Final Hospital Quality Indicators

Ministry Of Health and population
Minister Office Sector

General Directorate Of Quality
List of Indicators
Indicator Purpose Target

1 Inpatient Volume Confirms patient demand More than prior year
2 Outpatient Volume Confirms patient demand More than prior year
Operational efficiency More than 3:1 & annual
3 Outpatient/Inpatient Ratio
improvement
4A Gross unadjusted inpatient mortality rate Quality of Care Less than 2%
4B ICUs mortality rate Quality of Care
Gross unadjusted mortality(within 24 Quality of Care
4C
hours of admission) rate
4D NICU mortality rate Quality of Care
4E Mortality rate by clinical departments Quality of Care Vary by specialty
5A Hospital acquired infection rate Quality of Care Less than 5%
5B Surgery acquired infection rate Quality of Care Less than 5%
Readmission rate for inpatient within 30 Quality of Care Less than 2%
6
days
Readmission rate for emergency patients Quality of Care Less than 2%
7
within 72 hours
8 Average length of stay (ALOS) Operational efficiency Annual improvement
Operational efficiency Annual improvement
with a reduction in beds
9A Bed Occupancy rate (inpatient)
if below a specified level
(to be > 75%)
9B Bed Occupancy rate (ICUs) Annual improvement
Financial management Actual expenditures
10 Budget execution
within approved budget
Hospital Quality Indicators Profile
For Hospital Performance Targets
Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258
1
Measure ID: Quality Measure Department(s) included: Purpose :

Name: Confirms patient
(1) Inpatient volume All inpatient wards demand
Rationale: It is an indicator for utilization of Type of Measure:

services Provided by the hospital and also confirms Process
patients demand
Nominator Statement: Data Source: daily inpatient

census ( Admission office )
Included population : all patients admitted to the Excluded population:

hospital for more than 24 hour through emergency or Patients admitted less than 24
outpatient clinics hours
Patients admitted directly to ICUs
Denominator Statement Data Source
Included population Excluded population:
Target : Data reported as: Frequency of measurement:

More than prior year numerical value Monthly
 Inpatient definition: all patients admitted to the hospital department for more
than 24hours excluding patients admitted directly to ICUs or patients admitted
less than 24hours
2
Measure ID: Quality Measure Department(s) Purpose :

Name: included: Confirms patient
(2) Outpatient all outpatients demand
volume clinics
Rationale: It is an indicator of utilization of out Type of Measure:
patient clinics services provided by the hospital and Process
also confirms patient demands
Nominator Statement: number of patient visited Data Source: outpatient census
the outpatient clinics through a certain period of
time
Whether admitted or discharged
Included population : all patient visited the Excluded population

outpatient clinics through a certain period of time
Whether admitted or discharged
Denominator Statement Data Source

More than prior Year Numerical value Monthly
3
Measure ID: Quality Measure Department(s) Purpose :

Name: included: Operational efficiency
(3) Ratio of outpatients / All inpatients wards
inpatients Medical records
 all outpatients clinics
Rationale: it is an indicator for operational efficiency of Type of Measure:
the hospital process
Nominator Statement: No of patients received Data Source:

outpatients services  Daily outpatient census
Included population: Excluded population :

 All patients visited the outpatient clinics through a Emergency care
certain period of time.
Denominator Statement : Data Source :
No of inpatient census - admission office for inpatient
Included population : Excluded population:

 All patients admitted to the hospital for more than -ICU Patients
24 hours through emergency and outpatient clinics -Patients admitted less than 24
through the same period of time hours
Target :More than 3 : 1 & Data reported as: Frequency of measurement:
annual improvement Ratio Monthly
4
Measure Quality Measure Department(s) included: Purpose :

ID: Name: All inpatient departments Quality of care
(4 A) inpatient mortality
rate
Rationale: measuring effectiveness and efficiency Type of Measure:
of care provided by the hospital This is one of the
outcome measures. outcome
Nominator Statement: Data Source:

Number of Deaths within hospital inpatient census Mortality log book
Included population : Excluded population :
All Deaths in inpatient departments including -Mortality of patients who were
those inpatients who were transferred to ICU directly admitted to ICU.
within 48 hours before death. -Inpatients deaths that stays in
ICU<48 hours
-Deaths in Emergency
-inpatient deaths in less than 24
hours
Denominator Statement : Data Source :discharge register

Total Number of discharged patients (including (discharge office)
the deaths) -Mortality log book

-Inpatients staying in ICU>48
inpatients discharged including the deaths hours
-Emergency patients.
- Patients who were
directly admitted to ICU.

less than 2% Proportion Monthly
5

ID: Name: ICU departments Quality of care
(4 B) ICU mortality rate
of care provided by the hospital especially in
ICUs.This is one of the outcome measures. outcome

Number of Deaths within ICUs patient census Mortality log book
All Deaths in ICUs (medical coronary&
surgical) including those inpatients who were -Inpatients deaths that stays in
transferred to ICU for more than 48 hours before ICU less than 48 hours
death and patients admitted directly to ICUs. -patients admitted directly to
ICU and died within 24 hours
Total Number of ICUs discharged patients (discharge office)
(including the deaths)

all ICUs patients census -Inpatients staying in ICU less
than 48 Hours

6

ID: Name: All departments Quality of care
(4 C) Gross unadjusted
mortality(within
24 hours of
admission) rate
of care provided by the hospital especially in day
cases services (cases admitted for less than 24 outcome
hours services whether for surgical or medical
reasons) This is one of the outcome measures.

Number of Deaths within 24hours including day Mortality log book
cases patient census
All day cases Deaths in all departments - inpatient deaths who were
-deaths within 24 hours in all departments admitted and stayed more than
24 hour.
-ICUs deaths within 24hours
Denominator Statement : Data Source :discharge
Total Number of discharged patients within register
24hours (discharge office)

all cases discharged within 24hours including - Patients discharged after more
deaths than 24 hours stay
-ICUs discharged patients
7

ID: Name: ICU departments Quality of care
(4 D) NICU mortality
rate
of care provided by the hospital specially in
NICUs.this is one of the outcome measures. outcome

Number of Deaths within NICUs patient census Mortality log book
All Deaths in NICU departments including Patients admitted directly to
those inpatients who were transferred to ICU for NICU and died within 24 hours
more than 48 hours before death and patients
admitted directly to NICUs.

Total Number of NICUs discharged patients (discharge office)
(including the deaths)

all NICUs discharged patients census Patients admitted directly to
NICU and died within 24 hours
Proportion Monthly
8
Measure Quality Measure Department(s) Purpose :

ID: Name: included: Quality of care
Mortality rate by Clinical inpatient
(E 4) clinical departments
departments
Rationale: Type of Measure:

To initiate patient safety improvement efforts
because patients are at greater risk for health care-
associated specially if they stay longer duration time Outcome
at hospital ( the common wealth Fund, 2004 )

Number of patients who died in each clinical inpatients records
department separately during their stay for more (admission office)
than 24 hours
Included population : Excluded population

patients who died in each clinical department ICUs deaths and inpatient
separately during their stay for more than 24 hours deaths less than 24hours

Total number of patients discharged from each Discharge office
clinical department separately (including the deaths)
Target: Data reported as: Frequency of measurement:

Vary by specialty Proportion Monthly
9

ID: Name: All hospital clinical Quality of care
(5 A) Hospital acquired departments
infection rate
nosocomical infection is clinically evident
infections that do not originate from patient
original admitting diagnosis and become outcome
clinically evident after 48 hours of hospitalization.
this may range from minor insignificant to
considerable inflammation. Prolonged
hospitalization are then required giving high cost &
harm to patients which affects the quality of care.
It’s of great importance to reduce the incidence of
such adverse events.
Nominator Statement: total number of infection Data Source:

episodes/patient in all clinical departments including  IC data sheets
ICUs in a period of time (monthly)  IC committee
(episodes: one single site of infection)
Included population : all patient received inpatient Excluded population
service and acquired infection (by episode)after 48
hours of hospitalization
Denominator Statement : Total number of patient Data Source :

discharged from inpatient and ICUs within the same Discharge office
period of time (monthly)
Included population : all discharged patients Excluded population:

received inpatient and ICUs services (including
deaths of both inpatient and ICUs)
Less than 5% proportion Monthly

10

Measure Quality Measure Department(s) Purpose ;
(5 B) Surgery acquired Surgical wards
infection rate
(SSI)
Rationale: the occurrence of the a wound Type of Measure:
infection can have clinical consequences that
range from minor insignificant inflammation to
considerable pain and suffering wound
disruption, septicemia and even death Re-
operation and prolonged hospitalization are Outcome
often required. The incidence of wound infection
can be reduced by proper/pre, and pot-operative
care, in particular strict hygiene. It is long
known that hospital staff tends to neglect simple
measures like hand washing and use of
disinfectants
Given the high cost of hospital care is of great
importance to reduce the incidence of such
adverse events ( Millar and Mattake.2004)

Number of infected patients wound after surgical Infection control data sheets
operation done in the same hospital ( SSI data sheet )
-IC committee
Patients undergoing operation in the hospital and -Outpatients/procedures
acquired infections (during hospitalization and if -potentially infected surgery
readmitted with SSI within 30 days of discharge) eg: wet gangrene……etc

Total number of surgical operations. -OR log book
All surgical operations done in the hospital. Outpatients procedures
potentially infected surgery
eg: wet gangrene……etc
Less than 5% Proportion Monthly
11

(6) Readmission rate All medical departments
for- inpatients
within 30 days
Hospital readmission within as short time of Process
discharge is an important performance measure for
patient care.
Number of patients who were readmitted to the same Admission office
hospital within 30 days of discharge for the same ( information management
medical reason in a certain period of time. center )

Patients discharged to home care or self care ( routine  Patients discharged
discharge ) and readmitted within 30 days for the against medical advice
same medical reason that prompted the original  Patients
hospitalization discharged/transferred to
another facility for inpatient
care

Total number of patients discharged of the hospital Discharge office
During the month (including deaths.)

12

ID: Name:Readmission included:
(7) rate for emergency Emergency Room Quality of care
patients within 72 (ER)
hours
Rationale: Unscheduled return to the emergency Type of Measure:

department within 72 hours of discharge is expected
to be influenced by How the health care system is
organized.
Specifically around the use of the emergency Process
department as a portal into the health care system .It
is also a critical indicator capable of pointing
towards mishaps due to previous hospitalization
episodes, thus triggering the analysis of retracing
processes to understand the appropriateness of the
care and discharge planning.

Number of patients returned back to ER within 72 ER records
hours of leaving the ER.

Cases that received care at ER and returned back to -If the first visit was done in
ER within 72 hours for reason related to the same other hospital
condition. -If the second visit was due to
other diagnosis or not related
to the first diagnosis.

Number of patients discharged from ER ER records
Included population: Excluded population:

All cases who received ambulatory care at ER Cases attended ER and need
hospital admission
13

ID: Name: included:
(8) Average length of All inpatient wards Operational efficiency
stay ( ALOS )

Length-of-stay (LOS) is a widely used indicator of
hospital performance. Most commonly, it is viewed Process
as an indicator of hospital efficiency and as a
surrogate measure for costs.

Inpatient days of care ( sum of daily inpatient Daily inpatient census
census over the period of stay ) ( Inpatient registers at
admission office )
Patients admitted to inpatient -Patient discharged/or died
within 24 hours of admission
- (ICU, CCU, NICU) patients.
-patient discharged against
medical advice
Total number of discharged patients (including Discharge Office
deaths)
.
All discharged patients. (including deaths) -Patient discharged/or died
within 24 hours of admission
- (ICU, CCU, NICU) patients.
-patient discharged against
medical advice
Annual Improvement Average Monthly
14

ID: Name: included: Operational efficiency
(9 A) Bed Occupancy All inpatient wards
rate (inpatient)

It an indicator of hospital performance that
measures the degree to which hospital beds is full.
Currently, the bed occupancy rate is used as Outcome
indicator for utilization of the services .
However, many of the health facilities provide
outpatient Department services and emergency care,
not affecting the bed occupancy. ( WHO, 2006 )
Inpatient days of care ( sum of daily inpatient Daily inpatient census
census over the period of stay ) ( inpatient registers at
admission office )
Included population : Excluded population ;
Patients admitted to inpatient

Beds available ( Bed available x 30 or 31 ) Hospital record
Target: Annual Data reported as: Frequency of measurement:

improvement proportion Monthly
15

ID: Name: included: Operational efficiency
(9 B) Bed Occupancy All (ICUs)
rate (ICUs)

It an indicator of hospital performance that
measures the degree to which hospital beds is full.
Currently, the bed occupancy rate is used as Outcome
indicator for utilization of the services.
However, many of the health facilities provide
outpatient Department services and emergency care,
not affecting the bed occupancy. ( WHO, 2006 )
Inpatient days of care in ICU,CCU&NICU ( sum of Daily ICUs patients census
daily ICUs patients census over the period of stay ) (admission office )
Included population : Excluded population ;

Patients admitted in ICUs (ICU,CCU,NICU)
Beds available in ICUs ( Bed available x 30 or 31 ) Hospital record
Target: Annual Data reported as: Frequency of measurement:

improvement proportion Monthly
16

ID: Name: included: Financial management
(10) Budget execution financial department
Rationale: it’s an indicator to measure the Type of Measure:
Effectiveness of the hospital management
( Financial management ) Outcome
Nominator Statement: Data Source: the actual

actual expended budget expenditure budget
(financial department)
Included population : Excluded population
Denominator Statement : Approved budget Data Source :

The approved budget
(financial department)
Target: actual Data reported as: Frequency of measurement:

expenditure within
approved budget Proportion Monthly
17
Mortality review form in clinical departments and ICUS
Patient No. 1 2 3 4 5
Patient
name
age
Sex
Medical file
No
Date of
admission
Date of
death
Diagnosis
upon
admission
Clinical
wards
(mention)
ICUS
(mention)
Risk factor
Myocardial
infarction
Heart failure
angina
Arrhythmia
COPD
Pulmonary
embolism
Cerebral
stroke
Cancer
Renal failure
Liver failure
Diabetes
mellitus
Hyper
tension
anemia
trauma
smoking
surgery
Risk factor : Diseases that enhance mortality rate Yes :-( ) No :-( )
rate
ICUs : ICU – CCU – NICU
Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258 Email : gdq98_eg@yahoo.com
21
Mortality review form in NICUS and Maternal department
Patient No. 1 2 3 4 5
Patient name
age
Sex
Medical file No
Date of
admission
Date of death
Diagnosis upon
admission
Clinical wards
(mention)
ICUS(mention)
Risk factor in
NICU
Gestational age
less than 24w
Gestational
age24-28 w
Congenital
abnormalities
surgery
infection
Hypoxia
ischemia
encephalopathy
Small gestation
age
Birth trauma
Risk factors in
maternal
departments
Hemorrhagic
shock
D.I.C
Placenta
abnormalities
Gestational
hypertension
Maternal age
above 35 y
Risk factor: Diseases that enhance mortality rate Yes :-( ) No :-( )
22
Surveillance for infected cases sheet

Diagnosis upon admission:
Patient's MR: Place:

Patient’s Name: Date of admission:
1. Laboratory:
Sample sent: Urine Sputum Wound Blood Stool
Culture result:
2. Clinical rounds:
Especially ICU, CCU, dialysis. Endoscopies, clinical wards
History Diabetic CRF Cancer
Fever: Onset …………day from admission.
Associated chills Chest symptoms Urinary symptoms

with rash swelling GIT symptoms
FUO LN pain
Localized redness ,hotness
Antibiotic increased changed
If Surgery: Date of surgery ……………
Dressing done by physician Nurse
Frequency of dressing: ……………. / day
Wound oozing Delayed healing

Drains Purulent discharge
3. Readmitted case:
Time of 1st admission … Time of 1st discharge …
Time of 2-nd discharge …
Presented by
Fever wound ooze SSI Unhealed wound

23
Policy for Surveillance for infected cases

Definition:
Nosocomial infection is the infection that were not existing (Or wasn't clinically)
evident) at the time of admission.
Methods of detecting Nosocomial infection in the hospital ( source of data)
1.1- Samples referred for cultures to the lab.

2. 2- Clinical rounds with physicians & nurses of departments
Esp. ICU, CCU, dialysis, endoscopies, clinical wards
 Ask about new symptoms or signs of infection:
Fever with chills
Fever with chest symptoms
Fever with GIT symptoms
Fever with Urinary tract symptoms
Fever with Rash
Fever with Swellings, LNs.
 Fever of unknown origin >/ two weeks
 Include & follow up of these cases
 Ask for lab culture & sensitivity
 If C/S results was positive it has to be included in the report
 Add to surgical cases, ask about wound dressing
 Who dose the dressing
 Frequency of dressing
 Any oozing
 Delayed healing
 Drains.
 Include & follow up All diabetic patients with fever ,diabetic foot
3. Readmitted cases (within 7 days, 30 days) for:
 Fever
 SSI ( surgical site infection )
24
List of Indicators
Month Month Month Month Month Month

Indicator
( ) ( ) ( ) ( ) ( ) ( )
1 Inpatient Volume
2 Outpatient Volume
3 Outpatient/Inpatient Ratio
4A Gross unadjusted mortality rate
4B ICUs mortality rate
Gross unadjusted mortality(within 24
4C
hours of admission) rate
4D NICU mortality rate
4E Mortality rate by clinical departments
5A Hospital acquired infection rate
5B Surgery acquired infection rate
Readmission rate for inpatient within
6
30 days
Readmission rate for emergency
7
patients within 72 hours
8 Average length of stay (days)
9A Occupancy rate (inpatient)
9B Occupancy rate (ICUs)
10 Budget execution
25
Indicators glossary
Inpatient:
all patients admitted to the hospital for more than 24 hour through emergency or outpatient clinics
excluding:
- Patients admitted less than 24 hours And Patients admitted directly to ICUs.
Outpatient:
all patient visited the outpatient clinics through a certain period of time
Whether admitted or discharged.
Inpatient mortality:
All Deaths in inpatient departments including those inpatients who were transferred to ICU within 48
hours before death. excluding :
-Mortality of patients who were directly admitted to ICU.
-Inpatients deaths that stays in ICU<48 hours
-Deaths in Emergency
-inpatient deaths in less than 24 hours
Discharged patients:
Total Number of discharged patients (including the deaths)
(this definition is applicable for any discharge like inpatient,ICUs,NICU,……)
Nosocomical infection:
is clinically evident infections that do not originate from patient original admitting diagnosis and
become clinically evident after 48 hours of hospitalization. (all patient received inpatient service and
acquired infection (by episode)after 48 hours of hospitalization)
Infection episodes:
one single site of infection in the same patient
Readmitted patients to inpatient within 30days:

Patients discharged to home care or self care ( routine discharge ) and readmitted within 30 days for
the same medical reason that prompted the original hospitalization excluding:
 Patients discharged against medical advice
 Patients discharged/transferred to another facility for inpatient care
Departments mortality:
patients who died in each clinical department separately during their stay for more than 24 hours
Excluding:
- ICUs deaths and inpatient deaths less than 24hours
Inpatient days of care:

summation of daily inpatient census over the period of stay .
26
ICUs days of care:

Inpatient days of care in ICU,CCU&NICU ( summation of daily ICUs patients census over the period
of stay ).
Inpatient Beds available: total number of Beds available in inpatient .
ICUs Beds available: total number of Beds available in ICUs
ICUs mortality: All deaths in ICUs (medical coronary& surgical) including those inpatients who were
transferred to ICU for more than 48 hours before death and patients admitted directly to ICUs.
Excluding:
-Inpatients deaths that stays in ICU less than 48 hours
-patients admitted directly to ICU and died within 24 hours
Deaths within 24hours of admission:

All day cases deaths in all departments and-deaths within 24 hours in all departments
Excluding:
- inpatient deaths who were admitted and stayed more than 24 hour.
-ICUs deaths within 24hour
Day cases:
cases admitted for less than 24 hours services whether for surgical or medical reasons.
NICU mortality:
All deaths in NICU departments including those inpatients who were transferred to NICU for more
than 48 hours before death and patients admitted directly to NICUs. Excluding:
-Patients admitted directly to NICU and died within 24 hours
Surgical site infection(SSI):
It includes superficial surgical site infection, deep surgical wound infection and
organ/space surgical site infection
Superficial surgical site infection:
must meet the following criteria:
Infection occurs within 30 days after surgery and involves only skin and
subcutaneous tissue of the incision and any of the following:
-purulent drainage from the superficial incision.
-Organism isolated from an aseptically obtained culture of fluid or tissue from
superficial incision.
-Surgeon deliberately opens wound because of pain or tenderness, localized
27
swelling, redness or heat, unless wound is culture -negative.
-Surgeon's or attending physician's diagnosis of superficial incisional infection.
Deep surgical site infection:

Infection occurs within 30 days after surgery if no implant (a non- human derived implantable foreign
body) is left in place or within 1 year if implant is in place and infection appears related to surgery, and
infection involves deep, soft tissues (as superficial and muscle layer) and any of the following:
-Purulent drainage from deep incision but not from organ / space component
of surgical site.
-A deep incision spontaneously dehisces or is deliberately opened by surgeon
when patient has fever C>38° C and/or localized pain or tenderness, unless
wound is culture-negative.
-An abscess or other evidence of infection involving deep incision found on
direct examination, during reoperation, or radiological or histopathologic
examination.
-Surgeon's or attending physician's diagnosis of infection.
Organ/space surgical site infection:
Infection occurs within 30 days after surgery if no implant (a non -human derived implanted
foreign body) is left in place or within 1 year if implant is in place and infection appears related
to surgery and infection involves any part of the body excluding the skin incision, fascia or
muscle layers, that is opened or manipulated during surgery and any of the following:
-Purulent drainage from drain placed through a stab wound into the
organ/space.
-Organism isolated from aseptically obtained culture of fluid /tissue in the
organ /space.
-An abscess or other evidence of infection involving organ/space found on
direct examination during reoperation, histopathological or radiological
examination.
-Surgeon's or attending physician's diagnosis of infection. Wound.
28

Final Hospital Quality Indicators

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Final Hospital Quality Indicators

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Ministry Of Health and population

Minister Office Sector

Indicator Purpose Target

Hospital Quality Indicators Profile

For Hospital Performance Targets

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Measure ID: Quality Measure Department(s) included: Purpose :

Rationale: It is an indicator for utilization of Type of Measure:

Nominator Statement: Data Source: daily inpatient

Included population : all patients admitted to the Excluded population:

Denominator Statement Data Source

Included population Excluded population:

Target : Data reported as: Frequency of measurement:

Hospital Quality Indicators Profile

For Hospital Performance Targets

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Measure ID: Quality Measure Department(s) Purpose :

Included population : all patient visited the Excluded population

Included population Excluded population:

Target : Data reported as: Frequency of measurement:

Hospital Quality Indicators Profile

For Hospital Performance Targets

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Measure ID: Quality Measure Department(s) Purpose :

Nominator Statement: No of patients received Data Source:

Included population: Excluded population :

Included population : Excluded population:

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Hospital Quality Indicators Profile

For Hospital Performance Targets

Measure Quality Measure Department(s) included: Purpose :

Nominator Statement: Data Source:

Denominator Statement : Data Source :discharge register

Included population : Excluded population:

Target : Data reported as: Frequency of measurement:

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Hospital Quality Indicators Profile

For Hospital Performance Targets

Measure Quality Measure Department(s) included: Purpose :

Nominator Statement: Data Source:

Included population : Excluded population:

Target : Data reported as: Frequency of measurement:

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Hospital Quality Indicators Profile

For Hospital Performance Targets

Measure Quality Measure Department(s) included: Purpose :

Nominator Statement: Data Source:

Included population : Excluded population:

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Hospital Quality Indicators Profile

For Hospital Performance Targets

Measure Quality Measure Department(s) included: Purpose :

Nominator Statement: Data Source:

Denominator Statement : Data Source :discharge register

Included population : Excluded population:

Add. 3 Magless El shaab St., Tel.,- Fax. 02-7920258

Hospital Quality Indicators Profile

For Hospital Performance Targets

Measure Quality Measure Department(s) Purpose :

Rationale: Type of Measure:

Nominator Statement: Data Source:

Included population : Excluded population

Denominator Statement : Data Source :

Included population : Excluded population: