Quality Indicators Oct, Nov, Dec - 2016

Time for Initial Assessment Time of Out Patients Definition: The time shall begin from the patient's arrival at the OPD till the time initial assessment (Initial assessment includes vision & ophthalmic assessment is completed Formula: Sum of time taken for the assessment Total number of patients (OPD) Unit: Minutes Remark: The average time is 30 minutes for the initial assessment of out patient in general OPD.Those taking more than 20% of the average time will be audited. The hospital will make efforts to keep this measure at low levels, and track trends in times of increased patient flow Dept: General OPD

No. of patients seen within 90 minutes in a month Definition: The time taken for a patient to be attended to by doctor starting from the patient's registration time in the clinic Formula: No. of patient seen within 90 min in a specified period *100 Total no. of patient attending OPD in the specified month Unit: % Standard: >90% of the patient are seen within 90 minutes Remark: In order to provide priority to prompt attention to patient needs by reducing waiting time for consultation at all levels in the process of care Dept: All clinics (General and Specialty)

Waiting time for cataract surgery Definition: Time measured from the day a decision is made(as advised by the care provider and agrees by the patient) on the need for the cataract surgery to the date of appointment for cataract surgery Formula: No. of patients with waiting time for cataract surgery of < 12 weeks * 100 Total no. of patients advised for cataract surgery Unit: % Remark: >75% of patient have advised for cataract surgery within 12 weeks Dept: Cataract Clinic

Rate of Infectious Endophthalmitis Definition: Intraocular inflammation judged on clinical grounds to be caused by an infectious process Formula: Total no. of patient developing post operative endophthalmitis following intraocular surgery *100 Total no. of intraocular surgeries Unit: % Standard:<0.2% (2 cases per 1000 operations) Remark: The doctor who diagnoses a case of post operative infectious endophthalmistis should report Dept: HIC committee, Cataract clinic

Rate of Infectious Endophthalmitis Month Number of surgery Number of Endophthalmitis % of Endophthalmitis Oct 2547 1 0.04% Nov 2844 0% Dec 2866 2 0.07%

Post Capsular Rupture (PCR) Definition: A breach in the posterior capsule of the lens with or without vitreous loss at any point in the performance of cataract surgery Formula: No. of cases of PCR during cataract surgery * 100 Total no. of cataract surgeries performed in the period Unit:% Standard: <5% (50 cases per 1000 operations) Remark: Doctor , who encounter posterior capsular rupture to record it Dept: Cataract

Post OP visual acuity of 6/12 or better Definition:Post op visual acuity of 6/12 or better within 3 months following cataract surgery in patient with ocular co morbidity (ECCE, SICS, Phaco) Formula:Total no. of patients with ocular co morbidity, who underwent cataract surgery in a specified month and attained visual acuity of 6/12 or better within 3 months following surgery * 100 Total no. of patients with ocular co morbidity, who underwent cataract surgery in the corresponding month Unit:% Standard: >85% (850 cases per 1000 operations) Remark: Post operative visual acuity within 3 months for each patient operated, for both best corrected visual acuity(BCVA) and unaided vision with pin hole is to be recorded Dept: Cataract clinic

Intra Op complication Definition: Complication occurred during the surgery Formula: No. of Intra OP complications in the specific period* 100 Total no. of surgeries done in that period Unit:% Remark: Complication has to be entered in the case sheet by the surgeon

Post Op complication Standard: < 3% Definition: Complications identified at Post op check Formula: No. of post OP complications in the specific period *100 Total no. of surgeries done in that specific period Unit:% Remark: Complication has to be entered in the case sheet by the doctor Standard: < 3%

Re surgeries Total no. of surgeries done in that period Definition: Any procedure performed to manage complications found during surgery or postoperatively(immediately or late, but within 6 months) and enhances the outcome of surgery Formula: No. of re surgeries in the specific period *100 Total no. of surgeries done in that period Unit:% Standard: < 0.5%

Bed occupancy rate Definition: The percentage of official beds occupied by hospital inpatients for a given period of time Formula: No. of inpatient days in a given month *100 Number of available bed days in that month Unit:% Dept: In patient wards

Average length of stay( speciality wise) Definition: To measure the duration of single episode of hospitalization Formula :No. of inpatient days (speciality wise)in a given month No. of discharges and deaths in that month Unit: Days Dept: In patient wards

% of rescheduled surgeries Definition: Rescheduling of patients includes cancellation and postponement Formula: No. of cases re scheduled *100 No. of surgeries planned Unit:% Department : Ward/OT

No. of reporting errors Definition: Number of reporting errors/1000 investigation Formula: No. of reporting errors *1000 Number of tests performed Unit: Numbers of errors Dept: Laboratory

Month No of Test Performed No of Errors % of Reporting Errors October 16488 Nil November 17398 December 16545

Rate of Re - dos Definition: This include tests repeated before release of the result (to confirm the finding) Formula: No. of Redos *100 No. of tests performed Unit:% Dept: Laboratory and radiology

Equipment downtime Definition: Downtime refers to periods when a system is unavailable/ or fails to provide or perform its primary function Formula: Sum of downtime for all critical equipment in hours in a month Unit: Minor work in Hours, Major work in Days Standard: 60 Minutes for Minor work, 8 Days for Major work Remark: Checklist of all equipment should be updated in the unit on daily basis to monitor equipment utilization and downtime Dept: Instrument department

OP satisfaction index Definition: The degree to which the patient’s expectations are fulfilled Formula: Average score achieved*100 Maximum possible score Unit:% Depart: Patient feedback department

IP satisfaction index Definition: The degree to which the patient’s expectations are fulfilled Formula: Average score achieved * 100 Maximum possible score Unit:% Depart: Patient feedback department