Patient assessment (JCI chapters—assessment of patients and care of patient) |
Y1 | Initial medical assessment done within 24 h of admission | Percentage |
Y2 | Initial nursing assessment within 24 h of admission | Percentage |
Y3 | Percentage of pain assessments completed per month | Percentage |
Y4 | Percentage of completed pain reassessments per month | Percentage |
Surgical procedures (JCI chapters—patient and family rights, anaesthesia and surgical care, quality and patient safety) |
Y5 | Completion of the surgical invasive procedure consent | Percentage |
Y6 | Percentage of operating room (OR) cancellation of elective surgery (transformed) | Percentage |
Y7 | Unplanned return to OR within 48 h (transformed) | Percentage |
Medication error use and near-misses (JCI chapter—medication management and use) |
Y8 | Reported medication errors (transformed) | Per 1000 prescriptions |
Anaesthesia and sedation use (JCI chapter-anaesthesia and surgical care) |
Y9 | Percentage of completed anaesthesia, moderate and deep sedation consents | Percentage |
Y10 | Percentage of completed modified Aldrete scores (pre, post, discharge) | Percentage |
Y11 | Percentage of completed pre-anaesthesia assessments | Percentage |
Y12 | Percentage of completed anaesthesia care plans | Percentage |
Y13 | Percentage of completed assessments of patients receiving anaesthesia | Percentage |
Y14 | Effective communication of risks, benefits and alternatives of anaesthesia to patients | Percentage |
Availability, content and use of patient records (JCI chapter—management of communication and information) |
Y15 | Percentage of typed post-operative report completed within 48 h | Percentage |
Infection control, surveillance and reporting (JCI chapter—prevention and control of infections) |
Y16 | Hospital acquired methicillin-resistant Staphylococcus aureus rate (transformed) | Per 1000 Admissions |
Y17 | Surgical site infection rate (transformed) | Percentage |
Reporting of activities as required by law and regulation (JCI chapter—governance, leadership and direction) |
Y18 | Mortality rate (transformed) | Percentage |
International patient safety goals (JCI chapter -international patient safety goals) |
Y19 | Compliance with surgical site marking | Percentage |
Y20 | Compliance with the time-out procedure | Percentage |
Y21 | Screening for patient fall risk | Percentage |
Y22 | Overall hospital hand hygiene compliance rate | Percentage |
Y23 | Fall risk assessment and reassessment | Percentage |