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 |