Quality measures are standards for measuring the performance of healthcare providers, systems and education institutes. Quality measures can identify important aspects like safety, effectiveness, timeliness, efficiency, patient-centeredness, and fairness.

The secretariat regularly reviews and updates key performance measures for MTIs which can be used in their quality improvement and patient safety plans.

 

Library of Measures:

CODE	HOSPITAL KPIs	FORMULA		TYPE	FREQUENCY OF REPORTING	SOURCE OF DATA	LINKS	REQUIRED SAMPLE	TARGET	RESPONSIBLE PERSON	DATA VALIDATION
IDENTIFY PATIENTS CORRECTLY
1	Patient Correct Identification Compliance Rate	No. of Compliance Instances	X100	Process	Monthly	Observation, Patient Identification Data Collection Form (Online)		104	100%
		Total Opportunities
IMPROVE EFFECTIVE COMMUNICATION
2	Verbal and telephone order awareness rate	Number of staff who answered the verbal and telephone order questions correctly	X100	Outcome	Monthly	Feedback, Effective Communication Data Collection Form (Online)		104	100%
		Total number of staff sampled
2.1	Critical Value Result Reporting Compliance Rate	Number of critical value results  documented properly in the read back form	X100	Process	Monthly	Panic/Critical Value Sheet, Lab Data, Data Collection Form (Online)		104	100%
		Total number of critical value results reported from Lab
2.2	Handover Communication Compliance Rate	Number of shift handover done correctly	X100	Process	Monthly	Medical Records, Handover Data Collection Form (Online)		104	100%
		Total number of shift sampled
IMPROVE THE SAFETY OF HIGH ALERT MEDICATION
3	High Alert Medication including LASA and Concentrated Eletrolytes storage complince Rate	Number of audit criterias fully met	X100	Process	Monthly	Observation, HAM Data Collection Form (Online)		104	100%
		Total number of audited elements
ENSURE CORRECT SITE, CORRECT-PROCEDURE, CORRECT-PATIENT SURGERY
4	Surgical Site Marking Compliance Rate	Number of surgical site markings done	X100	Process	Monthly	Observation, OT Data Collection Form (Online)		104	0%
		Total number of surgical procedures where site marking is applicable
4.1	Time Out Procedure compliance Rate	Number of time out procedures completed	X100	Process	Monthly	OT/Endoscopy/Observation Time Out Procedure Data Collection Form (Online)		104	100%
		Total number of surgical procedures
REDUCE THE RISK OF HEALTH-CARE ASSOCIATED INFECTIONS
5	Hand Hygiene Compliance Rate	No. of Hand Hygiene Compliance Instances	X100	Process	Monthly	Observation, Hand Hygiene Data Collection Form (Online)		104	90%
		Total number of opportunities observed
REDUCE THE RISK OF FALL
6	Patient Fall Risk Assessment	Number of fall assessment completed	x100	Process	Monthly	Medical Records, Inpatient Data Collection Form (Online)		104	100%
		Total number of patients sampled
6.1	Patient falls with injury Rate	No. of falls	x 1000	Outcome	Monthly	Hospital Incidents, Sum of LOS (HMIS), Inpatient Data Collection Form (Online)		104	0
		Total number of patient bed days