THIS IS CQI DATA POWER POINT PRESENTATION.

1. HOSPITAL NAME
A STEP TOWARDS CONTINUOUS QUALITY IMPROVEMENT

2. Quality indicators
1. BED OCCUPANCY RATE
2. LENGTH OF STAY
3. ICU BED OCCUPANCY RATE
4. RETURN TO ICU IN 48 HOURS
5. RETURN TO EMERGENCY WITHIN 72 HOURS WITH SAME COMPLAINT
6. MORTALITY RATE
7.ADVERSE DRUG REACTION RATE
8.BLOOD TRANSFUSION REACTION RATE
9.VENTILATOR ASSOCIATED PNEUMONIA RATE
10.CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION RATE
11.CATHETER ASSOCIATED URINARY TRACT INFECTION RATE
12.SURGICAL SITE INFECTION RATE

3. Quality indicators
13. ADVERSE ANAESTHESIA REACTION RATE
14.MODIFICATION OF ANAESTHESIA
15.EMPLOYEE ABSEENTISM RATE
16. EMPLOYEE ATTRITION RATE
17. EMPLOYEE PRE PROPHYLAXSIS RATE
18. PERCENTAGE OF MEDICAL RECORDS NOT HAVING SUMMARY
19. PERCENTAGE OF MEDICAL RECORDS HAVING INCOMPLETE/IMPROPER CONSENTS.
20. INCIDENCE OF BED SORE

4. BED OCCUPANCY RATE
BED OCCUPANCY RATE
Period No. of Inpatient Days in a given
Month
No. of Available bed days in
that Month
Bed Occupancy Rate
JULY 1427 1860 76.72
AUGUST 1329 1860 71.45
SEPTEMBER 1077 1860 57.90
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
20.00
40.00
60.00
80.00
100.00
76.72 71.45
57.90
BED OCCUPANCY RATE
Bed Occupancy
Rate

5. LENGTH OF STAY
AVERAGE LENGTH OF STAY
Period
No. of Patient Days in a Given
Month
No. of Discharges and Deaths in that
Month Average Length of Stay
JULY 1427 290 4.92
AUGUST 1329 275 4.83
SEPTEMBER 1077 271 3.97
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
1.00
2.00
3.00
4.00
5.00
6.00
AVERAGE LENGTH OF STAY
Average
Days

6. ICU BED UTILIZATION RATE
ICU BED UTILIZATION RATE
Period
No. OF BED UTILIZED
DAYS
No. Bed Days Available ICU Utilization Rate
JULY 121 310
39.03
AUGUST 242 310 78.6
SEPTEMBER 152 300 50.67
Sample Size 100%
JULY AUGUST SEPTEMBER
0
40
80
ICU UTILIZATION RATE
ICU UTILIZATION RATE

7. RETURN TO ICU IN 48 HOURS
RETURN TO ICU WITHIN 48 HOURS
Period No. of returns to ICU
within 48 hours
No. of discharge and transfer
from the ICU
Percentage of PT. Return to ICU
Within 48 Hours
JULY
1 121 8.26
AUGUST
0 242 0.00
SEPTEMBER
0 152 0.00
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
2.00
4.00
6.00
8.00
10.00
PERCENTAGE OF PT. RETURN TO ICU WITHIN 48 HOURS
Percentage
RCA-HYPERTENSION.CREATININE INCREASED.
CAPA-DOCUMENTATION TRAINING.

8. RETURN TO EMERGENCY WITHIN 72 HOURS WITH SAME COMPLAINT
RETURN TO EMERGENCY WITHIN 72 HOURS WITH SAME COMPLAINT
PERIOD No. OF RETURNS TO EMR WITHIN 72
HOURS
TOTAL No. OF PATIENT IN
EMR IN THAT MONTH
PERCENTAGE OF PT. RETURN
TO EMR WITHIN 72 HOURS
JULY 1 121 8.26
AUGUST 0 242 0.00
SEPTEMBER 0 152 0.00
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
1.00
2.00
3.00
4.00
5.00
6.00
7.00
8.00
9.00
PERCENTAGE OF PT. RETURN TO EMR WITHIN 72HOURS
Percentage

9. MORTALITY RATE
MORTALITY RATE
PERIOD No. OF DEATHS No. OF DICHARGES AND DEATHS MORTALITY RATE
JULY
8
290
2.76
AUGUST
4
275
1.45
SEPTEMBER
3
271
1.11
SAMPLE SIZE 100%
JULY AUGUST SEPTEMBER
0.00
0.50
1.00
1.50
2.00
2.50
3.00
MORTALITY RATE
Mortality Rate

10. ADVERSE DRUG REACTION RATE
ADVERSE DRUGS REACTION
PERIOD NO. OF ADR NO. OF DISCHARGES & DEATHS
PERCENTAGE OF ADVERSE DRUG
RECTION
JULY 1 290 0.34
AUGUST 0 275 0
SEPTEMBER 1 271 0.37
SAMPLE SIZE 100%
RCA-HIGH RISK MEDICINE
CAPA-MEDICINE STOP
JULY AUGUST SEPTEMBER
0
0.2
0.4
ADVERSE DRUG REACTION
ADVERSE DRUG
REACTION

11. BLOOD TRANSFUSION REACTION RATE
PERCENTAGE OF TRANSFUSION REACTIONS
Period
No. of Transfusion
Reaction No. of Units Transfused
Percentage of Transfusion
Reactions
JULY 1 90 1.1
AUGUST 1 107 0.93
SEPTEMBER 1 76 1.31
Sample Size 100%
JULY AUGUST SEPTEMBER
0
0.2
0.4
0.6
0.8
1
1.2
1.4
PERCENTAGE OF TRANSFUSION REACTIONS
Percentage
RCA-PATIENT GOT ANXIOUS ,WEAKNESS.
CAPA-PATIENT COUNCELLING,BT SLOW/STOP.

12. CATHTHTER ASSOCIATED UTI
CATHETER ASSOCIATED URINARY INFECTION RATE
Period No. of Urinary Catheter
Associated UTIs in a Month
No. of Urinary Catheter Days in
that Month
Catheter Associated Urinary Infection
Rate
JULY 1 69 14.49
AUGUST 1 41 24.39
SEPTEMBER 0 18 0.00
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
5.00
10.00
15.00
20.00
25.00
30.00
14.49
24.39
0.00
Catheter Associated
Urinary Infection Rate
CATHETER ASSOCIATED URINARY INFECTION RATE
RCA-HAND HYGIENE,CATHETER CARE NOT MAINTAINED.
CAPA-TRAINING OF STAFF FOR HAND HYGIENE AND BUNDLE CARE.

13. SURGICAL SITE INFECTION RATE
SURGICAL SITE INFECTION RATE
Period
No. of SSI in a month
No. of Surgery in that month SSI Rate Bench Mark
JULY
0 10 0.00
5%
AUGUST
0 8 0.00
5%
SEPTEMBER
0 7 0.00
5%
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
0.01
0.02
0.03
0.04
0.05
0.06
Bench Mark
Ventilator Associated Pneumonia
Rate

14. Central line associated blood stream infection
CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION RATE
Period
No. of CLABSI in that Month
No. of central line days in that
Month
CLABSI RATE Bench Mark
JULY
1 126 0.79
5%
AUGUST
1 98 1.02
5%
SEPTEMBER
0 7 0.00
5%
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
0.20
0.40
0.60
0.80
1.00
1.20
CENTRAL LINE ASSOCIATED BLOOD STREAM INFECTION RATE
CLABSI
RATE
RCA-HAND HYGIENE,CENTRAL LINE CARE NOT MAINTAINED.
CAPA-TRAINING OF STAFF FOR HAND HYGIENE AND BUNDLE CARE.

15. INCIDENCE OF BEDSORES
INCIDENCE OF BED SORE
Period
INCIDENCE OF
BEDSORE
TOTAL IPD DAYS IN
THAT MONTH BED SORE Rate Bench Mark
JULY 0 1427 0.00 5%
AUGUST 0 1329 0.00 5%
SEPTEMBER
0 1077 0.00
5%
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
0.01
0.02
0.03
0.04
0.05
0.06
Bench Mark
INCIDENCE OF BEDSORE
INCIDENCE OF BED SORE

16. VENTILATOR ASSOCIATED PNEUMONIA RATE
VENTILATOR ASSOCIATED PNEUMONIA RATE
Period
N. of ventilator associated pneumonia
in a month
N. of ventilator days in that month Ventilator Associated Pneumonia Rate Bench Mark
JULY
0 55 0.00
5%
AUGUST
0 18 0.00
5%
SEPTEMBER
0 10 0.00
5%
Sample Size 100%
JULY AUGUST SEPTEMBER
0.00
0.01
0.02
0.03
0.04
0.05
0.06
Bench Mark
Ventilator Associated Pneumonia
Rate
VENTILATOR ASSOCIATED PNEUMONIA RATE

17. MODIFICATION OF ANAESTHESIA PLAN
MODIFICATION OF ANAESTHESIA PLAN
Period NO. OFMODI.ANAESTHESIA IN
THAT MONTH
No. of SURGERY IN THAT MONTH RATE OF AAE
JULY 0 10 0.00
AUGUST 0 8 0.00
SEPTEMBER 0 7 0.00
Sample Size 100%
JULY AUGUST SEPTEMBER
0
0.2
0.4
0.6
0.8
1
MODIFICATION OF ANAESTHESIA PLAN
MODIFICATION OF
ANAESTHESIA PLAN
Linear (MODIFICATION
OF ANAESTHESIA
PLAN)

18. ADVERSE ANAESTHESIA EVENT
ADVERSE ANAESTHESIA EVENT
Period No. of ADVERSE EVENTS HAPPEN
TOTAL PAT.UNDERWENT
ANAESTHESIA Percentage of AAE
JULY 0 10 0
AUGUST 0 8 0
SEPTEMBER 0 7 0.00
Sample Size 100%
JULY AUGUST SEPTEMBER
0
0.2
0.4
0.6
0.8
1
Percentage

19. MEDICAL RECORD NOT HAVING DISCHARGE SUMMARY
RCA=HUMAN ERROR
CAPA-STRICT ORDERS GIVEN TO MRD TECH. TO NOT TAKE FILES FROM STAFF WITHOUT DISCHARGE SUMMARY.
MEDICAL RECORD NOT HAVING DISCHARGE SUMMARY
Period
Total No. MR WITHOUT
DISCHARGE SUMMARY
Total n. of IPD FILES PERCENTAGE OF MEDICAL RECORD
WITHOUT DISCHARGE SUMMARY
Bench Mark
JULY 4 290 13.79 5
AUGUST 3 275 10.91 5
SEPTEMBER 0 271 0 5
Sample Size 100%
JULY AUGUST SEPTEMBER
0
5
10
15
PERCENTAGE OF RECORD
WITHOUT DISCHARGE
SUMMARY
BENCHMARK

20. MEDICAL RECORD WITH INCOMPLETE/IMPROPER CONSENT
RCA- STAFF DID NOT TAKE SIGNS OF WITNESS AND PATIENT SIGNATURE.
CAPA-MO AND CLINICAL ASSISSTANT ASKED TO RECHECK THE CONSENTS.
MEDICAL RECORD HAVING IMPROPER CONSENT
Period
Total No. MR HAVING
IMPROPER CONSENT
Total n. of IPD FILES PERCENTAGE OF MEDICAL
RECORD HAVING IMPROPER
CONSENT
Bench Mark
JULY 3 290 10.34 5
AUGUST 2 275 7.27 5
SEPTEMBER 1 271 3.69 5
Sample Size 100%
JULY SEPTEMBER Category 3
0
2
4
6
8
10
12
MR WITH INCOMPLETE
CONSENT
BENCHMARK

21. EMPLOYEE ATTRITION RATE
EMPLOYEE ATTRITION RATE
Period N. of STAFF LEFT IN THAT MONTH TOTAL NO OF STAFF EMP.ATTRITION RATE
JULY
0
113
0.00
AUGUST
2
113
1.77
SEPTEMBER
1
113
0.88
Sample Size 100%
JULY AUGUST SEPTEMBER
0
1
2
EMP.ATTRITION RATE
EMP.ATTRITION RATE

22. RE INTUBATION RATE
EMPLOYEE PRE PROPHYLAXSIS RATE
Period NO. OF PATIENT REINTUBATED TOTAL NO OF PATIENT INTUBATED REINTUBATION RATE
JULY
0
12
0
AUGUST 0 10 0
SEPTEMBER 0 6 0
Sample Size 100%
JULY AUGUST SEPTEMBER
0
0.2
0.4
0.6
0.8
1
REINTUBATION RATE
REINTUBATION RATE

23. EMPLOYEE ABSENTEESIM RATE
RCA-UNKNOWN REASON
CAPA-NEW RULE INTRODUCED TO TAKE FINE FROM STAFF IN CASE OF LEAVE WITHOUT APPROVAL.
EMPLOYEE ABSENTEESIM RATE
Period N. of STAFF ABSENT WITHOUT LEAVE TOTAL NO OF STAFF EMP.ABSENTEESIM RATE
JULY 5 113 4.40
AUGUST 7 113 6.19
SEPTEMBER 3 113 2.65
Sample Size 100%
JULY AUGUST SEPTEMBER
0
1
2
3
4
5
6
7
EMP.ABSENTEEISM RATE
BENCHMARK

24. THANK YOU