Clinical indicators are measures that assess healthcare processes and outcomes. They are needed to identify areas for improvement like preventable medical errors. Some key points about clinical indicators include that they can measure structure, process, outcomes, and be rate-based or sentinel. Examples provided include surgical site infection rates and unplanned returns to the operating room. Departments like nursing, surgery, emergency departments, and more have specific clinical indicators tailored to assess quality in their areas.

1. PRESENTED BY:
Dr. REKHA MULCHANDANI(2010HO027)
SNEHA LABHANE(2010HO015)

2. DEFINITION
Clinical Indicators can be defined as :
AS MEASURES THAT ASSESS A
PARTICULAR HEALTH CARE PROCESS
OR OUTCOME

3. WHY IS THERE A NEED FOR CLINICAL
INDICATORS?
The Harvard Medical Practice Study, which
reviewed over 30,000 hospital records in
New York state, found injuries from care
itself (“adverse events”) to occur in 3.7% of
hospital admissions, over half of which were
preventable and 13.6% of which led to death.

4. Other reasons……
 A lack of documentation about how major illnesses
are treated in most health care systems
 A lack of systematic outcome assessment
 A lack of resource evaluation related to quality for
specific diseases;
 Persisting variations among providers in care for
similar patients

5. To identify those clinical indicators which are
potentially relevant and appropriate, the
following points should be considered
 Does the indicator measure an important aspect of
clinical practice?
 Will the data collected on this indicator assist in
improving clinical care?
 Will the information be useful and meaningful to
clinicians in demonstrating how the service is
performing and ways that it may be improved?
 Will the data be accessible to clinicians to allow for
monitoring of the indicator?
 Are existing resources sufficient to allow for ongoing
monitoring of the indicator?

6. CATEGORIES OF CLINICAL INDICATORS
RATE BASED OR
SENTINEL
RELATED TO
STRUCTURE/PR
OCESS/OUTCO
ME
GENERIC OR
DISEASE
SPECIFIC
TYPE OF CARE FUNCTION MODALITY

7. Type of
care
Preventive
Chronic
Acute
Function
Screening
Treatment
Follow up
Diagnosis
Modality
History
Physical
examination
Laboratory
Medication
Other
interventions

8. RATE-BASED VERSUS SENTINEL INDICATORS
A rate-based indicator uses data about events that
are expected to occur with some frequency. These can
be expressed as proportions or rates (proportions
within a given time period), ratios, or mean values for a
sample population.
 A sentinel indicator identifies individual events or
phenomena that are intrinsically undesirable, and
always trigger further analysis and investigation.

9. EXAMPLES
 Rate-based indicators
Clean and contaminated wound infection
(1) Numerator: the number of patients who develop wound
infection from the fifth post-operative day after clean
surgery
(2) Denominator: the total number of patients undergoing
clean surgery within the time period under study who
have a post-operative length of stay of ≥5 days.
 Sentinel indicators
Numbers of patients who die during surgery
Numbers of patients who die during the perinatal
period

10. INDICATORS RELATED TO STRUCTURE, PROCESS, AND
OUTCOME
• THE ATTRIBUTES OF SETTINGS IN
WHICH CARE OCCURES
STRUCTURE
• WHAT IS ACTUALLY DONE IN
GIVING AND RECEIVING CARE
PROCESS
• DESCRIBES THE EFFECTS OF CARE
ON HEALTH STATUS OF PATIENT
AND POPULATION
OUTCOME

11. RISK ADJUSTMENT
Factors that are frequently included in risk adjustment
models include
 patient demographic, psychosocial characteristics (such as
age, sex, and functional status),
 lifestyle factors (smoking, alcohol use),
 severity of the illness that is the focus for measurement,
 health status, and
 co-morbid conditions.
Risk adjustment is essential before comparing patient
outcomes across hospitals or providers

12. GENERIC AND DISEASE-SPECIFIC INDICATORS
 Generic indicators measure aspects of care
that are relevant to most patients,
 disease-specific indicators are diagnosis-
specific and measure particular aspects of
care related to specific diseases. Both
generic and disease-specific indicators can
focus on structure, process, or outcome.

13. HOSPITAL-WIDE INDICATORS
MEDICATION SAFETY
 Documentation of previous adverse drug reactions on
the medication chart
 Error-prone abbreviations in medication orders
HOSPITAL READMISSIONS
 Unplanned and unexpected readmissions within 28
days
 unplanned readmission rate within 14 days

14. UNEXPECTED RETURNS TO OPERATING THEATRE
PRESSURE ULCERS
 one or more pressure ulcers during their admission
 A number of patients have pressure ulcers at the time of
admission
INPATIENT FALLS
 Inpatient falls
 Inpatient falls that require intervention
 Inpatient falls in people aged 65 years and over that
resulted in a closed head injury
 In people aged 65 years and older inpatient falls

15. REVIEW FOLLOWING PATIENT DEATH
 The proportion of patient deaths that were followed by
a clinical audit and review process
BLOOD TRANSFUSION
 Rate for adverse events related to a blood transfusion
 Informed patient consent was not documented
DAY OF SURGERY ADMISSIONS
 Measure of appropriateness for admission of elective
surgery patients on the day of surgery
THROMBOPROPHYLAXIS
 use of prophylaxis for venous thrombo embolism for
high risk medical patients

16. Patient safety
Return to operating room-
 rate of unplanned return to OR
In patient falls
 no intervention
 require some sort of intervention as a result of the fall
 Head injury in inpatients

17. Infection Control Indicators
 Surgical site infections
 Infection Control indicator
MRSA infection indicators per 10,000 bed days in ICU
Haemodialysis-associated infection surveillancethe infection
rate for AV fistula access
infections in central lines
 Neonatal infections
 first 48 hours following birth, the rate for blood and/or CSF
gestational age greater than 37 weeks
 After 48 hours, the rate for bloodstream
 infections among low birth weight babies
 Significant blood infections in the neonatal ICU for babies
<1,000 g and babies >1,000 g

18. 1. Volume Indicators :
 Volume of procedures
 Bed Occupancy
 ALOS
 Mortality

19.  Hospital Standardized Mortality Ratio
The hospital standardized mortality ratio (HSMR) is a measure
of patient safety that compares a hospital's mortality rate
with a national standard. The HSMR is a ratio of "observed"
to "expected" deaths, multiplied by 100. A ratio greater than
100 means more deaths occurred than expected, while a ratio
less than 100 suggests fewer deaths occurred than expected.
Therefore, hospitals want to have an HSMR below 100.

20. DEPARTMENT SPECIFIC
indicators

21. NURSING-SENSITIVE INDICATORS
The structure of nursing care is indicated by the supply of
nursing staff, the skill level of the nursing staff, the
education/certification of nursing staff.
Process indicators measure aspects of nursing care such
as assessment, intervention, and RN job satisfaction.
Patient outcomes that are determined to be nursing
sensitive are those that improve if there is a greater
quantity or quality of nursing care (e.g., pressure ulcers,
falls, and intravenous infiltrations).

22. ..contd
Some patient outcomes are more highly related to
other aspects of institutional care, such as medical
decisions and institutional policies (e.g., frequency of
primary C-sections, cardiac failure) and are
not considered "nursing-sensitive".
Nursing Hours per Patient Day
 Registered Nurses (RN) Hours per Patient Day
 Unlicensed Assistive (UAP) Hours per Patient Day
Nursing Turnover

23. ..contd
Nosocomial Infections
Patient Falls
Patient Falls with Injury
 Injury Level
Pressure Ulcer Rate
 Community-acquired
 Hospital-acquired
 Unit-acquired
Paediatric Pain Assessment, Intervention,
Reassessment (AIR) Cycle

24. ..contd
Paediatric Peripheral Intravenous Infiltration
Registered nurses Survey
 Job Satisfaction Scales
 Practice Environment Scale (PES)
Restraints
Additional Data Elements Collected:
 Patient population – Adult or Pediatric.
 Hospital Category, e.g. Teaching, Non-teaching,
etc.
 Type of Unit (Critical Care, Step-Down, Medical,
Surgical, Combined Med-Surg, Rehab &
Psychiatric).
 Number of staffed beds designated by the hospital

25. SURGICAL SAFETY CHECKLIST
Before the patient receives anesthesia, (briefing)
Before the incision, (surgical pause),
Before the patient leaves the OR (debriefing),
patient safety communication tool used by the operating
room team to facilitate team discussion and ensure that
everyone is familiar with the case, reducing reliance on
memory for certain necessary interventions.
Improved patient care and safety,
 Decreased complications and deaths from surgery
Better OR efficiency.

26. OPTHOMALMOLOGY SURGERY
Total No. of readmissions (related to the operated
eye)within 28 days of discharge following surgery/ Total
number of patients having cataract surgery.
Total no. of pats. having an unplanned readmission
within 28 days of discharge following surgery, due to
endophthalmitis in the operated eye/ Total number of
patients having cataract surgery during the 6 month time
period.

27. ..contd
CATARACT
Total No. of pats. having a discharge intention of
1day, who had an overnight admission following
surgery/ Total number of pats. having surgery
Retinal detachment surgery
Total number of patients with a LOS greater than
4 days following surgery/ Total no. of pats. having
surgery
GLAUCOMA surgery
Total number of patients with a LOS greater than
3 days following glaucoma surgery / Total no. of
pats.having surgery

28. ..contd
REFRACTIVESURGERY
Total No. of pats. having a discharge intention of 1day,
who had an overnight admission following surgery/
Total number of pats. having surgery during the 6
month time period

29. EMERGENCY DEPARTMENT
Emergency Department waiting times
Treatment of acute myocardial infarction (AMI)
Access block (MORE THAN 8 HRS)
Overall Length of Stay (hours) <2:35
Admitted Length of Stay (minutes) <253
Left Without Being Seen <2%
Triage to RN Evaluation <30 min
Triage to MD Evaluation <30 min.

30. DAY SURGERY
Patient fails to arrive
Procedure cancelled after arrival due to preexisting medical
conditions
Unplanned return to OR during the same admission.
Unplanned transfer following a procedure
Delay in patient discharge

31. GYNAECOLOGY
Injury to major viscera during lap surgery eg. bladder,
ureter,
% of recieving Lap management of ectopic pregnancy
Urogynaecology: - Injury to major viscus during pelvic
floor surgery
Antibiotic prophylaxis prior to hystrectomy (95%)
Blood transfusion following gynaecology sg for benign
disease

32. OBSTETRICS
Vaginal delievery following previous C-section
Appropriate antibiotic prophylaxis for Cosection
Appropriate thromboprophylaxis for high risk women for C-
section
Peer review of serious adverse event
% of induction of labour
% of spontaneous vaginal births
% of instumental vaginal delieveries
% of C-SECTION
% of having perineum following vaginal births

33. ..contd
% of who underwent episiotomy &had no tear
% of vaginal birth with perineal tears without episiotmy
% of vaginal birth with perineal tears with episiotmy
% of required Surgical repair of 3rd degree tear
% of required Surgical repair of 4th degree tear
Management of C-section
 % with general anaesthesia
Rate of Postpartum haemorrhage for VAGINAL &C-section.
Rate of term babies transferred to NICU
Rate of IUGR

34. INTERNAL MEDICINE
Endocrine diseases-rate of insulin treated diabetic pat.
experiencing blood sugar level < 4mmol/l preoperative
& postoperatively.
Neurological disease - propotion of inpatient with a
discharge diagnosis of stroke who also had CT-SCAN
Aged pats.-% of pats. For whom there is documented
assessment of mental functions
Rate of assessment of physical functions
Success rate of PTCA with or without Stenting

35. ..contd
CVS : Patient with AcMI should receive thrombolysis
within 1 hour of presentation to the hospital
Proportion of pats. who has CABG within 24 hrs of PTCA
RESPIRATORY DISEASES - referral of COPD pats. to
chronic disease management
Rate for documented objective assessment of asthma
severity on initial presentation
Rate of ongoing assessment of severity
Documented discharge plan for asthma pats.

36. ..contd
GASTROINTESTINAL - Proportion of patients Admitted
for haematemesis & malaena who received
Bloodtransfusion & had Gastroscopry wihin 24hrs
Proportion of patients Admitted for haematemesis &
malaena who received blood transfusion & subsequently
die
MEAN Rate of Patients discharged with specific
diagnosis
Rate for Notification of patients condition

37. ..contd
RENAL - % of patients who
develop macroscopic
haematuria within 24 hrs of
renal biopsy
Oncology - Proportion of
premenopausal pats.
withstage II CA breast who
has documented evidence of
treatment With poly
chemotherapy

38. DENTAL
The rate for teeth requiring retreatment within six months
of restorative treatment was 5.0%.
The rates for complications within 7days of routine surgical
extraction
 The proportion of dentures that had to be remade within 12
months
Retreatment within 6months of completing a course of
endodontic treatment
The Rate of completed / updated Medical histories
Rate of completed charting at initial assessment for a
general course of care

39. PEDIATRICS
Immunisation status documented and be offered or given
Catch up immunisation, particularly infants less than two
years old.
The rate for catch-up immunisation given or planned
Average length of stay for asthma The rate for
Readmission within 28 days of discharge
Access block measured by an inability to admit a patient
into a paediatric ICU

40. ..contd
The rate for deferred or cancelled elective surgery due to
a lack of ICU beds.
The proportion of patients whose discharge from the
ICU was delayed by more than 12 hour
Unplanned readmission into the ICU within 72 hours of
discharge

41. ICU
Nurse - Patient Ratio is 1:1
Hospital acquired infection
Doctor patient ratio is 1:12 (ideal ratio is1:5)
ICU Utilisation
ICU Mortality
 Adherence to interventions utilisation of patient
assessment systems. Access and exit block to the ICU
 The proportion of patients who were not admitted to an
ICU because of inadequate resources

42. ..contd
Access and exit block to the ICU
 Rate of deferred elective surgery due to lack of ICU / HDU
beds
 Rate for transferring patients to another unit due to a lack of
ICU beds
Intensive care patient management
 Rates for unplanned readmission to the ICU reflect :
less than optimal management of a patient.
premature discharge as a consequence of inadequate
resources or reflect the standard of ward care.in 72 hours

43. ..contd
Intensive care patient treatment
 Proportion of patients receiving thromboembolism
prophylaxis within 24 hours of admission to the ICU

44. GENERAL SURGERY
Delay in elective cases-around 15-30 minutes
Case cancellation rate on day of surgery- 4-5 per
month(4/199=2%), reasons being patient refusal,
unwilling. Pac reviewed on table and patient not fit, due
to bad weather patient does not turn up.
Turn over time for set up & cleaning (mean time from
previous patient out to next patient in) is10-30min.

45. ..contd
Prediction bias about
duration of case
Pre-operative & Post
operative stay-10-15 minutes
Readmission within 2 weeks

46. ..contd
 The rate of bile duct injury requiring
operative intervention following
laparoscopic cholecystectomy
 Orthopaedic surgery
The proportion of patients having a total
hip replacement who had a post-
operative infection
 Vascular surgery - Elective abdominal
aortic aneurysm (AAA) reported each
year
Cardiothoracic surgery
 The death rate for coronary artery graft
surgery (CAGS)
 Neurosurgery - The neurosurgical
infection rate