skmch&rc - lahore - shaukat khanum memorial cancer ......skmch&rc - lahore clinical performance...
TRANSCRIPT
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SKMCH&RC - Lahore
Clinical Performance Dashboard3rd Quarter 2020
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97%
98%
100% 100%
99% 99%
100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Inpatient 1
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsPatient Identification Compliance
Target = 100%
99% 99%100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Inpatient 2A
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
99%100% 100% 100%
99%98%
97%
99%100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
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tage
Inpatient 2B
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
97%
99%100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Inpatient 3
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
-
100%99%
100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Intensive Care Unit
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsPatient Identification Compliance
Target = 100%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Operation Rooms
Median
Median = 100% No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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ce P
erc
en
tage
Chemotherapy Bay
Median
Median = 100% No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
100% 100% 100%99%
100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
Nursing Outpatient/Emergency Assessment Room
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
-
100%
91%
96%
100%99%
100% 100% 100% 100% 100% 100%
70%
75%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Outpatient and Ambulatory Services
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsPatient Identification Compliance
Target = 100%
No adverse event of patient identification reported from Jan to Sep 2020
-
2
3
2
0
2 2
1 1 1
0
2
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Inpatient 1
Median
Median = 2No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsInpatient Falls Reported
Target = 0
1 1 1 1
2
3
1 1
0 0 0
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Inpatient 2A
Median
Median = 1No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
29
3
0
3 2 20
20 1 1
0
10
20
30
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Inpatient 2B
Median
Median = 2No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 1 (PDCA project started which resulted in increased
reporting)
2
0
1
2
0 0 0 0 0 0
1
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Inpatient 3
Median
Median = 0No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
-
0 0 0 0 0 0 0 0 0 0 0
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Intensive Care Unit
Median
Median = 0No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsFalls Reported
Target = 0
0 0 0 0 0 0 0 0 0 0 0
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Operation Rooms
Median
Median = 0No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
0
1
0 0
2
1
0
1
0 0
1
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Chemotherapy Bay
Median
Median = 0No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
3
1
0 0 0 0
1
0
1
0
1
0
1
2
3
4
5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Nursing Outpatient/Emergency Assessment Room
Median
Median = 0No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
-
100%
98%
94%
100%
98%
100% 100% 100% 100% 100% 100%
70%
75%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Outpatient and Ambulatory Services
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsFalls Risk Assessment
Target = 100%
-
90%
92%
96%97%
96%
93%
98%
80%
85%
90%
95%
100%
Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Inpatient 1
Median
Median = 96% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsFalls Risk Assessment
Target = 100%
86%87%
98%99%
100% 100%99%
80%
85%
90%
95%
100%
Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Inpatient 2A
Median
Median = 99% No. of Runs=2Shift = 0Trend = 1 (Staff education, increased safety rounds and development of new
alert for nurses (4 hours prior to assessment due time) improved the compliance)Astronomical Point = 0
88%
95%
100% 100%99% 99%
100%
80%
85%
90%
95%
100%
Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Inpatient 2B
Median
Median = 99% No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
92%
96%97%
98%100% 100%
99%
80%
85%
90%
95%
100%
Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Inpatient 3
Median
Median = 98% No. of Runs=2Shift = 0Trend = 1 (To improve process, new HIS FRAT alert was developed for nurses
(4hours prior to due time) and physicians were reminded by nurses to fill out FRAT
forms timely)Astronomical Point = 0
-
80%77%
80%82%
79%
83%
71%
85% 86%
97% 97%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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lian
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erc
en
tage
Doctors
Median
Median = 82% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsHand Hygiene Compliance
Target = 100%
79%
89%84%
87%
93% 94% 93% 94%96%
98% 98%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Nurses
Median
Median = 93% No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
86%
83%
86% 86% 87%90%
92% 93%96%
98% 98%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Health Care Assistants
Median
Median = 90% No. of Runs=2Shift = 0Trend = 1 (Regular educational
sessions, peer feedback and implementation of online system resulted in improved compliance) Astronomical Point = 0
83%87% 86%
82%
92%
87%
92%95%
97%99% 99%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Others
Median
Median = 92% No. of Runs=2Shift = 0Trend = 1 (Regular educational
Sessions , peer feedback and implementation of online system resulted in improved compliance) Astronomical Point = 0
-
99%
100%
99%
98%
97%
100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
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erc
en
tage
Operating Rooms
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsTime out Process Compliance
Target = 100%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
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tage
Endoscopy
Median
Median = 100% No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
100%99% 99%
100%99%
98%99% 99% 98.9%
100% 100%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Radiology
Median
Median = 99% No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
-
0.03
0.25
0.03 0.0
0.63
0.47
0.31
0.10.16
0.24
0.1
0
0.2
0.4
0.6
0.8
1
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Medication errors with harm per 10,000 items
Median
Median = 0.16No. of Runs= 7Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsSafety of High alert Medications
2.98
3.7
1.76
3.72
2.11
1.51 1.49
2.17
0.73
2.161.79
0
3
6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
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High alert medication errors per 10,000 items
Median
Median = 2.11No. of Runs=8Shift = 0
Trend = 0Astronomical Point = 0
0.84 0.81 0.79
0.5
1.09
0.25
0.63 0.670.74
0.35
0.57
0
1
2
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Look alike sound alike Errors per 10,000 items
Median
Median = 0.67No. of Runs= 6Shift = 0
Trend = 0Astronomical Point = 0
0.08
0
0.18
0.03 0 0
0.31
0.070 0 0
0
0.4
0.8
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Concentrated Electrolytes per 10,000 items
Median
Median = 0No. of Runs = 1Shift = 0
Trend = 0Astronomical Point = 0
-
91%
98%97%
99% 99%100% 100% 100% 100% 99.7% 100%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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lian
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erc
en
tage
Inpatient 1
Median
Median = 99.7% No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsNursing Handover Completeness
Target = 100%
84% 84%
100% 100%
92%94%
99% 99% 100% 100% 98%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Inpatient 2A
Median
Median = 99% No. of Runs=5Shift = 0
Trend = 0Astronomical Point = 0
97%
100%
98%97%
95%
98%
100% 100% 100% 100% 100%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Inpatient 2B
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
89%
85%
98%97%
90%
100% 100%98%
100% 100% 100%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
Inpatient 3
Median
Median = 98% No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
-
International Patient Safety GoalsNursing Handover Completeness
Target = 100%
95%
99% 99% 99%100% 100%
99%
93%
100% 100% 100%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
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erc
en
tage
Intensive Care Unit
Median
Median = 99% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
80%
85%
90%
95%
100%
Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
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erc
en
tage
Nursing Outpatient/Emergency Assessment Room
Median
Median = 100% No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
75% 76%
95%99% 100% 100% 100% 100% 100% 100% 100%
40%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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lian
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erc
en
tage
Chemotherapy Bay
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
-
99%100% 100% 100% 99.8%
97.4%98.7%
99.9%99% 99.5% 99.7%
80%
85%
90%
95%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
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erc
en
tage
Pathology
Median
Median = 99.7% No. of Runs= 5Shift = 0
Trend = 0Astronomical Point = 0
International Patient Safety GoalsCritical Alert Reporting
Target = 100%
54%
78%
88%
89%89%
100% 100%
75%
100%95%
20%
40%
60%
80%
100%
Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
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erc
en
tage
Nuclear Medicine
Median
Median = 89% No. of Runs=4Shift = 0
Trend = 1 (To improve the reporting, regular educational sessions were arranged for residents/fellows)Astronomical Point = 0
96%94%
84%
94% 94%
88.7%
96% 95.4%98.6%
96.8%99.0%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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lian
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erc
en
tage
Radiology
Median
Median = 95.4% No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
No alert reported in Q1 2018
-
2319
32
26
2018
14
34
21
33
28
0
10
20
30
40
50
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Type A ADRs
Median
Median = 23No. of Runs=6Shift = 0
Trend = 1 (Under reporting of ADRs)Astronomical Point = 0
Adverse Drug Events-Pharmacy
18
1014
18
79
12
28
14
8
21
0
10
20
30
40
50
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Type B ADRs
Median
Median = 14No. of Runs=7Shift = 0
Trend = 0Astronomical Point = 0
41
29
46 44
27 27 26
62
3541
49
0
20
40
60
80
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Total ADRs Reported
Median
Median = 41No. of Runs=6Shift = 0
Trend = 0Astronomical Point = 0
ADRs – Adverse drug reactions
-
34
54
8
10
12
4
9
7 7
0
6
12
18
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Medication Errors
Median
Median = 7No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
Average Items dispensed in last one year=112,310
Medication Errors and Adverse Drug Events
194
129145
5579
4557
75
2845 46
0
100
200
300
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Near Miss
Median
Median = 57No. of Runs= 6Shift = 0
Trend = 0Astronomical Point = 0
1
6
34
7
9
78
9
1
3
0
6
12
18
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Adverse Events Anesthesia
Median
Median =6No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
0 0 0 0 0 0
1
0 0 0 0
0
2
4
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Adverse Events Sedation
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
-
0 0 0 0 0 0 0 0 0 0 00.96
4.82
0
2
4
6
8
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Infe
ctio
n r
ate
/10
00
de
vice
day
s
CAUTISKM Rate
Median
NHSN Rate
INICC Rate
Median = 0No. of Runs=0Shift = 0
Trend = 0Astronomical Point = 0
Infection Control Statistics-Intensive Care Unit
2.2
0 0
2.2
0
3.8
0 0
5.05
0 00.8
4.19
0
2
4
6
8
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Infe
ctio
n r
ate
/10
00
de
vice
day
s
CLABSI SKM RateMedian
NHSN Rate
INICC Rate
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0* Number of infections = 2
*
6.2
0 0 0 0
3.3
0 0
3.2
0 0
6.4
12.2
0
5
10
15
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Infe
ctio
n r
ate
/10
00
de
vice
day
s
VAP SKM RateMedian
NHSN Rate
INICC Rate
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0* Number of infection = 1
*
CAUTI – Catheter Associated Urinary Tract Infection, CLABSI – Central Line Associated Blood Stream Infection VAP – Ventilator Associated Pneumonia, NHSN – National Healthcare Safety NetworkINICC – International Nosocomial Infection Control Consortium
-
87%
83%
96%94% 95%
99% 98% 99%100% 99.7% 100%
70%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Percentage of In-time radiation treatment
Median
Median = 98 %No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
Blood Transfusion Reactions
Radiation Oncology Activity
8
15 14
6 5
13
10
18
7
10
19
0
10
20
30
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Total Reactions
Median = 10No. of Runs=6Shift = 0
Trend = 0Astronomical Point = 0
-
94%
100% 100% 100% 100% 100% 100% 100% 100% 100% 100%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Pain Assessment
Median
Median = 100%No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
Hospital-wide Indicators
74%
92%
98% 98% 99% 99% 99% 99%99.7% 99.3% 98%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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en
tage
Pain Re-assessment
Median
Median = 99%No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
7
2 21
0 01
0 0 01
0
5
10
15
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
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er
Axis Title
Hospital Acquired Pressure UlcersInpatient 1
Median
Median =1No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
3
6
2
1
0
3
2
1
0 0 0
0
2
4
6
8
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Hospital Acquired Pressure UlcersInpatient 2A
Median
Median = 1No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
-
Hospital-wide Indicators
2 2
1
2
0
1
0 0 0 0 0
0
2
4
6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Hospital Acquired Pressure UlcersInpatient 2B
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
2 2
0 0 0 0 0 0 0 0 0
0
2
4
6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Hospital Acquired Pressure UlcersInpatient 3
Median
Median = 0 No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
0
4
6
10 10
32
01 1
3
0
5
10
15
20
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Axis Title
Hospital Acquired Pressure UlcersIntensive Care Unit
Median
Median =3No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
-
0.1
0
0.1
0 0 0
0.1
0 0 0 0
0
0.1
0.2
0.3
0.4
0.5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
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nta
ge
Axis Title
Internal Medicine
Median
Median =0No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
Clinical Performance IndicatorsRe-admission within 7 days of discharge
Specialty wise
0.3
0.2
0.3
0 0 0 0 0
0.1
0 0
0
0.2
0.4
0.6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Medical Oncology
Median
Median = 0.0 No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
0.2
0.5
0.1
0.2 0.2
0.6
0.2
0.5
0.3
0
0.1
0
0.2
0.4
0.6
0.8
1
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Pediatric Oncology
Median
Median = 0.2No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
0.1
0.2 0.2
0.1
0.4
0.1
0.2
0.4
0.1
0.3 0.3
0
0.2
0.4
0.6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgical Oncology
Median
Median = 0.2No. of Runs=6Shift = 0
Trend = 0Astronomical Point = 0
-
0.3
0.71 1 1.1
0.50.7
1.1
2 2.1
1.1
0
2
4
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
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nta
ge
Axis Title
Surgeon 1
Median
Median =1.0 No. of Runs= 4Shift = 0
Trend = 1Astronomical Point = 0
Clinical Performance IndicatorsRe-admission within 30 days of discharge
Surgical Oncology
0
1.1
0.3
0 0 0 0 0 0 0 0
0
1
2
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 2
Median
Median = 0.0 No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
0
4.5
0 0
2.3
0 0
6.0
0 0
2.2
0
2
4
6
8
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 3
Median
Median = 0.0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
0.9
0 0
0.7
0 0 0 0
1
0 0
0
1
2
3
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 4
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
-
Clinical Performance IndicatorsRe-admission within 30 days of discharge
Surgical Oncology
0 0 0 0 0 0 0 0
1.0
0.0
3.7
0
5
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 6
Median
Median = 0.0 No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
0.0
3.5
0.0 0.0 0.0
2.0
0.00.7 1.0
4.4 4.1
0
4
8
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 7
Median
Median = 0.7No. of Runs= 6Shift = 0
Trend = 0Astronomical Point = 1 (Due to COVID, fewer procedures were planned that
resulted inflated percentage)
0 0 0 0
1.0
0 0 0
1.0
0 0
0
1
2
3
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 8
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
0
4.5
0 0
2.8
0 0 0 0 0 0
0
2.5
5
7.5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Axis Title
Surgeon 5
Median
Median =0.0 No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
-
0.60.3
1.4 1.3 1.4
0.5
1.3
0.7
1.31.0
3.0
0
2
4
6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
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nta
ge
Axis Title
Surgeon 1Median
Median = 1.3No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
Clinical Performance IndicatorsMultiple Surgical Procedures in One admission
0
0.4
0
0.5
0
0.3
0.5
0.2
0.0
0.7
0
0
0.5
1
1.5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 2
Median
Median =0.2No. of Runs=9Shift = 0
Trend = 0Astronomical Point = 0
0 0 0
3
0
9.8
3.3
0 0 0 0
0
5
10
15
20
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 3
Median
Median = 0.0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
6.9
0.0 0.0 0.0
4.7
2.3
0.0 0.0 0.0 0.0 0.0
0
5
10
15
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 4
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
-
Clinical Performance IndicatorsMultiple Surgical Procedures in One admission
0 0 0 0 0 0 0
2.62.2
5.0 4.8
0
5
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 5
Median
Median = 0.0 No. of Runs=1Shift = 0Trend = 0
Astronomical Point = 1 (Due to COVID, fewer procedures were planned that resulted inflated percentage)
1/20 procedures
1.1 0.9
0.0 0
2.3
1.5
3.3
0
1.6
3.1
0
0
2
4
6
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 6
Median
Median = 1.1No. of Runs= 5Shift = 0
Trend = 0Astronomical Point = 0
0 0 0 0 0 0
0.9
0 0 0
1.3
0
1
2
3
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 7
Median
Median = 0No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
6.1
0.9
4.4
3.42.5
00.8
1.30.7
6.7
2.2
0
5
10
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Surgeon 4
Median
Median = 2.2No. of Runs= 5Shift = 0Trend = 0
Astronomical Point = 1 (Due to COVID, fewer procedures were planned that resulted inflated percentage)
3/45 procedures
-
99% 99%98%
99% 99% 99% 99%97%
96.0%
99.4%98.5%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Radiology95% IPD, ICU & ER reports within 24 hours of working days
Median
Median = 99% No. of Runs=3Shift = 0
Trend = 0Astronomical Point = 0
Clinical Performance Indicators Compliance with defined Turnaround Time for Reporting
99% 99%98% 98% 98%
99% 99%97%
98.0%99.5% 98.7%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
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tage
Radiology96.5% OPD, Diagnostic & Walk In Reports within 48 hours of
working days
Median
Median = 98.7% No. of Runs=5Shift = 0
Trend = 0Astronomical Point = 0
99%100%
96%98%
99%
96%
99%97%
100% 100%98.2%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20Co
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tage
Radiology95% PET CT Reports within 72 hours of working days
Median
Median = 99% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
98% 98%99% 99% 99%
97%99% 99.5% 99.7% 98.2%
99.5%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
Pathology
Median
Median = 99% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
-
Chemotherapy Activity Break-up
7455 75237920
83368635 8439 8502
9011 9255
69367262
2,500
5,000
7,500
10,000
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
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Adult Patients
Median
Median = 8336No. of Runs=3Shift = 0
Trend = 1Astronomical Point = 0
2447 2407
27722694
2544 2602
3128
2881
2427
1855
2589
1500
2000
2500
3000
3500
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
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Pediatric Patients
Median
Median = 2589No. of Runs=5Shift = 0
Trend = 0Astronomical Point = 0
Outpatient Parenteral Antibiotic Therapy
383 440558 573
1034840
682
10761138
503
757
0
500
1000
1500
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Adult Patients
Median
Median = 682No. of Runs=4Shift = 0
Trend = 1Astronomical Point = 0
2177 2085 2129
26163037 3227
3580 3459
2508
1132
1955
0
2500
5000
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
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Pediatric Patients
Median
Median = 2508No. of Runs=3Shift = 0
Trend = 1Astronomical Point = 0
-
4.84.1
2.5
4.3 4.5
3.64.2 4.2 4.0
5.3
4.1
0
2
4
6
8
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Internal Medicine
Median
Median = 4.2No. of Runs= 6Shift = 0
Trend = 0Astronomical Point = 0
Average Length of Stay–Inpatients
5.96.1
5.96.1 6.0
5.1 5.1
5.7 5.6
5.1
5.8
4
6
8
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Medical Oncology
Median
Median = 5.8No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
2.4
2.82.5
2.92.6
2.4 2.52.8 2.8
2.42.6
0
2
4
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Nuclear Medicine
Median
Median = 2.6No. of Runs= 7Shift = 0
Trend = 0Astronomical Point = 0
2.93
2.8 2.8
3.0
2.6
2.8 2.8 2.8
3.3
2.8
2
3
4
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Pediatric Oncology
Median
Median = 2.8No. of Runs= 3Shift = 0
Trend = 0Astronomical Point = 0
-
2.4
2.5 2.5
2.6
2.4
2.5
2.4
2.2 2.2
2.1 2.1
2
2.5
3
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Surgical OncologyInpatients
Median
Median = 2.4No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
Average Length of Stay
4:23 4:20 4:17 4:214:33
3:36 3:41
4:02
3:263:11
3:41
2:24
3:36
4:48
6:00
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
h:m
m
Internal MedicineEmergency Assessment Room
Median
Median = 4 hours 2 minutesNo. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
2:44 2:41 2:45 2:462:49
2:33
2:48 2:46
2:18 2:202:32
1:12
2:24
3:36
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
h:m
m
Pediatric OncologyEmergency Assessment Room
Median
Median = 2 hours 44 minutesNo. of Runs= 5Shift = 0
Trend = 0Astronomical Point = 0
3:49
3:31 3:35 3:333:41
3:053:14
3:24
2:522:45
3:06
2:24
3:36
4:48
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
h:m
m
Overall Average Length of StayEmergency Assessment Room
Median
Median = 3 hours 24 minutesNo. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
-
1.0 1.1 0.9
1.3 1.3
0.91.1 1.0
0.8
2.2
0.9
0
1
2
3
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Internal Medicine
Median
Median = 1.0No. of Runs= 8Shift = 0
Trend = 0Astronomical Point = 1 (Length of stay increased due to COVID)
Average Length of Stay–Intensive Care Unit
0.2
0.4
0.8 0.8
0.3 0.3 0.30.4
0.50.6 0.6
0
0.5
1
1.5
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Medical Oncology
Median
Median = 0.4No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
0.3
0.5 0.5
0.3
0.4
0.2 0.2
0.4
0.2
0.3
0.2
0
0.5
1
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Pediatric Oncology
Median
Median = 0.3No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
0.7 0.7 0.7 0.7
0.6 0.6
0.7
0.8 0.8
0.7
0.8
0
0.5
1
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Surgical Oncology
Median
Median = 0.7No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
-
5.0
6.0
5.0 5.0
4.0
3.0 2.7
4.7
1.0
0
2
4
6
8
Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Internal Medicine
Median
Median = 4.7No. of Runs= 2Shift = 0
Trend = 1Astronomical Point = 0
Average Length of stay- Ventilated Patients
5.0
4.0 4.0
3.0
4.0
2.0 2.3
5.0
2.0
0
2
4
6
8
Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Medical Oncology
Median
Median = 4No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
45
8
23
22.5
4.5
2.0
0
4
8
12
Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Pediatric Oncology
Median
Median = 3No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
2 2 2 2
4
21.7
1.6
2.0
0
1
2
3
4
5
Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Day
s
Surgical Oncology
Median
Median = 2.0No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
-
Bed Occupancy Rate
83% 81% 81%84% 85% 84% 84% 82%
89%
65%
73%
40%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Inpatients
Median
Median = 83%No. of Runs= 5Shift = 0
Trend = 0Astronomical Point = 0
61%57%
60%
72% 72%
54%60%
57%
36%40%
60%
20%
40%
60%
80%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Intensive Care Unit
Median
Median = 60% No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
82%79% 80%
83% 84% 82% 82% 80%83%
62%
72%
40%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Axis Title
OverallMedian
Median = 82%No. of Runs= 5Shift = 0
Trend = 0Astronomical Point = 0
-
84%
93%
100% 100% 100% 100% 100% 100%97%
92.3%
100%
60%
80%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
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tage
ESI Level 1
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
18/18
patients
Emergency Assessment Room StatisticsPatients Seen within Defined Waiting Times – ADULTS
97%99%
100% 100% 100% 100% 100% 100% 100%99% 99%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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erc
en
tage
ESI Level 2
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
743/751
patients
96%97% 97%
98%99%
97% 97%98% 98% 98%
97%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
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tage
ESI Level 3
Median
Median = 97% No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
2811/2900
patients
95%97% 97%
98%100%
97% 97%96%
98% 98%97%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
ESI Level 4
Median
Median = 97% No. of Runs=4Shift = 0
Trend = 0Astronomical Point = 0
1517/1563
patients
ESI - Emergency Severity Index
-
97% 100% 100% 100% 100% 100% 100% 100%
87.5%
50%
92%
0%
50%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
PEWS Level 4-6
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 1 (Documentation delayed in 2 cases)
10/11
patients
Emergency Assessment Room StatisticsPatients Seen within Defined Waiting Times – Pediatrics
99%100% 100% 100% 100% 100% 100% 100% 100%
96%
99%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
PEWS Level 3
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
156/157
patients
98%99%
100% 100% 100% 100% 100% 100%99% 99% 99%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
PEWS Level 2
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
258/261
patients
99%100% 100% 100% 100% 100% 100% 100%
98%99% 99%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
PEWS Level 1-0
Median
Median = 100% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
420/423
patients
PEWS – Pediatric Early Warning Scoring System
-
150192
315 299 285 285267
243219
245
378
0
100
200
300
400
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
Total number of Complaints
Median
Median = 267No. of Runs= 4Shift = 0
Trend = 1Astronomical Point = 0
Complaints–Clinical Departments
21
13
29
0
10
20
30
40
Q1 20 Q2 20 Q3 20
Nu
mb
er
Established Clinical Complaints by CategoriesCOP - Care Coordination
Median
Median = 21No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
COP – Care of Patients
-
11
3
12
0
5
10
15
Q1 20 Q2 20 Q3 20
Nu
mb
er
Administrative
Median
Median = 1No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
Established Clinical Complaints by Categories
13
2
8
0
5
10
15
20
Q1 20 Q2 20 Q3 20
Nu
mb
er
COP - Communication
Median
Median = 8No. of Runs=2Shift = 0
Trend = 0Astronomical Point = 0
5
14 14
0
5
10
15
Q1 20 Q2 20 Q3 20
Nu
mb
er
AOP - Lab Specimen/Test
Median
Median = 14No. of Runs= 1Shift = 0
Trend = 0Astronomical Point = 0
1
4
12
0
10
20
Q1 20 Q2 20 Q3 20
Nu
mb
er
AOP - Assessment/ Diagnosis
Median
Median = 4No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
AOP – Assessment of PatientsCOP – Care of Patients
-
99% 98%99% 99%
98%
100%
90%
95%
100%
Jan-Jun 18 Jul-Dec 18 Jan-Jun 19 Jul-Dec 19 Jan-Jun 20
Co
mp
lian
ce P
erc
en
tage
Cancer Stage Documentation
Median
ASCO Benchmark
Median = 99% No. of Runs=1Shift = 0
Trend = 0Astronomical Point = 0
Cancer-Specific Indicators
97%96%
99% 99%97% 97% 97% 97% 97%
96%97%
90%
80%
90%
100%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
Quality of Histopathology Reports
Median
ASCO Benchmark
Median = 97% No. of Runs= 3Shift = 0
Trend = 0Astronomical Point = 0
100%98%
81%76%
95.6%100%
25%
50%
75%
100%
Jan-Jun 18 Jul-Dec 18 Jan-Jun 19 Jul-Dec 19 Jan-Jun 20
Co
mp
lian
ce P
erc
en
tage
Follow-up visits with treating Physicians
Median
ASCO Benchmark
Median = 95.6% No. of Runs= 2Shift = 0
Trend = 0Astronomical Point = 0
0.1%
0.9%
0.4% 0.3% 0.4% 0.4% 0.2%0.4% 0.4%
0.6% 0.5%
3.6%
0%
2%
4%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Co
mp
lian
ce P
erc
en
tage
Cancer Patients’ Readmission (Surgery)
Median
ASCO Benchmark
Median = 0.4% No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
ASCO - American Society of Clinical Oncology
-
2125
21 2733
56 5335 34 32 30
233
0
100
200
300
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
pe
r 1
00
0
Chemotherapy Patients’ Inpatient Admissions
Median
ASCO Benchmark
Median = 32No. of Runs= 3Shift = 0
Trend = 0Astronomical Point = 0
Cancer-Specific Indicators
5%
3%4%
6%
8%7% 7%
10%
5%6%
7%
6%
0%
5%
10%
15%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Patients’ Proportion receiving chemotherapy in the last 14 days of life
Median
ASCO Benchmark
Median = 6.4% No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
84 81 80 70 87
135 13286 75 78 76
465
0
250
500
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Nu
mb
er
pe
r 1
00
0
Chemotherapy Patients’ Emergency Room Admissions
Median
ASCO Benchmark
Median = 81No. of Runs= 4Shift = 0
Trend = 0Astronomical Point = 0
39%36%
30%
38% 39%
25%
34%
11%
5% 4% 3%10%
0%
25%
50%
Q1 18 Q2 18 Q3 18 Q4 18 Q1 19 Q2 19 Q3 19 Q4 19 Q1 20 Q2 20 Q3 20
Pe
rce
nta
ge
Patients’ Proportion admitted to the ICU in the last 30 days of life
Median
ASCO Benchmark
Median = 30% No. of Runs= 4Shift = 0
Trend = 1 (Oncologist review process initiated)Astronomical Point = 0
ASCO - American Society of Clinical Oncology