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Table 1 Quality measure descriptions

From: The impact of hospital accreditation on quality measures: an interrupted time series analysis

Dimension of measurement   Measures Value
Patient Assessment Y1 Initial medical assessment done within 24 hours of admission Percentage
Y2 Initial nursing assessment within 24 hr. of admission Percentage
Y3 Pain assessment form completed 100% per month Percentage
Y4 Percentage of completed pain reassessment Percentage
Laboratory Safety Y5 Monitor the timeliness of complete blood count (cbc) as routine lab results (in hours)
Y6 The turnaround time of troponin lab results (in minutes)
Surgical Procedures Y7 Completion of surgical invasive procedure consent Percentage
Y8 Percentage of operating room (or) cancellation of elective surgery Percentage
Y9 Unplanned return to OR within 48 hours Percentage
Medication error use and near-misses Y10 Reported medication error Per 1000 prescriptions
Anaesthesia and Sedation Use Y11 Completed anaesthesia, moderate and deep sedation consent forms Percentage
Y12 Completed Modified Aldrete Scores (Pre, Post, Discharge) Percentage
Y13 Completed pre-anaesthesia assessments Percentage
Y14 Completion of anaesthesia care plan Percentage
Y15 Percentage of completed assessment of patient who received anaesthesia Percentage
Y16 Effective communication of risk, benefit and alternatives of anaesthesia explained to patients Percentage
Availability, Content and Use of Patient Records Y17 Percentage of typed post-operative report completed with 48 hours Percentage
Infection Control, Surveillance and Reporting Y18 Hospital acquired methicillin resistant staph aureus (MRSA) rate Per 1000 Admissions
Y19 Healthcare associated infection hospital-wide per 1000 patient days
Y20 Surgical site infection rate Percentage
Reporting of Activities as Required by Law and Regulation Y21 Mortality rate Percentage
International Patient Safety Goals Y22 Monitoring correct site marking Percentage
Y23 Monitoring compliance with the time-out procedure Percentage
Y24 Screening of patient fall risk Percentage
Y25 Overall hospital hand hygiene compliance rate Percentage
Y26 Patient fall rate Per 1000 patient days
Y27 Fall risk assessment and reassessment Percentage
  1. Source: Subashnie Devkaran.