ARUANI MEDICAL COLLEGE AND HOSPITAL - NABH

Aligned to NABH 6th Edition • Published for public transparency • Review cycle: Quarterly

A. Patient Assessment & Access

KPI	Description	Target / Standard*	Recent Performance**
Initial Assessment Time	Arrival/registration to first clinical assessment (triage/FMC).	≤ 15 minutes (ED benchmark / policy)	—
Triage Accuracy / Triage Time	Time to triage; % appropriately classified by acuity.	Time ≤ 5 min; Accuracy ≥ 95%	—
OPD Wait Time	Arrival/registration to physician consultation.	≤ 30 minutes	—
Diagnostic Wait Time	Order to result/report time (lab/imaging).	Within service-line TAT (policy-defined)	—

* Targets per triage protocol & departmental TAT policy. ** Latest audited quarter.

B. Patient Safety & Risk Indicators

KPI	Description	Target / Standard*	Recent Performance**
Safety Precautions Compliance	Hand hygiene, patient ID, PPE use, time-out, etc.	≥ 95% compliance	—
HAIs (SSI, VAP, CAUTI, CLABSI)	Rates per 1,000 device days / per 100 surgeries.	Continuous reduction; within NABH & internal benchmarks	—
Falls	Patient falls per 1,000 patient-days (with/without injury).	Zero harm goal; ≤ 0.3 injurious	—
Pressure Ulcers	Hospital-acquired pressure injuries per 1,000 patient-days.	Continuous reduction; Stage 3+ near zero	—
Near Miss Events	Reported near misses per 1,000 patient encounters.	Healthy reporting culture; ↑ reporting, ↓ recurrence	—

* Device-day denominators & surveillance as per Infection Control policy. ** Rolling quarterly rates.

C. Clinical Outcomes

KPI	Description	Target / Standard*	Recent Performance**
SMR (ICU Deaths)	Standardized Mortality Ratio: observed vs expected.	≤ 1.0 with improving trend	—
Return to ED Within 72 Hours	% of discharged patients returning within 72 hours.	< 2–3%	—
Surgery Reschedule Rate	% surgeries rescheduled due to non-clinical/logistic causes.	Low (process reliability target)	—

* Risk-adjusted where applicable. ** ICU SMR methodology per Critical Care policy.

D. Clinical Governance & Rational Care

KPI	Description	Target / Standard*	Recent Performance**
Rational Prescription Rate	Adherence to formulary & antibiotic stewardship.	≥ 90%	—
Balloon Time (Cardiac PPCI)	Decision-to-balloon reperfusion time.	≤ 90 minutes	—

* Audited via Pharmacy/AMS & Cath Lab logs. ** Quarterly medians and compliance %.

E. Disease / Specialty-Specific KPIs

KPI	Description	Target / Standard*	Recent Performance**
COPD Management	Guideline adherence; exacerbation/readmission rates.	High adherence; ↓ exacerbations/readmits	—
Bronchiolitis Care	Admission rate; respiratory support; LOS.	Efficient, safe pediatric care	—
Dialysis-Related	Adequacy (Kt/V); access infection; session wait time.	Adequacy ≥ 1.2; low access infections	—

* Protocols per Pulmonology, Pediatrics & Nephrology. ** Denominators noted in departmental dashboards.

Notes
* Targets/standards are aligned with NABH 6th Edition, national guidance, and AMCH policies.
** “Recent Performance” reflects the latest audited quarter; device-day and case-mix denominators apply where relevant.
Methodologies: ICU SMR (risk adjusted), HAI per 1,000 device days / 100 surgeries, falls/pressure ulcers per 1,000 patient-days, PPCI decision-to-balloon median minutes, OPD/Diagnostic times per TAT policy.