0

0
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
Re –exploration rate

(31) Mortality Rate
(A)
DENOMINATOR
(B)
VALUE
Mortality Rate
(CQI 3h)
No. of deaths No. of discharges
& deaths A/B*100
1 January 2018 4 173 2.31%

2.31%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
Jan/18
Percentage
Month
Mortality Rate

Root cause analysis
Mortality Rate
Our Hospital is Tertiary care Hospital so we
get Terminally Ill patients from other
Hospitals.
We cater swine flu Patients in which
mortality Rate is high

1 Death Audits 1 NA

(32) Return to ICU within 48 hours
(A)
DENOMINATOR
(B)
VALUE
Return to
ICU within
48 hours
No. of returns
to ICU in 48
hours
No. of
discharges/transfers
&deaths in ICU
A/B*100
1 June 2017 1 54 1.8%
2 July 2017 0 74 0
3 August 2017 3 37 8.1%
4 September 2017 0 38 0
5 October 2017 1 36 2.7%
6 November 2017 0 47 0

1.80%
0.00%
8.10%
0
2.70%
0
0.00%
1.00%
2.00%
3.00%
4.00%
5.00%
6.00%
7.00%
8.00%
9.00%
Percentage
Month
Return to ICU within 48 hours

Root cause analysis
Return to ICU
within 48 hours
Older
patients with
co-
morbidities
Immunocomprised
patients
critical illness
chronic health
issue

1 Following proper admission and discharge
policy.
1 Defining stable and unstable criteria for
patients.

(39) % of Drugs and consumables procured by local purchase
(A)
% of Drugs and
consumables
procured by
local purchase
No. of Items
purchased by local
purchase
NO. of drug listed in
hospital formulary and
hospital consumable list.
A/B*100
1 January 2018 2 1393 0.14%

0.14%
0.00%
0.02%
0.04%
0.06%
0.08%
0.10%
0.12%
0.14%
0.16%
Jan/18
PERCENTAGE
MONTH
% of Drugs and consumables procured by local purchase

Root cause analysis
Drugs and
consumables
procured by local
purchase
Requisition
for new
molecule and
new brands
Shortage at
Supplier end.
Stock outs
No internal
collaboration
with sister
concerns

1 To work in more on the drug formulary. 1 Effective inventory management through Re-
order.
2 Re ordering level 2 Collaboration with sister concern.

(40) % of stock out including Emergency drugs
SL.NO MONTH QI NUMERATOR (A) DENOMINATOR
(B)
VALUE
% of stock out
including
Emergency
drugs
No. of stock outs
No. of drug listed in
hospital formulary and
hospital consumable list.
A/B*100
1 January 2018 17 1393 1.22%

1.22%
0.00%
0.20%
0.40%
0.60%
0.80%
1.00%
1.20%
1.40%
Jan/18
PERCENTAGE
MONTH
% of stock out including Emergency drugs

Root cause analysis
Stock Outs
No buffer
stock
available
Shortage at
suppliers end

1 Re order level maintained. 1 Kept Buffer inventory storage.
2 Additional valid vendor list for
procurement.
2 Collaboration with sister concern.
3 Local purchase. 3

(41) % of Drug & Consumables rejected before preparation of goods
receipt note(GRN)
(A)
DENOMINATOR
(B)
VALUE
% of Drug &
Consumables
rejected before
preparation of
goods receipt note.
Total Quantity
Rejected
Total Quantity
received before
GRN
A/B*100
1 January 2018 2 1923 0.10%

0.10%
0.00%
0.02%
0.04%
0.06%
0.08%
0.10%
0.12%
Jan/18
PERCENTAGE
MONTH
% of Drug & Consumables rejected before preparation of goods
receipt note(GRN)

Root cause analysis
Drug &
Consumables
rejected before
preparation of
goods receipt note
Due to near
expiry
Quantity not
matching
Due to
damage
Wrong brand
name
Wrong supply
Detail
specification
not
mentioned

1 Procurement of long expiry drugs . 1 PO with detail specification
2 Cross verification with purchase order. 2 Training to staff regarding receiving of goods.
3 Check for quantity as per PO 3

(42) % of Variation from the procurement process
SLNO MONTH QI NUMERATOR (A) (A) DENOMINATOR (B) VALUE
% of Variation from
the procurement
process
Total no. of variations
from the usual
procurement process
Total no. of items
procured whole
sellers/Distributors
A/B*100
1 January 2018 3 1923 0.15%
2
3

0.15%
0.00%
0.02%
0.04%
0.06%
0.08%
0.10%
0.12%
0.14%
0.16%
Jan/18
PERCENTAGE
MONTH
% of Variation from the procurement process

Root cause analysis
Variation from
the
procurement
process
Emergency
purchase
Purchase
from non
assigned
vendor
Purchase
without PO
Wrong PO

1 All orders through PO . 1 Developing SRV format for PO and GRN auto
download.
2 GRN checked against every PO. 2 Focus on re order level.

(47 a) Bed occupancy rate
(A)
DENOMINATOR
(B)
VALUE
Bed occupancy
rate (CQI 4c)
No. of Inpatient days in
given a month
No. of Available Bed
days in a month
A/B*100
1 June 2017 1411 1457 96.84%

82.98%
90.91%
94%
96%
90.66%
85.80%
75.00%
80.00%
85.00%
90.00%
95.00%
100.00%
Percentage
Month
Bed occupancy rate

Root cause analysis
Bed occupancy rate
Heavy patient
flow
Denial from
insurance
company
Denial from
Govt.
schemes

1. Making adequate paper work for insurance
companies.
1. Channelized paper work.
2. Government schemes explained to
patients.
2.

(47 b) Average Length Of Stay
(A)
DENOMINATOR
(B)
VALUE
No. of
admission No. of Inpatient days in
given a month
No. of Discharges &
Deaths in that
month
A/B
1 January 2018 1411 173 8.15

8.15
0
1
2
3
4
5
6
7
8
9
Jan/18
LENGTH
OF
DAYS
MONTH
Average Length Of Stay

Root cause analysis
Average Length
Of Stay
Insurance
patients require
approval
Surgical recovery
may vary.

Sr.No Preventive Action Taken
1 Policy and procedures for insurance are well defined.
2 Policy and procedures for discharge of patients are defined.

(49) Critical Equipment down time
SLNO MONTH QI VALUE
Critical Equipment down
time
Sum of Down time for all
critical equipments in hours
1 January 2018 34.33 hrs

34.33
0
5
10
15
20
25
30
35
40
Jan/18
TIME
TAKEN
IN
HRS.
MONTH
Critical Equipment down time

Root cause analysis
More Down time for
Critical Equipment
Unavailability
of Spares
Unavailability of
company personnel
machine was send to
outstation for repair

1 Kept Standby arrangement ready 1 Training to Operators to avoid Breakdowns
2 In house Repairing whenever possible 2 Schedule for Preventive Maintenance
3 Daily Check round for Critical Care
Equipment's

(50) Nurse Patient ratio for ICU`s & Wards
(A)
DENOMINATOR
(B)
VALUE
Nurse Patient
ratio for ICU`s &
Wards
No.of Staff/No.of
Shifts
No.of Beds A/B
1 January 2018 55/3 47 0.39%

0.39
0
0.05
0.1
0.15
0.2
0.25
0.3
0.35
0.4
0.45
Jan/18
TIME
TAKEN
IN
HRS.
MONTH
Critical Equipment down time

Root cause analysis
Nurse: Patient Ratio
Some staff
Left for
Exams
staff Left for
Better
Prospectus
Some Staff
Left for
Personal
Reasons
Some Staff
Left for In
satisfaction

1 Exit Interviews taken 1 New recruitments going on

(51) Outpatients satisfaction Index
(A)
Outpatients
satisfaction
Index (CQI 4d)
Average Score
achieved
Maximum possible
score
A/B*100
1 January 60720 69696 87.12%

87.12%
0.00%
10.00%
20.00%
30.00%
40.00%
50.00%
60.00%
70.00%
80.00%
90.00%
100.00%
Jan/18
Percentage
Month
Outpatients satisfaction Index

Root cause analysis
Outpatients
satisfaction
Index
High Number
of patients
Emergency
Patient
OT schedule
Referred
patient from
outside

1 Telephonic appointment. 1 Display of OPD timing
2 Token System 2

(52) Inpatients satisfaction Index
SL.NO MONTH QI NUMERATOR (A) DENOMINATOR
(B)
VALUE
Inpatients
satisfaction Index
(CQI 4d)
Score achieved Maximum possible
score
A/B*100
1 Jan 2018 1434 1760 81%

81%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
Jan/18
PRCENTAGE
MONTH
Inpatients satisfaction Index

Root cause analysis
Inpatients
satisfaction
Index
Slow billing
process
Inferior quality of
food
Delayed
investigations
House keeping in
toilet not
appropriate and
frequent

1.
Food services asked to deliver better quality
of food. 1. Continuous training on soft skill.
2. Reporting of diagnostic services made
prompt.
2. TAT for diagnostic to be reviewed and
followed .
3. Billing and reception personnel to update
and finalize bills one day before.
3. Update of billing sheet one day prior to
discharge.
4. Housekeeping supervisor asked to take
frequent rounds in the wards to monitor
toilet cleaning.
4. Toilet cleaning checklist to be monitored and
checked by nursing in-charge

(53) Waiting time for outpatient consultation
(A)
DENOMINATOR
(B)
VALUE
Waiting time for
services including
diagnostics &
outpatient consultation
Sum (Patient in time for
consultation/procedure-
Patient reporting time in
OPD/Diagnostics)
No. of Patients
reported in
OPD/Diagnostics
A/B
1 13219.2 mins 426 31.2 mins

0
5
10
15
20
25
30
35
40
45
50
TIME
IN
MIN
MONTH
Waiting time for services including diagnostics &

Root cause analysis
Waiting time for services
including diagnostics &
Hospital's
Enquiry/Reception
Service
Chief Consultant's
Communication
Healthcare services
& Treatment

1 Telephonic appointment 1 Councelling for preparation time
2 Councelling of unstable patient 2

(54) Time taken for discharge
(A)
Time taken for
discharge
Sum of Time taken for
discharge
No.of patients
Discharged A/B
1 June 2017 11265 195 57.76
2 July 2017 11532 202 57.08
3 August 2017 11989 213 56.28
4 September 2017 12444 221 56.31
5 October 2017 12902 205 62.94
6 November 2017 10705 184 58.18

57.76
57.08
56.28 56.31
62.94
58.18
52
54
56
58
60
62
64
Time
in
Hrs.
Month
Time taken for discharge

Root cause analysis
Time taken for
discharge
Delay in
insurance
settlement
Documentation
not complete

1 Insurance documents prepared before
hand.
1 Documents updated 1 day prior.

Bed Sores
Bedsores — also called pressure ulcers and decubitus ulcers — are injuries to skin and underlying tissue
resulting from prolonged pressure on the skin.
MONTH No of patient who develop new
worsening of pressure ulcer (A)
Total no of patient days
(B)
VALUE (A/B)
Jun 2017 1 1442 0.6
July 2017 0 1468 0
August 2017 1 1722 0.5
sep2017 0 1789 0
Oct2017 0 1604 0
Nov2017 0 1315 0

Bed Sores
No of patient who develop new worsening of pressure
ulcer *1000
Std-less than -1%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7

Root cause analysis
Incidence of bed sores
after admission
Morse fall scale not filled
carefully
Lack of awareness about
repositioning of the patient.
Patient care not
taken

1 Training on Morse fall scale. 1 Training of nursing staff on nursing care.

Patient fall
June 2017 No of patient
fall (A)
(B)
VALUE (A/B)
1 June 2017 0 1442 0
2 July 2017 0 1468 0
3 August 2017 0 1722 0
4 September 2017 0 1789 0
5 October 2017 0 1604 0
6 November 2017 0 1315 0

patient fall
No of patient fall *1000
Std-less than-1%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1

(55) Employee Satisfaction Index
SLNO MONTH QI NUMERATOR (A) DENOMINATOR
(B)
VALUE
Employee Satisfaction Index
(CQI 4e)
Score achieved Maximum
Possible Score
A/B*100
1 June 2017

80
83
78.5
79
79.5
80
80.5
81
81.5
82
82.5
83
83.5
Jan/16 Feb/16 Mar/16 Apr/16 May/16 Jun/16 Jul/16
Months
Employee Satisfaction Index
Percentage

Root cause analysis
Employee
Satisfaction
Index
Low Salary
No Leave
Policy
Flexibility in
Working
Hours
No Medical
Benefits
Appointment
on
Contractual
Role
Inadequate
Training &
Development

1 Revision of Salaries done 1 Yearly Appraisal Started
2 Medical Benefits like free consultation,
Discounts on IPD/Diagnostics.
2 10% Discount on IPD/Diagnostics & Pharmacy
3 Various Training & Development session
started
3 Training calendar for the year prepared &
training is going on accordance to scheduled.
4 Flexibility given in working ours in some
cases.
4 Manpower planning Done for the Hospital &
Preference given to existing employees.
5 Employee promoted from Contractual role
to UCH role based on performance

(56) Employee Attrition Rate
(A)
DENOMINATOR
(B)
VALUE
Employee
Attrition
Rate
No.of Employees
who have left
No.of Employees at the
Beginning of the
month+Newly joined staff
A/B*100
1 January 2018 1 134 0.74%

0.74%
0.00%
0.10%
0.20%
0.30%
0.40%
0.50%
0.60%
0.70%
0.80%
Jan/18
PRECENTAGE
MONTH
Employee Attrition Rate

Root cause analysis
Employee Attrition
Rate
Low salary
Personal reasons

1 Can’t say since left without any intimation. 1 Exit Interview Policy developed

(57) Employee Absenteeism Rate
(A)
DENOMINATOR
(B)
VALUE
Employee
Absenteeism
Rate
No. of employees who
are on unauthorized
absence
No. of Employees A/B*100
1 January 2018 6 134 4.47%

4.47%
0.00%
0.50%
1.00%
1.50%
2.00%
2.50%
3.00%
3.50%
4.00%
4.50%
5.00%
Jan/18
PERCENTAGE
MONTH
Employee Absenteeism Rate

Root cause analysis
Employee
Absenteeism Rate
Sickness
Personal
Lack of
Professional
Approach

Corrective action/Preventive action
1 Adjustment in Duty Hours/Timings 1 Training about work Ethics

(63) % of Medical Record not Having Discharge summary
SLNO MONTH QI NUMERATOR (A) DENOMINATOR (B) VALUE
% of Medical Record
not Having
Discharge summery
(CQI 4g)
No.of Medical
Record not Having
Discharge summery
No.of Discharges &
Deaths A/B*100
1 January 2018 0 173 0

0.03%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH
% of Medical Record not Having Discharge summary

(65) % of Medical Records having incomplete &/ or Improper consent
(A)
DENOMINATOR
(B) VALUE
% of Medical Records
having incomplete &/
or Improper consent
No.of Medical Records
having incomplete &/
or Improper consent
No. of Discharges &
Deaths A/B*100
1 June 2017 0 173 0

0.46%
0
0.1
0.2
0.3
0.4
0.5
0.6
0.7
0.8
0.9
1
Jan/18
PERCENTAGE
MONTH

(66) % of Missing records (Documentwise)
(A)
DENOMINATOR
(B)
VALUE
% of Missing
records
No. of Missing
records
No. of Records A/B*100
1 January 2018 0 108 0

0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Jan/18
PERCENTAGE
MONTH
% of Missing records (Documentwise)

(67) Appropriate handovers during shift changes
(A)
DENOMINATOR
(B)
VALUE
Appropriate
handovers during
shift changes
No. of handovers
done appropriately No. of handover
opportunities
A/B*100
1 January 2018 3 rd floor 1299 1314 98%
General Ward 2086 2116 98.58%

96.96%
96.21%
94.60%
97.70%
94.60%
98.40%
92.00%
93.00%
94.00%
95.00%
96.00%
97.00%
98.00%
99.00%
PERCENTAGE
MONTH
Appropriate handovers during shift changes(Nurses)

Root cause analysis
Lack of
training
Lack of daily
audits
Lack of
awareness
Lack of record
integrity
implementation
Late
implementation
of deficiency
checklist
No Medical
Record
protocol and
indexing

1 Started record keeping 1
Supervision started in uniform manner
2
Started Analysis of Files
2 Ward Checklist Implemented for proper
documentation
3
Deficiency Checklist Implemented
3
Training on Good documentation practices
4
Training Given for Employees
5
Started daily audits

No. of patient identification error
No. of identification error *1000
No. of patient in a month
MONTH No. of identification error No. of patient in a month VALUE (A/B)
June2017 4 1442 0.2
July 2017 6 1468 0.4
August2017 3 1722 0.1
Sept 2017 2 1789 1.1
Oct2017 0 1604 0
Nov2017 3 1315 2.2

No. of patient identification error
0
0.5
1
1.5
2
2.5
june2.17 Jul-17 Aug-17 Sep-17 Oct-17 Nov-17

Root cause analysis
Patient Identification
Error
Improper Documentation
Unavailability of Stickers
Negligence in good
documentation practices
Duplication of name

1 Training on good documentation practices. 1 Training of staff on proper documentation.

HAND HYGIENE COMPLANCES
Total no. of actions performed
Total no. of Hand hygiene opportunities *100
MONTH Total no. of actions
performed
Total no. of Hand hygiene
opportunities
Compliance(A/B)
132
132
132
132
132
132

HAND HYGIENE COMPLANCES
78
80
82
84
86
88
90
92
94
96
98

Root cause analysis
Hand hygiene
compliances
Negligence in hand washing
technique
Lack of supervision
Lack of awareness of
moments of hand hygiene
No hand rub in the dispenser or
missing at sink

Thank You,
Quality Department, Kunal Hospital.

CQI Presentation KUNAL HOSPITAL- 2018.pptx

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