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Checklist of Quality Indicators for NABH accreditation

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Checklist of Quality Indicators for NABH accreditation preparatio

Quality Indicators are the backbone on which quality assurance programme of a hos
relies. NABH ( National Accreditation Board for Hospitals & Healthcare Providers..C
here to know more) accreditation expects hospitals to calculate several quality indic
and use it for monitoring the quality of care. These are the list of quality indicators
a hospital preparing for accreditation must necessarily monitor.
S.N. Indicator Formula Remark
The time taken can be

Average time taken for initial Sum of time taken for

1. assessment of patients initial assessment of all
admitted in IPD admitted patients in a
Percentage of IPD patients period / total number of
2. for whom the initial assessment patients admitted in that
was completed period
within defined timeframe (Number of patients for
Average time taken for initial whom the initial
3. assessment of patients assessment was completed
coming to emergency within a defined time
frame
/ total number of patients
admitted) x 100
Sum of time taken for
initial assessment of all
patients who accessed
emergency services in a
period / total number of
patients who accessed
emergency services in that
4. Percentage of emergency (Number of patients in Timeframe for in
patients for whom the initial emergency for whom the assessment of
initial assessment was emergency patien
 BOOK A DEMO

accreditation

editation preparation
rance programme of a hospital
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ulate several quality indicators
e list of quality indicators, which
nitor.
Remark

taken from time when

patient was registered
for admission till the
time at which initial
assessment was
completed and
documented
Timeframe for initial
assessment of patient
getting admitted must
be defined by the
hospital
The time taken can be
taken from time at
which patient arrived
at emergency
department till the
time at which initial
assessment was
completed and
Timeframe for initial
assessment of
emergency patients
 within defined timeframe time frame / total number
of patients admitted) x 100
(Number of case records in

Percentage of in-patients which plan of care with

wherein the plan of care with desired outcomes is
5. desired outcomes is documented documented and
and countersigned by the
countersigned by the clinicians clinicians / Total number of
Percentage of in-patients case records checked) x
6. wherein screening for 100
nutritional needs has been (Number of admitted
done patients who has been
7. Reporting error rates (per screened for nutritional
1000) in laboratory requirements / Total
8. Percentage of re-dos in number of patients
laboratory admitted) x 100
Percentage of lab reports (Number of lab reports in
9. co-relating with clinical which errors detected /
diagnosis Number of lab reports
checked) x 1000
(Number of lab tests which
has to be repeated in a
period/ Total lab tests
conducted in that period) x
100
(Number of lab reports in
which the diagnosis
matches with the clinical
diagnosis of the doctor /
Total lab tests conducted)
x 100
10. Percentage of adherence to (Number of observations
safety precautions by employees that indicates adherence
working in labs to safety precautions in a
period / Total number of
hospital
This can be further

broken down into

subcomponents such as
case records with
documented plan of
care, documented
desired outcomes and
countersigned
Nutritional screening
format can
be used and is required
for all admitted
patients
The error rates can be
separately calculated
for each unit of
laboratory
Only those repeat test
shall be considered in
calculation, where the
reason of repeating is
related to errors,
mistake or quality
issues
While higher
correlation shall be
expected, it may not
necessarily be 100%
Safety precautions
must be clearly defined.
Data must be gathered
through random
monitoring of
 period) x 100 staff. Most safety
precautions shall be related safety from infection,
medical waste and safety from chemicals.

11. Reporting error rates (per (Number of lab reports in

1000) in Imaging which errors detected /
Percentage of re-dos in Number of lab reports
checked) x 1000
(Number of Imaging tests
that has to be repeated in
a

12. Imaging period / Total Imaging

13.
14. Percentage of Imaging tests
reports co-relating with conducted in that period) x
clinical diagnosis 100
Percentage of adherence to (Number of Imaging
safety precautions by reports in which the
employees working in diagnosis matches with the
Imaging clinical diagnosis of the
doctor / Total Imaging
tests conducted) x 100
(Number of observations
that indicates adherence
to safety precautions in a
period / Total number of
observations made in that
period) x 100
15. Medication error rate (Number of medication
OR errors reported in a
Medication error per 1000 patient period / Total number of
days medication administration
events) x 100
OR
errors reported in a period
/
Total patient days in that
period) x 1000
(Number of patients who
suffered adverse drug
reactions in a period /
Number of admitted
16. Percentage of adverse drug patients in that period) x
100
reactions
(Number of patients
Percentage of adverse drug
developing adverse drug
reaction from high-risk
 staff. Most safety
ted safety from infection, bio-
from chemicals.

The error rates can be

separately calculated
for each imaging
modality
Only those repeat test
shall be considered in
calculation, where the

reason of repeating is
related to errors,
mistake or quality
issues
While higher
correlation shall be
expected, it may not
necessarily be 100%
Safety precautions
must be clearly defined.
Data must be gathered
through random
monitoring of practices
followed by staff. Most
safety precautions shall
be radiation safety and
infection control
For data on medication
error a strong
medication error
reporting system must
be in place.
further be divided into
various types of
medication errors, such
as administration error,
dispensing error, error
of route, error of dose
etc.
Adverse drug reaction
and medication error
shall be defined and
should not overlap with
each other
List of high-risk
medicines shall be
specified by the
hospital and any
17. reaction due to high-risk medicines in a period /
18.
medicine Number of patients given
Percentage of medical high-risk medicine in that
records with error-prone period) x 100
abbreviations (Number of medical
records which contains
error-prone abbreviations /
Number of medical records
screened) x 100

19. Percentage of modification (Number of patients in Each patient mus

of anaesthesia plan whom anaesthesia plan was undergo pre-
modified immediately anaesthesia chec
before induction of which anaesthesi
anaesthesia / Number of (type of anaesthe
patients that have and anaesthetic a
undergone anaesthesia) x is determined. An
100 change in this pla
adverse reaction
happening due to these
medicines shall be
counted for this
indicator
List of accepted
abbreviations shall be
determined by the
hospital and any
abbreviation other than
that shall be considered
as error prone
Each patient must
undergo pre-
anaesthesia check-up in
which anaesthesia plan
(type of anaesthesia
and anaesthetic agent)
is determined. Any
change in this plan
 Percentage of unplanned (Number of patients who
ventilation following required unplanned
anaesthesia ventilator support
following anaesthesia /
Number of patients who
20 were given anaesthesia) x
100
(Number of planned

21. Percentage of re-scheduling surgeries re-scheduled or scheduling for themanageme

of surgeries cancelled / Number of

Compliance rate to surgical surgeries planned) x 100
(Number of surgical
patients in which all
surgical safety practices
22. safety practices where adhered / Number
23.
Percentage of cases who of surgical patientsʼ cases
received prophylactic reviewed) x 100
antibiotic within specified (Number of surgical
time-frame patients who has received
prophylactic antibiotic /
Total number of patient
undergone surgery) x 100

24. Percentage of transfusion (Number of patients who To get data for t

reactions developed blood or blood indicator a transf
component transfusion administration fo
a modification
Unplanned ventilation is
the situation in which
patient has to be put on
the ventilator after
surgery, due to
complications resulting
from anaesthesia
This indicator can
further be classified as
per causes of re-
scheduling for themanagement to take appropriate corrective and preventive measuresFor surgical safety practices, ‘WHO surgical safety ch
materialʼ.
The compliance rate of
individual practices can
also be calculated for
detailed analysis
The hospital must
define the time-frame
for giving prophylactic
antibiotic.
The documentation of
administration of
antibiotics and the time
shall be done for
getting data
To get data for this
indicator a transfusion
administration form
 patients who underwent
blood or component
transfusion) x 100
(Units of blood and blood
components wasted or
discarded in a period /
Percentage of blood and Total units of blood and
25
blood components wasted blood components under
storage during that period)
x 100
(Total units of blood
components transfused to

26.Percentage of blood patients / Total units of The percentage s

component usage whole blood plus blood be high
Turn-around time for the components transfused to The time taken s
patients) x 100 be considered fr
Sum of time taken for the
issuing blood and blood

27. issue of blood and blood taken in each requisition / time of receipt of
28.
components Total number of requisition till the
Percentage of blood and requisition received for of dispatch of blo
blood components issued blood and blood blood component
within defined time frame component The time frame m
(Number of blood and defined by the
blood component organization
requisitions that were
issued within defined
time- frame / Total
number of requisition
received for blood and
 29. Catheter associated Urinary (Number of patients CA-UTI shall be
Tract Infection (CA-UTI) rate developing CA-UTI in a determined clinica
period / Total urinary (CDC guidelines mu
catheterization days in followed)
that period) x 1000 The catheterizati
days shallofbedays e
number
patient spent wit
urinary catheter
period of calculat
VAP shall be
determined clinic
(CDC guidelines m
be followed)
(Number of patients
The ventilator da
developing VAP in a period
30.Ventilator associated shall be calculate
/ Total ventilator days in
pneumonia (VAP) rate sum of number of
that period) x 1000
Central line catheter each patient spen
(Number of patients
ventilator in the
developing CA-BSI in a
of calculation
CA-BSI shall be
determined clinic
(CDC guidelines m
be followed)
The central line d
transfusion, which shall
have a column for
indicating reactions if
any
Blood and blood
components being
discarded because of
unfit in lab tests, shall
not be counted as
wastage. Wastage shall
be because of reasons
of expiry, errors, poor
storage conditions etc.

The percentage should

be high
The time taken shall
be considered from
the

time of receipt of
requisition till the time
of dispatch of blood or
blood component
The time frame must be
defined by the
organization
CA-UTI shall be
determined clinically
(CDC guidelines must be
followed)
The catheterization
days shallofbedays each
number
patient spent with
urinary catheter in the
period of calculation
VAP shall be
determined clinically
(CDC guidelines must
be followed)
The ventilator days
shall be calculated as
sum of number of days
each patient spent on
ventilator in the period
of calculation
CA-BSI shall be
determined clinically
(CDC guidelines must
be followed)
The central line days
31. associated blood stream period / Total central line
32.
infection (CA-BSI) rate days in that period) x 1000
Surgical site infection (SSI) (Number of patients
rate developing SSI in a
period / Total number of
clean surgeries performed
in that period) x 100

33. Gross mortality rate (Total number of deaths

happened in the hospital in a period / Total number of deaths
discharges during that period) x 100
shall be calculated as
sum of number of days
each patient spent with
central line catheter in
the period of
calculation
CA-BSI shall be
determined clinically
(CDC guidelines must be
followed)
This can be further
bifurcated in
superficial, deep and
organ/space infections
All deaths (including
deaths in emergency
and ICU) shall be
counted.
34. Net mortality rate (Total number of deaths
35. ICU specific mortality rate that happened after 48
36. Return to ICU within 48 hours hours of admission of the
Return to emergency within patient / Total number of
37. 72 hours with similar deaths and discharges
presenting complaints during that period) x 100
38. Re-intubation rate (Total number of deaths in
Percentage of research ICU patients in a period /
39. activities approved by ethics Total number of patients
committee discharged from ICU in
that period) x 100
(Number of patients who
were re-admitted to ICU
within 48 hours of being
discharged from ICU /
Total number of patients
discharged from ICU) x
100
(Number of patients who
returned to emergency
within 72 hours with
similar presenting
complaints / Total number
of patients discharged
from emergency) x 100
(Number of patients who
has to be re-intubated
after ex-tubation / Total
number of ex-tubation
done during the period) x
100
(Number of research
activities approved by
ethics committee /
Number of research
proposal submitted to
ethics committee) x 100
types of discharges
shall be considered
Deaths happening
within 48 hours of
discharge should also
be counted in
numerator
On similar lines,
condition specific or
speciality specific
deaths rates can also
be calculated
The patients who were
discharged against
medical advice from
ICU should be ignored
The patients who were
discharged against
medical advice from
emergency should be
ignored
Data on re-intubation
and ex-tubation shall be
taken from individual
medical record or a
master register
Applicable to hospital
undertaking clinical
research
40. Percentage of patients withdrawing from research
41.
42. withdrawing from clinical study / Number of patients
43. research originally enrolled in the
44. Percentage of protocol study) x 100
45.
46. violations/deviations in (Incidence of protocol
clinical research study violations/deviations
Percentage of serious events observed in clinical
in clinical research study research study / Number
reported to ethics of observations made) x
committee 100
Error rates during shift (Number of serious
hand- overs adverse events reported to
Percentage of medical error ethics committee / Number
due to of serious adverse events
wrong identification of identified) x 100
patient (Number of errors
Hand hygiene compliance detected in patient
rate handovers during shift
Compliance rate to changes / Number of hand
medication prescription in over records reviewed) x
100
capitals
(Number of medical errors
reported that happened
due to wrong identification
of patient / Total number
of medical errors
reported) x 100
(Number of observations in
which staff complied with
hand hygiene guidelines /
Total number of
observations made) x 100
(Number of prescriptions
in which medications are
written in capital letters /
Total number of
 Compliance rate to changes / Number of hand
medication prescription in over records reviewed) x
100
capitals
(Number of medical errors
reported that happened
due to wrong identification
of patient / Total number
of medical errors
reported) x 100
(Number of observations in
which staff complied with
hand hygiene guidelines /
Total number of
observations made) x 100
(Number of prescriptions
in which medications are
written in capital letters /
Total number of
47. Percentage of procurement (Value of drugs and Local purchases ar
through local purchase consumables purchased unplanned, emerge
Applicable to hospital
undertaking clinical
research
Applicable to hospital
undertaking clinical
research
Applicable to hospital
undertaking clinical
research
A handover checklist
must be available
against which errors
can be detected
A robust system of
medical
error reporting must
be in place to get
appropriate data
Hand hygiene guidelines
must be specified.
Data shall be gathered
through monitoring
Not applicable, if
prescription is
computerized
Hand hygiene guidelines
must be specified.
Data shall be gathered
through monitoring
Not applicable, if
prescription is
computerized

Local purchases are

unplanned, emergency
48. Percentage of stockouts for Total value of drugs and
49.
50. emergency drugs consumables purchased in
51. Percentage of drugs and that period) x 100
consumables rejected before (Number of emergency
preparation of goods receipt drugs on the stock-out /
note Total number of
Percentage of variation from emergency drugs) x 100
procurement process (Number of drugs and
Percentage of variations consumables rejected
observed in mock drills before preparation of
goods receipt note / Total
number of drugs and
consumables received) x
100
(Number of times standard
procurement process was
not followed / Total
number of procurements
done) x 100
(Number of variations
observed in mock drills /
Total number of
observations made) x 100
(Number of patient fall
52. Patient fall rate per 1000 reported in a period /
patient days Total
53. Hospital-associated pressure patient days in that
ulcer rate period) x 1000
(Number of patients
developing hospital
associated pressure ulcers
/ Number of bedridden
patient days) x 1000
increase the cost of
purchasing
Stock out is a situation
when the inventory level
of the medicine has
gone below the defined
minimum level
The data can be taken
through a random
sample of items that
were checked
A standard operating
process for
procurement must be in
place to calculate this
indicator
This should be
separately calculated
for different mock
drills such as code
blue, code red, code
pink, disaster handling
etc.
Patient fall must be
defined. Generally, all
kind of fall (fall from
bed, in washroom, on
stairs, while walking
etc.) must be counted
Criteria for determining
pressure ulcers shall be
specified.
Patients at risk of
developing pressure
54. Percentage of staff provided (Number of staff who
pre-exposure prophylaxis received pre-exposure
55. Bed Occupancy Rate prophylaxis / Total
56. Average Length of Stay (ALOS) healthcare staff) x 100
57. OT utilization rate (Total patient days in a
period / Total bed days
available during that
period) x 100
Sum of length of stay of
individual patients / Total
number of patients whose
length of stay has been
taken
(Total hours for which
actual surgeries were
performed in OT / Total
OT hours available) x 100
58. ICU utilization rate (Total ICU patient days in a
period / Total ICU bed days
identified
Pre-exposure
prophylaxis can be
given for different
conditions such as
Hepatitis, certain kinds
of Pneumonia etc.
Total patient days is
the sum of days spent
by each admitted
patient in hospital
Total bed days is the
product of number of
functional beds in
hospital with the
number of days in that
period
ALOS must be
separately calculated
for different disease
conditions, specialities
and ICU/Non-ICU
cases
Total hours of
surgeries can be
calculated by summing
up the 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
This is similar to
calculation bed
 100 only for ICU
A list of critical
59 Percentage of downtime of Total duration (in days or
Critical equipment hours) for which a critical
equipment was down /
Total duration (in days or
hours) in that period
Total number of nurse

60. Nurse patient ratio for wards working in a shift / Total

61. Nurse patient ratio for ICU number of patient in that
62. Out-patient satisfaction index shift
63. In-patient satisfaction index Total number of nurse
64. Average waiting time for working in ICU in a
services shift / Total number of
patient in that shift
Average rating given by
patient of OPD to the
hospital
Average rating given by
patient of IPD to the
hospital
Total waiting time of all
patients for a particular
only for ICU

equipment shall be
made.
This indicator shall be
calculated separately
for each critical
equipment
An average ratio of the
month can be taken.
This should be
separately calculated
for each shift and each
ward
An average ratio of the
month can be taken.
This should be
separately calculated
for each shift and each
ICU
A standard patient
satisfaction feedback
form can be used for
obtaining rating from
patients. Number of
feedback collected
should be statistically
significant
A standard patient
satisfaction feedback
form can be used for
obtaining rating from
patients. Number of
feedback collected
should be statistically
significant
Average waiting time
A standard patient
satisfaction feedback
form can be used for
obtaining rating from
patients. Number of
feedback collected
should be statistically
significant
Average waiting time
shall be separately
65. Average discharge time patients whose waiting
66. Employee satisfaction index time has been taken
67. Employee attrition rate Sum of time taken for
68. Employee absenteeism rate discharging patients /
69. Percentage of employee aware Total patients whose
of employee rights discharge time is taken
Percentage of sentinel Average rating given by
70. events analysed within a employee to the
defined time frame organization
(Number of employee who
resigned during a period /
Total number of employee
on roll) x 100
(Total number of
absenteeism of employee
in a period / Total
employee days) x 100
(Number of employee
aware of employee rights /
Total number of employee)
x 100
(Number of sentinel
events analysed within
defined time frame /
Number of sentinel events
reported) x 100
consultation, Billing,
Pharmacy and
diagnostics
Time taken for
discharge shall be taken
from the time when the
discharged was ordered
by the doctor till the
time when patient was
relieved from room/bed
An employee
satisfaction study must
be conducted for this.
The index can be
calculated for different
categories of employees
This should be
calculated overall as
well as category wise
Absenteeism shall be
considered as absent
without information.
This indicator shall also
be calculated category
wise
Category-wise
calculation shall be done
Timeframe and sentinel
events must be defined
71. Percentage of near misses reported / Total number of
reporting errors
errors and near-miss near misses must
reported) x 100 place
(Number of needle stick Needlestick injur

72. Needlestick injury rate injury reported / Total reporting and data
Percentage of medical patient days in that collection mechani
period) x 100 must be in place
(Number of medical Sufficient sample
records not having

73. records not having discharge summary / Total

74.
75. discharge number of medical records
76. summary screened) x 100
Percentage of medical (Number of medical
records not having ICD records not having ICD
codes codes / Total number of
Percentage of medical medical records screened)
records having incomplete x 100
and improper consent (Number of medical
Percentage of missing records having incomplete
records and improper consent /
Total number of medical
records where consent was
applicable
(Number of medical
records missing / Total
number of medical records
in MRD) x 100
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 reporting errors and
near misses must be in
place
Needlestick injury

reporting and data

collection mechanism
must be in place
Sufficient sample size

must be ensured
Sufficient sample size
must be ensured
Standard process of
informed consent must
be in place to
determine what
constitutes incomplete
or improper consent
A definition of missing
shall be available.
Generally, any 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
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