1. Quality Indicators Oct, Nov, Dec - 2016

2. 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

4. 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)

6. 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

8. 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

9. 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%

10. 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

12. 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

14. 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

16. 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%

18. 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%

20. 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

22. 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

24. % 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

26. 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

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

28. 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

30. 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

32. 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

36. 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