Quality Indicators are the backbone on which quality assurance programme of a

hospital relies. NABH accreditation expects hospitals to calculate several quality

indicators and use it for monitoring the quality of care. These are the list of quality
indicators, which a hospital preparing for accreditation must necessarily monitor.
(Also check - Performance measures for hospital business)

S.N. Indicator Formula Remark

1.         Average time taken for Sum of time taken for The time taken can be
initial assessment of initial assessment of all taken from time when
patients admitted in IPD admitted patients in a patient was registered
period / total number of for admission till the
patients admitted in that time at which initial
period assessment was
completed and
documented

2.         Percentage of IPD (Number of patients for Timeframe for initial

patients for whom the whom the initial assessment of patient
initial assessment was assessment was getting admitted must
completed within defined completed within a be defined by the
timeframe defined time frame / total hospital
number of patients
admitted) x 100

3.         Average time taken for Sum of time taken for The time taken can be
initial assessment of initial assessment of all taken from time at
patients coming to patients who accessed which patient arrived
emergency emergency services in a at emergency
period / total number of department till the
patients who accessed time at which initial
emergency services in assessment was
that period completed and
documented.

4.         Percentage of emergency (Number of patients in Timeframe for initial

patients for whom the emergency for whom the assessment of
initial assessment was initial assessment was emergency patients
completed within defined completed within a must be defined by
timeframe defined time frame / total the hospital
number of patients
admitted) x 100

5.         Percentage of in-patients (Number of case records This can be further

wherein the plan of care in which plan of care broken down into
 with desired outcomes is with desired outcomes is subcomponents such
documented and documented and as case records with
countersigned by the countersigned by the documented plan of
clinicians clinicians / Total number care, documented
of case records desired outcomes and
checked) x 100 countersigned

6.         Percentage of in-patients (Number of admitted Nutritional

wherein screening for patients who has been screening format can
nutritional needs has screened for nutritional be used and is
been done requirements / Total required for all
number of patients admitted patients
admitted) x 100

7.         Reporting error rates (per (Number of lab reports in The error rates can be
1000) in laboratory which errors detected / separately calculated
Number of lab reports for each unit of
checked) x 1000 laboratory

8.         Percentage of re-dos in (Number of lab tests Only those repeat test
laboratory which has to be shall be considered in
repeated in a period/ calculation, where the
Total lab tests reason of repeating is
conducted in that period) related to errors,
x 100 mistake or quality
issues

9.         Percentage of lab reports (Number of lab reports in While higher

co-relating with clinical which the diagnosis correlation shall be
diagnosis matches with the clinical expected, it may not
diagnosis of the doctor / necessarily be 100%
Total lab tests
conducted) x 100

10.     Percentage of adherence (Number of observations Safety precautions

to safety precautions by that indicates adherence must be clearly
employees working in labs to safety precautions in defined. Data must be
a period / Total number gathered through
of observations made in random monitoring of
that period) x 100 practices followed by
staff. Most safety
precautions shall be
related safety from
infection, bio-medical
 waste and safety from
chemicals.

11.     Reporting error rates (per (Number of lab reports in The error rates can be
1000) in Imaging which errors detected / separately calculated
Number of lab reports for each imaging
checked) x 1000 modality

12.     Percentage of re-dos in (Number of Imaging Only those repeat test

Imaging tests that has to be shall be considered in
repeated in a period / calculation, where the
Total Imaging tests reason of repeating is
conducted in that period) related to errors,
x 100 mistake or quality
issues
13.     Percentage of Imaging (Number of Imaging While higher
reports co-relating with reports in which the correlation shall be
clinical diagnosis diagnosis matches with expected, it may not
the clinical diagnosis of necessarily be 100%
the doctor / Total
Imaging tests
conducted) x 100

14.     Percentage of adherence (Number of observations Safety precautions

to safety precautions by that indicates adherence must be clearly
employees working in to safety precautions in defined. Data must be
Imaging a period / Total number gathered through
of observations made in random monitoring of
that period) x 100 practices followed by
staff. Most safety
precautions shall be
radiation safety and
infection control

15.     Medication error rate (Number of medication For data on

OR errors reported in a medication error a
Medication error per 1000 period / Total number of strong medication
patient days medication error reporting system
administration events) x must be in place.
100
OR This indicator can
(Number of medication further be divided into
errors reported in a various types of
period / Total patient medication errors,
 days in that period) x such as administration
1000 error, dispensing
error, error of route,
error of dose etc.

16.     Percentage of adverse (Number of patients who Adverse drug reaction

drug reactions suffered adverse drug and medication error
reactions in a period / shall be defined and
Number of admitted should not overlap
patients in that period) x with each other
100
17.     Percentage of adverse (Number of patients List of high-risk
drug reaction due to high- developing adverse drug medicines shall be
risk medicine reaction from high-risk specified by the
medicines in a period / hospital and any
Number of patients adverse reaction
given high-risk medicine happening due to
in that period) x 100 these medicines shall
be counted for this
indicator

18.     Percentage of medical (Number of medical List of accepted

records with error-prone records which contains abbreviations shall be
abbreviations error-prone determined by the
abbreviations / Number hospital and any
of medical records abbreviation other
screened) x 100 than that shall be
considered as error
prone

19.     Percentage of (Number of patients in Each patient must

modification of whom anaesthesia plan undergo pre-
anaesthesia plan was modified anaesthesia check-up
immediately before in which anaesthesia
induction of plan (type of
anaesthesia / Number of anaesthesia and
patients that have anaesthetic agent) is
undergone anaesthesia) determined. Any
x 100 change in this plan
shall be considered as
a modification

20.     Percentage of unplanned (Number of patients who Unplanned ventilation

ventilation following required unplanned is the situation in
 anaesthesia ventilator support which patient has to
following anaesthesia / be put on the
Number of patients who ventilator after
were given anaesthesia) surgery, due to
x 100 complications
resulting from
anaesthesia

21.     Percentage of re- (Number of planned This indicator can

scheduling of surgeries surgeries re-scheduled further be classified as
or cancelled / Number of per causes of re-
surgeries planned) x 100 scheduling for the
management to take
appropriate corrective
and preventive
measures

22.     Compliance rate to (Number of surgical For surgical safety

surgical safety practices patients in which all practices, ‘WHO
surgical safety practices surgical safety
where adhered / Number checklist can serve
of surgical patients’ as a good reference
cases reviewed) x 100 material’.

The compliance rate

of individual practices
can also be calculated
for detailed analysis

23.     Percentage of cases who (Number of surgical The hospital must

received prophylactic patients who has define the time-frame
antibiotic within specified received prophylactic for giving prophylactic
time-frame antibiotic / Total number antibiotic.
of patient undergone The documentation of
surgery) x 100 administration of
antibiotics and the
time shall be done for
getting data

24.     Percentage of transfusion (Number of patients who To get data for this
reactions developed blood or indicator a transfusion
blood component administration form
transfusion reaction / must be filled for each
Number of patients who transfusion, which
 underwent blood or shall have a column
component transfusion) for indicating reactions
x 100 if any

25.     Percentage of blood and (Units of blood and Blood and blood
blood components wasted blood components components being
wasted or discarded in a discarded because of
period / Total units of unfit in lab tests, shall
blood and blood not be counted as
components under wastage. Wastage
storage during that shall be because of
period) x 100 reasons of expiry,
errors, poor storage
conditions etc.

26.     Percentage of blood (Total units of blood The percentage

component usage components transfused should be high
to patients / Total units
of whole blood plus
blood components
transfused to patients) x
100

27.     Turn-around time for the Sum of time taken for The time taken shall
issue of blood and blood issuing blood and blood be considered from
components taken in each the time of receipt of
requisition / Total requisition till the time
number of requisition of dispatch of blood or
received for blood and blood component
blood component
28.     Percentage of blood and (Number of blood and The time frame must
blood components issued blood component be defined by the
within defined time frame requisitions that were organization
issued within defined
time-frame / Total
number of requisition
received for blood and
blood component) x 100

29.     Catheter associated (Number of patients CA-UTI shall be

Urinary Tract Infection developing CA-UTI in a determined clinically
(CA-UTI) rate period / Total urinary (CDC guidelines must
catheterization days in be followed)
that period) x 1000 The catheterization
 days shall be
calculated as sum of
number of days each
patient spent with
urinary catheter in the
period of calculation

30.     Ventilator associated (Number of patients VAP shall be

pneumonia (VAP) rate developing VAP in a determined clinically
period / Total ventilator (CDC guidelines must
days in that period) x be followed)
1000 The ventilator days
shall be calculated as
sum of number of
days each patient
spent on ventilator in
the period of
calculation

31.     Central line catheter (Number of patients CA-BSI shall be

associated blood stream developing CA-BSI in a determined clinically
infection (CA-BSI) rate period / Total central line (CDC guidelines must
days in that period) x be followed)
1000 The central line days
shall be calculated as
sum of number of
days each patient
spent with central line
catheter in the period
of calculation

32.     Surgical site infection (Number of patients CA-BSI shall be

(SSI) rate developing SSI in a determined clinically
period / Total number of (CDC guidelines must
clean surgeries be followed)
performed in that period) This can be further
x 100 bifurcated in
superficial, deep and
organ/space infections
due to surgeries

33.     Gross mortality rate (Total number of deaths All deaths (including
happened in the hospital deaths in emergency
in a period / Total and ICU) shall be
 number of deaths counted.
discharges during that In denominator all
period) x 100 types of discharges
shall be considered

34.     Net mortality rate (Total number of deaths Deaths happening

that happened after 48 within 48 hours of
hours of admission of discharge should also
the patient / Total be counted in
number of deaths and numerator
discharges during that
period) x 100

35.     ICU specific mortality rate (Total number of deaths On similar lines,
in ICU patients in a  condition specific or
period / Total number of speciality specific
patients discharged from deaths rates can also
ICU in that period) x 100 be calculated

36.     Return to ICU within 48 (Number of patients who The patients who
hours were re-admitted to ICU were discharged
within 48 hours of being against medical
discharged from ICU / advice from ICU
Total number of patients should be ignored
discharged from ICU) x
100

37.     Return to emergency (Number of patients who The patients who

within 72 hours with returned to emergency were discharged
similar presenting within 72 hours with against medical
complaints similar presenting advice from
complaints / Total emergency should be
number of patients ignored
discharged from
emergency) x 100

38.     Re-intubation rate (Number of patients who Data on re-intubation

has to be re-intubated and ex-tubation shall
after ex-tubation / Total be taken from
number of ex-tubation individual medical
done during the period) record or a master
x 100 register

39.     Percentage of research (Number of research Applicable to hospital

activities approved by activities approved by undertaking clinical
 ethics committee ethics committee / research
Number of research
proposal submitted to
ethics committee) x 100

40.     Percentage of patients (Number of patients Applicable to hospital

withdrawing from clinical withdrawing from undertaking clinical
research research study / Number research
of patients originally
enrolled in the study) x
100

41.     Percentage of protocol (Incidence of protocol Applicable to hospital

violations/deviations in violations/deviations undertaking clinical
clinical research study observed in clinical research
research study / Number
of observations made) x
100

42.     Percentage of serious (Number of serious Applicable to hospital

events in clinical research adverse events reported undertaking clinical
study reported to ethics to ethics committee / research
committee Number of serious
adverse events
identified) x 100

43.     Error rates during shift (Number of errors A handover checklist

hand-overs detected in patient must be available
handovers during shift against which errors
changes / Number of can be detected
hand over records
reviewed) x 100

44.     Percentage of medical (Number of medical A robust system

error due to errors reported that of medical
wrong identification of happened due to wrong error reporting must
patient identification of patient / be in place to get
Total number of medical appropriate data
errors reported) x 100

45.     Hand hygiene compliance (Number of observations Hand hygiene

rate in which staff complied guidelines must be
with hand hygiene specified.
guidelines / Total Data shall be
number of observations gathered through
 made) x 100 monitoring

46.     Compliance rate to (Number of prescriptions Not applicable, if

medication prescription in in which medications are prescription is
capitals written in capital letters / computerized
Total number of
prescriptions checked) x
100

47.     Percentage of (Value of drugs and Local purchases are

procurement through local consumables purchased unplanned,
purchase through local purchase / emergency purchases
Total value of drugs and which increase the
consumables purchased cost of purchasing
in that period) x 100

48.     Percentage of stockouts (Number of emergency Stock out is a situation

for emergency drugs drugs on the stock-out / when the inventory
Total number of level of the medicine
emergency drugs) x 100 has gone below the
defined minimum level

49.     Percentage of drugs and (Number of drugs and The data can be taken
consumables rejected consumables rejected through a random
before preparation of before preparation of sample of items that
goods receipt note goods receipt note / were checked
Total number of drugs
and consumables
received) x 100

50.     Percentage of variation (Number of times A standard operating

from procurement process standard procurement process for
process was not procurement must be
followed / Total number in place to calculate
of procurements done) x this indicator
100

51.     Percentage of variations (Number of variations This should be

observed in mock drills observed in mock drills / separately calculated
Total number of for different mock
observations made) x drills such as code
100 blue, code red, code
pink, disaster
handling etc.
52.     Patient fall rate per 1000 (Number of patient fall Patient fall must be
patient days reported in a period / defined. Generally, all
Total patient days in that kind of fall (fall from
period) x 1000 bed, in washroom, on
stairs, while walking
etc.) must be counted

53.     Hospital-associated (Number of patients Criteria for

pressure ulcer rate developing hospital determining pressure
associated pressure ulcers shall be
ulcers / Number of specified.
bedridden patient days) Patients at risk of
x 1000 developing pressure
ulcers must be
identified

54.     Percentage of staff (Number of staff who Pre-exposure

provided pre-exposure received pre-exposure prophylaxis can be
prophylaxis prophylaxis / Total given for different
healthcare staff) x 100 conditions such as
Hepatitis, certain
kinds of Pneumonia
etc.

55.     Bed Occupancy Rate (Total patient days in a Total patient days is
period / Total bed days the sum of days spent
available during that by each admitted
period) x 100 patient in hospital
Total bed days is the
product of number of
functional beds in
hospital with the
number of days in that
period

56.     Average Length of Stay Sum of length of stay of ALOS must be

(ALOS) individual patients / Total separately calculated
number of patients for different disease
whose length of stay has conditions, specialities
been taken and ICU/Non-ICU
cases

57.     OT utilization rate (Total hours for which Total hours of

actual surgeries were surgeries can be
performed in OT / Total calculated by
 OT hours available) x summing up the
100 duration of each
surgeries performed in
the period

Total OT hours can be

calculated by
multiplying functional
hours available for
each OT with the
number of OT

58.     ICU utilization rate (Total ICU patient days This is similar to
in a period / Total ICU calculation bed
bed days available in occupancy rate, but
that period) x 100 only for ICU

59.     Percentage of downtime Total duration (in days or A list of critical

of Critical equipment hours) for which a critical equipment shall be
equipment was down / made.
Total duration (in days or This indicator shall be
hours) in that period calculated separately
for each critical
equipment

60.     Nurse patient ratio for Total number of nurse An average ratio of
wards working in a shift / Total the month can be
number of patient in that taken. This should be
shift separately calculated
for each shift and
each ward

61.     Nurse patient ratio for ICU Total number of nurse An average ratio of
working in ICU in a shift / the month can be
Total number of patient taken. This should be
in that shift separately calculated
for each shift and
each ICU

62.     Out-patient satisfaction Average rating given by A standard patient

index patient of OPD to the satisfaction
hospital feedback form can
be used for obtaining
rating from patients.
Number of feedback
 collected should be
statistically significant

63.     In-patient satisfaction Average rating given by A standard patient

index patient of IPD to the satisfaction
hospital feedback form can
be used for
obtaining rating from
patients. Number of
feedback collected
should be statistically
significant

64.     Average waiting time for Total waiting time of all Average waiting time
services patients for a particular shall be separately
service / Total number of calculated for OPD
patients whose waiting consultation, Billing,
time has been taken Pharmacy and
diagnostics

65.     Average discharge time Sum of time taken for Time taken for
discharging patients / discharge shall be
Total patients whose taken from the time
discharge time is taken when the discharged
was ordered by the
doctor till the time
when patient was
relieved from
room/bed

66.     Employee satisfaction Average rating given by An employee

index employee to the satisfaction study
organization must be conducted for
this.
The index can be
calculated for different
categories of
employees

67.     Employee attrition rate (Number of employee This should be

who resigned during a calculated overall as
period / Total number of well as category wise
employee on roll) x 100

68.     Employee absenteeism (Total number of Absenteeism shall be

 rate absenteeism of considered as absent
employee in a period / without information.
Total employee days) x
100 This indicator shall
also be calculated
category wise

69.     Percentage of employee (Number of  employee Category-wise

aware of employee rights aware of employee calculation shall be
rights / Total number of done
employee) x 100

70.     Percentage of sentinel (Number of sentinel Timeframe and

events analysed within a events analysed within sentinel events must
defined time frame defined time frame / be defined
Number of sentinel
events reported) x 100

71.     Percentage of near (Number of near misses A robust system of

misses reported / Total number reporting errors and
of errors and near-miss near misses must be
reported) x 100 in place

72.     Needlestick injury rate (Number of needle stick Needlestick injury

injury reported / Total reporting and data
patient days in that collection mechanism
period) x 100 must be in place

73.     Percentage of medical (Number of medical Sufficient sample size

records not having records not having must be ensured
discharge summary discharge summary /
Total number of medical
records screened) x 100

74.     Percentage of medical (Number of medical Sufficient sample size

records not having ICD records not having ICD must be ensured
codes codes / Total number of
medical records
screened) x 100

75.     Percentage of medical (Number of medical Standard process of

records having incomplete records having informed consent
and improper consent incomplete and improper must be in place to
consent / Total number determine what
of medical records constitutes incomplete
 where consent was or improper consent
applicable
76.     Percentage of missing (Number of medical A definition of missing
records records missing / Total shall be available.
number of medical Generally, any
records in MRD) x 100 medical record which
has been able to be
traced for last 3 days
shall be considered
missing. In case, a
missing record has
been found it shall be
removed from the
missing data