Page 122 - NATIONAL POLICY QUALITY IN HEALTHCARE: Bridging Silos, Accelerating Improvements 2022-2026
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National Policy for Quality in Healthcare
Bridging Silos, Accelerating Improvements
Appendix 8 : Initial List of Indicators According to STEEEPA Domains
A. Safety Indicators
1. Patient Safety Indicators
No
Programme
Indicator
No Programme Indicator
1. Hospital Hand Hygiene Compliance Rate
2. Hospital Rate of Catheter Associated Blood Stream Infection (CABSI)
--no of CABSI per 100 admissions
3. Hospital with OT Numbers of wrong surgeries performed
4. Hospital with OT Number of unintended retained surgical item (RSI)
5. Hospital Number of incorrect Blood Component Transfused (IBCT)
6. Hospital + Clinic Rate of patient fall (for inpatient and outpatient clinic)
7. Hospital + Clinic Number of incidences caused by wrong patient
identification (detected through incident reporting &
investigation)
8. Hospital +Clinic Number of medication error related to severe harm or
death
9. Hospital +Clinic Implementation of Incident Reporting & Learning System
10. Pharmacy Percentage of recall product directives issued within the
stipulated timeline
11. Pharmacy Percentage of health facilities achieving full compliance
≥80% for medication safety self-assessment
12. Oral Health Percentage of MOH dental facilities which achieved at least
80 percent compliance during Safety and Health Audits to
ensure audited facilities are at optimum levels
13. Nursing (All hospitals) Compliance rate of administration of Oral Medication
14. Nursing (All hospitals) Compliance rate of administration of Intravenous (IV)
infusion
15. Nursing (All hospitals) Compliance rate to Blood / Blood Component Transfusion
16. Nursing (All hospitals) Compliance rate of Receiving patients at the reception area
17. Nursing (All hospitals) Compliance ate of Sponges, sharp & instruments count
18. Nursing (All Public Compliance rate of Cold Chain Management
Health facilities)
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