technical specifications for key performance indicators (kpi) clinical
TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 BURN AND TRAUMA NO SUBSPECIALTY D 1 - D D 2 3 Burn D 4 Trauma I 5 - I 6 - I 7 - TYPE INDICATOR Timeliness for crash operation within (≤) 60 minutes Minor trauma mortality rate Severe burn mortality rate Percentage of non-therapeutic laparotomy (NTL) for trauma cases Percentage of trauma alert responded by surgeon within (≤) 30 minutes Percentage of patients with duration of surgery within (≤) 90 minutes in crash trauma laparotomy Percentage of cases with unplanned return to the operating theatre within the same admission following an elective surgical procedure (General Surgery) CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) DIMENSION STANDARD HOSPITAL REPORTING FREQUENCY Customer ≥ 75% 3 Monthly Effectiveness Effectiveness < 8% < 30% 3 Monthly 3 Monthly Effectiveness < 20% 3 Monthly Customer > 75% 6 Monthly Customer > 75% 3 Monthly Effectiveness ≤ 10% Monthly PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 Indicator 1 Discipline Name of indicator Dimension of Quality Rationale Definition of Terms : : : : : Departmental Burn and Trauma Timeliness for crash operation within (≤) 60 minutes Customer centeredness 1. Mortality risk of exsanguinating patient is related to delay in definitive surgery. 2. Refers to KKM policy of waiting time for very urgent surgery. 3. WHO guidelines for essential trauma care 2004. : Crash operation: Any operation that is required based on rapid deterioration of hemodynamic status as a direct result of trauma in which if delayed may result in death and/ or permanent disability. Within (≤) 60 minutes: Time taken from the referral made to Trauma Unit and decision made for operation to the time operation commenced. : Inclusion: 1. Any exsanguinating patient managed/ referred to the Trauma Unit from Emergency Department. Criteria Type of indicator Numerator Denominator Formula : : : : Standard Data Collection : : Remarks : Indicator 2 Discipline Name of indicator Dimension of Quality Rationale : : : : : Exclusion: 1. Exsanguination from non-trauma causes e.g. bleeding peptic ulcer. 2. Exsanguinating cases not managed by the trauma unit e.g. base of skull bleeding. Rate-based process indicator Number of crash operations performed within (≤) 60 minutes Total number of crash operations performed Numerator x 100% Denominator ≥ 75% 1. Where: Data will be collected in wards that cater for the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 3 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from OT notes/ patient’s case note (refer to KPI MOH Guidelines). Departmental Burn and Trauma Minor trauma mortality rate Effectiveness 1. Trauma mortality is related to severity. The group with minor trauma is expected to have a high probability of survival and any mortality is a potentially preventable death. CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 Definition of Terms Criteria : : 2. US National Trauma Database results as a basis for comparison. Minor trauma: Any injury with Injury Severity Score (ISS) <16. Inclusion: 1. Minor trauma cases admitted under Trauma Unit. Exclusion: 1. Minor trauma cases not admitted under Trauma Unit. Type of indicator Numerator Denominator Formula : : : : Standard Data Collection : : Remarks : Indicator 3 Discipline Name of indicator Dimension of Quality Rationale : : : : : Definition of Terms : Criteria : Type of indicator Numerator Denominator Formula : : : : Rate-based outcome indicator Number deaths following minor trauma Total number minor trauma cases admitted Numerator x 100% Denominator < 8% 1. Where: Data collected in wards that cater for the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 3 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from registration book (refer to KPI MOH Guidelines). Departmental Burn and Trauma (Burn) Severe burn mortality rate Effectiveness 1. Mortality is correlated with severity of burns and expertise/ facilities available. 2. Mortality index = % burns + age. 3. By having the performance of this indicator, comparison with other Burns Unit can be made. Severe burns: >20% body surface area. Mortality: Deaths occur within the same admission. Inclusion: 1. Burns between 20 – 40% as the primary diagnosis. Exclusion: 1. Burn associated with inhalational injuries. 2. Age less than 12 years old. 3. Patients who died due to other secondary diagnosis. Rate-based outcome indicator Number of deaths due to severe burn Total number of patients with severe burn Numerator x 100% CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 Standard Data Collection : : Remarks : Indicator 4 Discipline Name of indicator Dimension of Quality Rationale : : : : : Definition of Terms : Criteria : Type of indicator Numerator Denominator Formula : : : : Standard Data Collection : : Remarks : Denominator < 30% 1. Where: Data collected in wards that cater for the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 3 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from Burns admissions records/ registry (refer to KPI MOH Guidelines). Departmental Burn and Trauma (Trauma) Percentage of non-therapeutic laparotomy (NTL) for trauma cases Effectiveness 1. Unnecessary exploratory laparotomy for intra-abdominal injuries where the bleeding has already stopped by itself is associated with post-operative morbidity. 2. These patients can be safely managed with conservative management thus avoiding the complications of surgery. Non-therapeutic laparotomy (NTL): Laparotomy performed for suspected intraabdominal injuries where no surgical therapeutic procedure was needed upon exploration. NTL includes cases where peritoneal washout of haemoperitoneum was performed and the injured organ has no active bleeding/ does not need surgical haemostasis or repair. Inclusion: 1. All trauma cases. Exclusion: 1. Cases where only a diagnostic laparoscopy was performed. Rate-based process indicator Number of non-therapeutic laparotomy (NTL) for trauma cases performed Total number of laparotomy for trauma cases performed Numerator x 100% Denominator < 20% 1. Where: Data collected in wards that cater for the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 3 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from OT notes/ record (refer to KPI MOH Guidelines). CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 Indicator 5 Discipline Name of indicator Dimension of Quality Rationale : : : : : Definition of Terms : Criteria : Individual Burn and Trauma Percentage of trauma alert responded by surgeon within (≤) 30 minutes Customer centeredness 1. Timeliness in response to a trauma alert determines how fast a patient with major trauma gets attended to. 2. Trauma alerts in an institution is made for major trauma and within a specified predetermined clinical situation. Response time: Time taken from the time cases referred to Trauma Unit to the time cases reviewed by the Trauma Surgeon. Inclusion: 1. All trauma alerts as defined by the institution made to the trauma surgeon. Exclusion: NA Rate-based process indicator Number of trauma alerts responded by surgeon within (≤) 30 minutes Total number of trauma alerts Numerator x 100% Denominator > 75% 1. Where: Data will be collected in Emergency Department. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 6 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from patient’s case notes/ record book (refer to KPI MOH Guidelines). Type of indicator Numerator Denominator Formula : : : : Standard Data Collection : : Remarks : Indicator 6 Discipline Name of indicator : Individual : Burn and Trauma : Percentage of patients with duration of surgery within (≤) 90 minutes in crash trauma laparotomy : Customer centeredness : 1. Excessive time taken during conduct of a trauma laparotomy leads to poor outcome as the haemodynamically unstable patients has little or no physiological reserves. 2. Decision for damage control procedures need to be made early in the conduct of the laparotomy. : Duration of surgery: Time taken from the start of abdominal incision until closure of wound (by whatever technique e.g. stapler, suture, vacuum assisted closure, etc). Dimension of Quality Rationale Definition of Terms Crash trauma laparotomy: The conduct of an emergency laparotomy for intraCLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 abdominal bleeding due to trauma where the patient is haemodynamically unstable. Criteria : Type of indicator Numerator : : Denominator Formula : : Standard Data Collection : : Remarks : Indicator 7 Discipline Indicator : : : Dimension of Quality Rationale : : Definition of Terms : Criteria : **Haemodynamically unstable: Any systolic BP <100 mmHg (or requires use of inotropes to maintain SBP >100 mmHg) where initial resuscitation has resulted in transient response or requires large amounts of fluids and blood/ blood products to maintain a SBP >100 mmHg before or during surgery. Inclusion: 1. Any trauma laparotomy for haemodynamically unstable patient. Exclusion: 1. Cases where more than one compartment involved e.g. laparotomy with thoracotomy. 2. Patients or relatives refused or delay in giving consent for surgery. Rate-based process indicator Number of patients with duration of surgery within (≤) 90 minutes in crash trauma laparotomy Total number of patients underwent crash trauma laparotomy Numerator x 100% Denominator > 75% 1. Where: Data will be collected in wards that cater for the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: 3 monthly data collection. 4. Who should verify: Data will be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from OT notes/ patient’s case note (refer to KPI MOH Guidelines). Individual Burn and Trauma Percentage of cases with unplanned return to the operating theatre within the same admission following an elective surgical procedure Effectiveness 1. Any unplanned return to the operation theatre may indicate a quality problem due to the occurrence of intra-operative problems that are serious enough to warrant intervention post-operatively. Unplanned return: Unexpected return to the operating theatre to address a previous complication of the original operation. Inclusion: 1. Elective surgical procedure performed under general anaesthesia. Exclusion: 1. Endoscopy cases. 2. Day care cases. CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0 TECHNICAL SPECIFICATIONS FOR KEY PERFORMANCE INDICATORS (KPI) CLINICAL SERVICES MEDICAL PROGRAMME 2014 Type of indicator Numerator : : Denominator Formula : : Standard Data Collection : : Remarks : Rate-based process indicator Number of cases with unplanned return to the operating theatre within the same admission following an elective surgical procedure Total number of cases underwent elective surgical procedure Numerator x 100% Denominator ≤ 10 % 1. Where: Data will be collected at surgical wards or wards that cater the above condition. 2. Who: Data will be collected by Officer/ Nurse in-charge (indicator coordinator) of the department/ unit. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is suggested to be collected from OT book/ registration book/ patient’s case note (refer to KPI MOH Guidelines). National Institutes of Health (NIH) USA data reports an unplanned return rate of between 5% and 15%, depending on the type of surgery performed. CLINICAL PERFORMANCE SURVEILLANCE UNIT D(Departmental); I(Individual) PERFORMANCE SURVEILLANCE 3.0
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