KEY PERFORMANCE

INDICATORS
CLINICAL &
MANAGERIAL
 FLORENCE NIGHTINGALE
The Ultimate Goal Is
To Manage Quality,
But You Cannot Manage It
Until You Have A Way
To Measure It,
And You Cannot Measure It
Until You Can Monitor It.
 KEY PERFORMANCE INDICATORS

KPIs Are A Set Of Quantifiable

Measures
That A
Health Care Organization
Can Use To Gauge Its
Clinical Or Managerial
Performance
Over Time
 WHAT IS A KPI ?
Indicator Is A
Statistical Measure
Of The Performance Of A System
Through Evaluation Of Its
Structure Or
Processes Or
Outcomes
Over Time
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 CLINICAL INDICATORS RELATE TO AREAS OF
PATIENT ASSESSMENT & CARE
 Out Patient Care  Individual Unit services
o Intensive care services
 Inpatient Care o Obstetric Services
 Emergency Patient Care o Anesthesia Services
 Laboratory Services o Surgical Services
o Paediatric Services
 Radiology Services o Ophthalmic Services
 Blood Bank Services o Otorhinolaryngology Services
 Medication Management o Orthopedic services
o Dermatologic Services
 Infection Control o Superspecialty services
 Patient Safety Indices  Endoscopy Services
 Dialysis Services
 Cath. Laboratory Services
 Burns Unit Services
 MANAGERIAL INDICATORS RELATE TO AREAS
OF
ORGANIZATIONAL MANAGEMNT
 Registration & SERVICES
 Pharmacy Related
o Out Patient Medical Record Services
o Inpatient Realated
 Discharge  Various Utilization Indices
 Average Length Of Stay 
Human Resources Related
 Average Waiting Times  Equipment Down Times
For Various Service  Facility Safety & Drills
 Patient Satisfaction
 Billing Related
Indices
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Quality Or Safety

 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 “STRUCTURE” INDICATORS
Structure Denotes The Attributes Of
The Settings In Which Care Occurs.
Material Resources
Civil,Electrical, Water, Engineering &
Biomedical Engineering Equipment,
HVAC, Medical Gases
Financial Resources
Documented Policies, Procedures &
SOPs
 “STRUCTURE” INDICATORS

Structure Denotes The Attributes Of The

Settings In Which Care Occurs.
Human Resources
Medical, Nursing & Para & Non Medical Staff
Their Qualifications, Registration, Experience &

Training
Organizational Structure
Hierarchy & Organogram
Review Model

Reimbursement Model
 “STRUCTURE” INDICATORS
EXAMPLES
Availability Of
Specialists24 / 7

12
Emergency Medications 24 / 7
Diagnostic Modalities 24 / 7
Ambulances Services 24 / 7
The Required Nurse - Patient
Ratio For ICUs & Wards
 “PROCESS” INDICATORS
 Processes Are A Set Of
InterrelatedOr Interacting Activities
That Convert An Input Into An Output
 Any Health Care Delivery Includes
Medical
Nursing
Technical
Managerial Processes
 “PROCESS” INDICATORS
Process Indicators Measure The
Activities And Tasks In Episodes
Of Care Given To Patients.
Assesses What The Provider Did
For The Patient And How Well
It Was Done.
 “PROCESS” INDICATORS EXAMPLES

Modification Of Anesthesia Plan

Rescheduling Of Surgeries
Adherence To Wrong Side Site
Patient And Procedure Process
Adherence To Safety Precautions In
Laboratory & Radiology
 “PROCESS” INDICATORS EXAMPLES
 Prophylactic Antibiotic In Specified Time
Frame
 Compliance To Hand Hygiene Practices
 Compliance To Medication Prescription
In Capitals
 Variations In Mock Drills
 Incidence Of Communication Errors
 Patient Identification Errors
 “OUTCOME” INDICATORS
The End Results Of Health Care
Delivery Constitute The Outcome.
Quality Of Health Care Delivery Is
Finally Defined By
Safety
Effectiveness
Efficiency
Timeliness
Patient Orientation
 “OUTCOME” INDICATORS
Stakeholders’Satisfaction In The
Delivery Of Health Care
Improvements In
Quality Adjusted Life Years
Patients’ Knowledge
Patients’ Behaviour
The “Turn Around Times” For
Important Processes
 “OUTCOME” INDICATORS EXAMPLES

 Times  Rates
 Initial
Assessment  Bed Occupancy
 Discharge Times  ALOS
 Turn Around Times For  Mortality Rates
Laboratory & Radiology
 Reintubation Rate
 Waiting Times
 Return To ICU Within 48
 Rescheduling Of Surgeries
Hours
 Indices
 Return To Emergency
 Utilization Percentage
 ICU Department Within 72 Hours
 O. T.  HAI
 Equipment Downtime
 CAUTI
 Patient Satisfaction

 Employee  CLABSI
 Satisfaction  VAP
 Attrition
 SSI (%)
 Absenteeism
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 BLURRED MARGINS
BETWEEN QUALITY & SAFETY

They Are Not One And The

Same
Safety Is A Subset Of The Larger
Issue Of Quality Of Care
Safety Is The Foundation
On Which All Other Aspects Of
Quality Of Health Care Is Built
 BLURRED MARGINS
BETWEEN QUALITY & SAFETY

However, It Is Difficult
To Identify Where One Ends &
The Other Starts
Especially When It Comes To
Measuring Performances &
Changing Systems
 THE DIFFERENCE BETWEEN
QUALITY & SAFETY INDICATORS

A 70 Year Old Man With A Chest Pain & MI

 Diagnosed In Casualty

 Seen By Cardiologist After I Hour

 Gets Metformin Instead Of Metoprolol

 Door To Balloon Time Is 150 Minutes

 Survives With A Moderate Heart Damage ( EF =

35% )
 THE DIFFERENCE BETWEEN
QUALITY & SAFETY INDICATORS

Prolonged Door To Balloon Time

Less Than Acceptable Outcome

Quality
 Issue
Easy To Monitor & Measure & Manage The First One
A Transparent Auditable Process Is All That Is Needed

Wrong Medicine
Safety Issue
• Can Prove To Be A Problem
Depends On Self Reporting

Depends On Safety Culture Of The HCO

 SAFETY MONITORING I

 Medical Record Review

 Use of IHI Triggers Tools
 Active

 Closed

 Incident Report Monitoring & Review

Sentinel Event Monitoring & Review
 Patient Safety Indicators Monitoring
 Leadership WalkRounds
 SAFETY MONITORING II
 Medication Monitoring
 Blood Transfusion Monitoring
 Mortality Review
 Litigation Review
 Facility Safety Rounds
 The Following May Be Focused On
Patient Safety
 Medical Audit
 Nursing Audit
 Patient Complaints Review
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
EXAMPLES OF INDICATORS
INCIDENCE
 THE FORMULAE USED FOR KPI

Number Of Occurrence
Incidence = -------------------------------------
Day/ Week/ Month/ Year
 EXAMPLES OF INDICATORS
PERCENTAGE

Percentage Of Medical Records Having Discharge

Summary
100%
90%
80%
70%
60%
50% Percentage of Medical
Records having Discharge
40%
summary
30%
20%
10%
0%
Month 1 Month 2 Month 3 Month 4
 THE FORMULAE USED FOR KPI

Number Of Occurrence
Percentage = ---------------------------------- X 100
Total No. Examined
 EXAMPLES OF INDICATORS
RATE PER 1000 PATIENT DAYS
 THE FORMULAE USED FOR KPI

Number Of Occurrence
Rate / 1000 = ---------------------------------------- X 1000
Patient Days Total No. Of Patient days
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per 1000

 Numerator, Denominator And Multiplication Factor

 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size

 Data To Be Sent To NABH

 DEFINITIONS
Are Needed For Most Indicators
Help Every One To Understand
The Indicator Being Collected
Who All Should Collect It ?
Where It Should Be Collected From ?
That Every One Is Talking In The Same
Language
The Process Of Collection
 DEFINITIONS

It Is Important To Use

Definitions That Are Approved
Or Issued By National Or
International Bodies
Clear Cut Definitions Exist
For Most Indicators
 DEFINITIONS
 Clear Cut Definitions Exist For Most Indicators
 Bed Occupancy, Average Length Of Stay
 Morbidity, Mortality Related Issues
 Medication Management Related
 Medication Error, Adverse Event , Adverse Drug Event , Adverse
Drug Reaction
 Health Care Associated Infections
 CRBSI, CAUTI, VAP, HAP, SSI
 Health Care Associated Events
 Bed Sore, DVT, Delirium, Fall, Sharp Injury, Body Fluid
Splash
 DEFINITIONS

Occasionally
Such Definitions May
Not Be Widely Available
When This Is The Case Then The
HCO Should
Follow The Definition Given By The
Agency Issuing The Standard
Create An Acceptable Definition That Is
Uniformly Applied Across The HCO
Eg. Rescheduling Of Surgeries

 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 STARTING AND END TIME
 When The Indicator Is Concerned With
Time Calculation, It Is Necessary To
Define
The Starting Time
The Ending Time
 Every One Should Understand & Follow
This
 Or Else, The Data collected
WillBe Different From Different Areas
Can Not Be Validated
INDICATORS THAT NEED TIME DEFINITION

Initial Assessment
IP,Emergency
Doctors & Nurses
Waiting Time For Services
Discharge Time
Turn Around Time For Blood
OT & ICU Utilization Rates
Critical Equipment Down Time
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 MONITORING FREQUENCY
Most Clinical Indicators Need To Be
Monitored
Daily & Continuously
Some Managerial Indicators May Be
Collected
Weekly
Monthly
Quarterly
HalfYearly Or
Annually
 UNDERSTANDING INDICATORS
 Clinical Or Managerial
 Structure, Process Or Outcome

 Quality Or Safety

 Number Or Ratio, Percentage Or Rate Per

1000
 Numerator, Denominator And Multiplication
Factor
 Definition

 Starting And End Time

 Continuous Or Periodic Monitoring

 Sample Size
 SAMPLE SIZE
Depends On
The Indicator
Population Size
 Ease Of Collection

The Sample Size Has to Produce

Statistically Acceptable &
Significant Results
 TWO DIFFERENT METHODS
FOR SAMPLE SIZE

Screening Population Sample Size

50 44
100 79
150 108
200 132
500 217
1000 278
2000 322
5000 357
10000 370
20000 377
 TWO DIFFERENT METHODS
FOR SAMPLE SIZE

Screening Population Sample Size

< 30 Cases 100% Sampling

30 - 100 Cases 30 Cases
100 - 500 Cases 50 Cases
> 500 Cases 70 Cases
 SOME ISSUES
 Everyone Wants Measurement But No One
Wants To Be Measured
 If You Do Not Measure You Cannot Improve

 Removing Apprehensions For Getting Accurate

Data
 Avoiding Punitive Measures Associated With
The Result Of Collected Data
 Need For Pre And Post Intervention
Measurement
 AREAS OF CONCERN

• Data Collection At Grass Root Level Is A

Doubtful Process
• Lack Of Uniformity In Data Collection
• Lack Of Key Performance Indicators Data
Within India
• Lack Of Uniformity In Measurement Of
Indicators
• How Much Of The Indicators Are Being
Utilized
 AREAS OF CONCERN

• Some Indicators Are Good, Others Patchy

And Some Poor
• Indicator Tracking Not Being Done
• Indicators Tracked But Not Acted Upon
• Hospitals Are Reluctant To Share Data
• Top Management Not Firm When Faced
With Unacceptable Indicators
 GOOD PRACTICES
• Use Of Dash Boards
• Use Of Clinical Excellence Scorecard
• ACE 25 Score (10 Mandatory And 15
Independent Choice)
• Use Of Statistical Tools For Analysis
• Organizational Climate Surveys
• Patient And Employee Satisfaction
Surveys
 SUGGESTIONS

• Collection Of Mandatory Indicators

• Select And Capture Only Those That You
Require
• Limit Your Indicators
• Indicators Need To Talk Back To You
• Statistical Analysis Must Be Done
• Upper And Lower Control Limits To Be Set
 SUGGESTIONS

• Benchmarking Required
• Need To Analyze If Patient Has Benefitted
• Quality Performance Indicators And
Clinical Excellence Score Cards Are One
Of The Drivers Of Clinician Participation
And Improvement In Clinical Care
• Clinicians Are Suspicious On Data Sharing
 KPI MANAGEMENT
 Identify The KPI Gatherers
 Train On Relevant KPIs
 Clear All Doubts

 Define, Understand Start & End Times

 Understand Numerator, Denominator And
Multiplication Factor
 Continuous Means 6 / 7 & 25 / 30
 Periodic Needs Clear Cut Time Schedule
 IDENTIFY THE KPI GATHERERS

 QMS Personnel  Surgery

 ICN s  Labour Room
 Clinical Pharmacists  Laboratory
 MRD & Front Office  Radiology
 Pharmacy
 Blood Bank
 Nursing Department
 Ethics Committee
 Operation Theatre
 Human Resources
 ICU
Department
 Emergency
 Engineering & BM
 Anesthesiology
Engineering
 KPI MANAGEMENT
IT Enablement of The Entire
Process
Use A “Right Template” For
Data Collection
Utilize The Software Used In
 FO, Registration, MRD, HRD,
Laboratory, Radiology, Operation
Theatres, Emergency, ICU
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To the Accreditation Authority as required
SEVEN BASIC QUALITY TOOLS
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis And Or A RCA
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To the Accreditation Authority as required
 SYSTEM ANALYSIS
SHARP & BLUNT END
 SYSTEM ANALYSIS FRAME WORK
S. No Frame Work Contributory Factors
1 Patient Complexity Of Disease;
Language Issues
Personality & Social Factors

2 Staff Knowledge & Skills

Motivation & Attitude
Physical & Mental Health

3 Task Availability & Use Of Protocols

Availability & Accuracy Of Test Results
4 Team Verbal Communications
Written Communication
Supervision & Willingness To Seek Help
Team Leadership
 SYSTEM ANALYSIS FRAME WORK
S. No Frame Work Contributory Factors
5 Work Staffing Levels & Mix Of Skills
Environment Patterns Of Work Load & Shifts
Design, Availability & Maintenance Of
Equipment
Administrative & Managerial Support
6 Organisation & Financial Resources & Constraints
Management Policy Standards & Goals
Safety Culture & Priorities

7 Institutional Regulatory Context

Medico Legal Environment
‘5’ WHYS?
10/07/2020 WS ME SESSION 1.7
64
TEMPLATE
RCA
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To The Accreditation Authority As Required
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To The Accreditation Authority As Required
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To The Accreditation Authority As Required
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To The Accreditation Authority As Required
 KPI MANAGEMENT

 QMS Department Collates & Reviews The Data

 Daily, Weekly, Monthly, Quarterly
 Do A Systems Analysis
 When The Values Fall Outside Expected Limits
 Discuss In Quality Committee

 Share The Discussion With Stakeholders, &

Committees
 Send The Results Of Discussion To The Board Of
Directors
 Submit To The Accreditation Authority As Required
 FLORENCE NIGHTINGALE
The Ultimate Goal Is
To Manage Quality,
But You Cannot Manage It
Until You Have A Way
To Measure It,
And You Cannot Measure It
Until You Can Monitor It.
 NEW ADAGE

The Ultimate Use Of KPIs Is

To Manage Quality,
But You Cannot Manage It
Until You & Your
Top Management Really
Want To Do So