A. PATIENT ASSESSMENT INDICATORS 1. 2.

Time taken for initial assessment by optometrist Percentage of cases wherein care plan is documented & countersigned by the clinician INITIAL TIME TAKEN FOR EXAMINATION ANTERIOR SEGMENT:
TIME MOTION ANALYSIS SEPTEMBER

Anterior Segment
Average waiting time for Average Examination counseling by consultant time 1 Hr 13 Min

Average waiting time for Tima initial Period examination New Sep-10 25 min Follow Up 17 Min Post op 7 Min Procedures

Average dilation Time 16 min

Average total time stay of patient at hospital 1 Hr 14 Min

Sep-10

11 Min

53 Min

57 Min

Sep-10

NA

34 Min

NA

35 Min

Sep-10

16 Min

8 Min

Depends on duration of procedure

Depends on duration of procedure

Initial time taken for Examination

30 25 Minutes 20 15 10 5 0 New Follow up Procedures post op Series1

TIME TAKEN FOR EXAMINATION (In Minutes)

30 25 25 20 16 15 17 10 5 0 N ew Follow up Procedures post op 7

POSTERIOR SEGMENT:
TIME MOTION ANALYSIS SEPTEMBER

RMG
Average waiting time for Examination by consultant 1 Hr 30 Min Average total time stay of patient at hospital 1 Hr 34 Min

Average waiting time for Time initial Period examination New Sep-10 25 min Follow Up 29 Min Post op 26 Min Procedures

Average dilation Time 27 min

Average counseling time NA

Sep-10

24 Min

1 Hr 14 Min

NA

1 Hr 20 Min

Sep-10

23 Min

1 Hr 14 Min

NA

1 Hr 15 Min

Sep-10

18 Min

19 Min

Depends on duration of procedure

NA

Depends on duration of procedure

Initial time taken for Examination

35 30 25 Minutes 20 15 10 5 0 New Follow up Procedures post op Series1

Initial time taken for Examination

35 30 25 Minutes 20 15 10 5 0 New Follow up Procedures post op 25 18 29 26

3.

CASES WHEREIN CARE PLAN IS DOCUMENTED AND COUNTERSIGNED

97% of cases have a clearly written and documented plan of treatment and related follow up.

B. SAFETY AND QUALITY CONTROL PROGRAMMES-DIAGNOSTIC SERVICES

1. No of reporting errors by auto refractor i.e K reading errors 2. Percentage of wrong IOL power calculations 3. Percentage of patients dilated without prescription S No: 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 Patients Name Aastha sood Aman Saxena Ashima goel Ashok Kumar Astha Disha Pant Devanshu M C Tyagi Preeti Pravesh S D Sharma S V Bhave Sheela Shobha Sarla Devi Difference -0.25 -0.25 0 0 0 0 -0.25 0 -0.25 0 0 0 -0.25 0 0

Out of the 15 patients observed 5 are reported with a difference of -0.25 and that is acceptable.

C. PERFORMANCE INDICATORS INVASIVE PROCEDURES 1. Re-exploration rate residual lens matter 2. Percentage of cases with posterior capsular rupture 3. Incidence of post operative visual activity of 6/9 within 3 weeks following cataract in a patient without a co morbid condition 4. Percentage of re-scheduling of surgical procedures 5. Percentage of patients with endopthalmitis 6. Percentage of detachment of desemets membrane 7. Percentage of error in surgery- Wrong eye surgery ADVERSE EVENT IN SURGERY ADVERSE EVENT July - Sep 2010
S.No 1 2 3 4 5 6 7 Date of surgery 6-Jul-10 8-Jul-10 28-Jul-10 10-Aug-10 17-Aug-10 17-Sep-10 21-Sep-10 89180 89253 MRD No 1465 85316 85547 86891 Patient Name Asha Rani Jain Saroj Malik Sunder Lal Manmohan Bhatnagar M.S. Talwar Subhash Puri Bhoori Singh Procedure RE Phaco +PCIOL LE Phaco ,SICS LE Phaco +PCIOL RE Phaco +PCIOL LE SICS +ACIOL SICS +PCIOL LE Phaco +ACIOL Consultant Dr Triveni Dr Mahipal Dr Hemlata Gupta Dr Triveni Dr R Bakshi Dr Sheela Nair Dr Triveni Adverse Event PCR PCR Retina Detachment PCR PCR PCR PCR

Posterior Capsule Rupture Retina Detachment Wrong Eye Endopthalmitis Detachment of Desemts membrane

6 1 0 0 0

MONTHS JULY AUGUST SEPTEMBER

No OF CASES 3 2 2

TYPE OF EVENTS

No of Cases

Endopthalmitis

Detachment

Detachment

Wrong Eye

of Desemts

NUMBER OF CASES-MONTH WISE TREND: :

MONTH JULY AUGUST SEPTEMBER ADVERSE EVENTS 3 2 2 TOTAL PROCEDURES 500 503 522 PERCENTAGE 0.60 0.40 0.38

membrane

Posterior

Capsule

Rupture

7 6 5 4 3 2 1 0

Typ O E ts e f ven

Series1

Retina

PERCENTAGE 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 JULY AUGUST SEPTEMBER

PERCENTAGE 0.7 0.6 0.5 0.4 0.3 0.2 0.1 0 JULY AUGUST SEPTEMBER 0.4 0.38 0.6

THIRD WEEK POST OPERATIVE VISION

Vision More than 6/9 Vision equal to 6/9 Vision less than 6/9 TOTAL 64 20 10 94 Cases Cases Cases Cases

90% percent of cases have the best corrected vision of equal to or more than 6/9.

100 90 80 70 60 50 40 30 20 10 0

94

64

Total Cases >6/9 = 6/9 <6/9 20 10

Total Cases

>6/9

= 6/9

<6/9

20

10 Total Cases >6/9 94 = 6/9 <6/9

64

RESCHEDULED SURGERIES

MRD NO 82118 75262 80679 86283 71625 80667 88621 88063 77079

Geeta Yadav Vivek Aparajit Chavi Jain Hamid Vivek Sagar Veena Manocha Basim Hamid Baby Sahiba Mr Najmuddin

Surgery Rediling of IOL IOL Explantation Rediling of ICL Re VR RD Re VR Re VR under GA Conjuctival Foreign Body removal Lasik Redo

Dr Name Dr Mahipal Dr Mahipal Dr Mahipal Dr Dinesh Talwar Dr Avinendra Gupta Dr Lalit Verma Dr Dinesh Talwar Dr Kanak Tyagi Dr Mahipal

Date of Surgery 7/14/2010 7/19/2010 8/9/2010 8/10/2010 9/3/2010 9/3/2010 9/10/2010 9/11/2010 9/29/2010

REDO SURGERIES Jul-10 Aug-10 Sep-10

5 3 2

REDO SURGERIES Anterior Segment Posterior Segment

R edo S urgeries
6 No of Cases 5 4 3 2 1 0 A nterior S egm ent

5 5

S eries1

P osterior S egm ent

D ifferen S ecialities t p

REDO SURGERIES: MONTH WISE MONTH WISE TREND:

REDO SURGERIES Jul-10 Aug-10 Sep-10

no of redo surgeries 5 3 3

Total procedures 500 503 522

Percentage 1.00 0.60 0.38

R edo S urgeries
6 No of Cases 5 4 3 2 1 0 Jul-10 A ug-10 Mn s o th S ep-10 S eries1

Percentage 1.20 1.00 0.80 0.60 0.40 0.20 0.00 Jul-10 Aug-10 Sep-10 0.60 0.38 Percentage 1.00

D. PERFORMANCE INDICATORS-ADVERSE DRUG EVENTS 1. Percentage of medication errors 2. Incidence of adverse drug reaction 3. Percentage of contrast related reactions
CONTRAST RELATED ADVERSE DRUG REACTIONS

S.No 1 2 3

DATE Sep-10 Sep-10 Sep-10

NAME Sumegha Hussan Jabbar Atiyah Archana Anupam

MRD No 89294 89503 89870

AGE 35 40 40

SEX M M F

CONSULTANT Avnindra Gupta H. K. Tiwari Harsh Kumar

DYE Flouroscien Flouroscien Flouroscien

REACTION Rashes Itching Vomitting

C N R S R L T DR A T N O T A T E A E E C IO S 3.5 no of casescs 3 2.5 2 1.5 1 0.5 0 1 sep 2010 S ep-10

Frequency of medication errors:

E. PERFORMANCE INDICATORS-ANESTHESIA RELATED EVENTS 1. Percentage of unplanned ventilation following anesthesia 2. Percentage of adverse anesthesia events 3. Anesthesia related mortal perforation during local anesthesia ADVERSE ANAESTHESIA EVENTS
August 503 0 September 522 0

Total Surgeries Adverse Anaesthesia Event

ADVERSE ANAESTHESIA EVENT AUGUST

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Adverse Anaesthesia Event Series1

ADVERSE ANAESTHESIA EVENT SEPTEMBER

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Adverse Anaesthesia Event Series1

F. PERFORMANCE INDICATORS- AVAILABILITY AND CONTENT OF MEDICAL RECORDS 1. 2. 3. 4. Percentage of medical records not having discharge summary Percentage of medical records not having initial assessment & plan of care Percentage of medical records having incomplete & /or improper consent Percentage of missing records

IPD indicators: 1, 2 & 3 Total Total Particular August Total percent September total percent cases documents Documents 10 400 2.5 8 400 2 18 800 without percent 2.25

discharge Without prescription 12 Prescription without signature of doctor 10 Incomplete / missing consent 16

400

10

400

2.5

22

800

2.75

400 400

2.5 4

2 7

400 400

0.5 1.75

12 23

800 800

1.5 2.875

Indicator-4 Other Documents Missing Lens Undertaking for Cataract Biometry Report Total 18 17 Number of cases Percentage 530 3.40 530 3.21

Laboratory reports when advised by consultant 150 cases admission Form Bill/Permission letter/Letter of Credit 2 cases 36 Cases

TREND:

G. PERFORMANCE INDICATORS-PROCUREMENT OF MEDICATION SUITABLE TO MEET PATIENTS NED 1. Percentage of stock out including emergency drugs 2. Percentage of consumables rejected before receiving them 3. Incidence of variations from the procurement process

STOCK OUT REPORT-APR10 TO AUG10

S.No. Item Month of Stock Out Vendor Reason for Stock out Remedial Action

1 2

Blade Cresent Buds

Apr-10 Apr-10

Saivision S S Vision

Short Supply Short Supply

Purchased from NCS Network Purchased from Local Vendor Procured from Shreya Life Sciences Procured from K - Medi Optics Procured from Friends International Procured from Icon Medicare NA NA

3 4

Inj Hynidase Oint. Ciplox

May-10 May-10

City Drugs City Drugs Medicare International National Industrial NA NA

Short Supply Short Supply

5 6 7 8

Reliseal Glue Troker Set Nil Nil

May-10 Jun-10 Jul-10 Aug-10

Short Supply Short Supply NA NA

Item April-10 May-10 June-10 July-10 August-10 2 3 2 1 0

Stock out Report

3 2.5 2 No. of Items 1.5 1 0.5 0

Apr-10

May-10

Jun-10 Months

Jul-10

Aug-10

TREND DEPICTING STOCK OUTS:

Stock out Report
3.5 3 2.5 2 No. of Items 1.5 1 0.5 0 3 2 2 1 0 Apr-10 May-10 Jun-10 Months Jul-10 Aug-10

H. PERFORMANCE INDICATORS- REPORTING OF ACTIVITIES AS REQUIRED BY LAWS AND REGULATIONS 1. 2. 3. 4. No of deaths No of notifiable disease Submission of report/ data pertaining to bio medical waste Submission of tax return & deduction of taxes as specified DEATH RATE
August 503 0 September 522 0

Total Surgeries Death

DEATH - AUGUST 2010

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Death Series1

DEATH - SEPTEMBER 2010

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Death Series1

I. PERFORMANCE INDICATORS FOR RISK MANAGEMENT 1. No of variations observed in mock drill 2. Incidence of fall within hospital premises due to slippery tiles, broken stairs or absence of side rails on the staircase. 3. No of employees provided with pre exposure prophylaxis PATIENT FALLS

TOTAL PATIENTS FALLS

AUGUST 6084 0

SEPTEMBER 5935 0

PATIENT FALLS IN AUGUST

7000 6000 No OF CASES 5000 4000 3000 2000 1000 0 TOTAL PATIENTS FALLS Series1

PATIENT FALLS IN SEPTEMBER

7000 6000 No OF CASES 5000 4000 3000 2000 1000 0 TOTAL PATIENTS FALLS Series1

EMPLOYEE HEALTH RECORD

EMPLOYEE HEALTH RECORD Total No of employees Health Problems 125 0

EMPLOYEE HEALTH RECORD

140 120 TOTAL No 100 80 60 40 20 0 Total No of employees Health Problems Series1

J. PERFORMANCE INDICATORS FOR UTILIZATION OF SPACE, MANPOWER &EQUIPMENT 1. OT Utilization rate 2. Optimum utilization of capital intensive equipment 3. Equipment down time 1) Engineering dept 2) Biomedical engineering dept 3) IT dept 4. Ratio of patient: optometrist 5. Ratio of patient: Doctor OT Utilization: Operating room utilization is a measure of the use of an operating room that is properly staffed with people needed to successfully deliver a surgical procedure to a patient. Total hours of cases performed Raw Utilization = -------------------------------------------------Total hours of OT time allocated Total hours of cases + Credit time Adjusted Utilization = --------------------------------------------------Total Hours of OR time allocated Credit time: turnover time necessary to set up and clean up OT rooms between cases

Month/OT Aug-10 Sep-10 Oct-10

OT 1 85 85 90

OT 2 80 85 83

OT 3 60 65 85

Equipment down Time:

Equipment Indirect Ophthalmoscope Immersion Machine Slit Lamp Location Exam - 5 Basement Exam Breakdown date 1-Apr-10 7-Apr-10 12-Apr-10 Rectification date 1-Apr-10 7-Apr-10 21-Apr-10 Down Time Within 24 hours Within 24 hours 8 days

IOL Master ECG Machine Slit Lamp Slit Lamp A Scan ECG Machine Slit Lamp Slit Lamp Chart Projector ETO Machine IOL Master Fields Machine Fields Machine Slit Lamp

12 First Floor Basement Exam 10 Exam 12 First Floor Basement Exam 12 Exam 12 Exam 11 OT First Floor Basement Basement Exam - 4 <24 Hours 3

23-Apr-10 6-May-10 24-May-10 29-May-10 2-Jun-10 7-Jul-10 6-Aug-10 12-Aug-10 16-Aug-10 27-Aug-10 22-Sep-10 24-Sep-10 26-Sep-10 15-Oct-10

24-Apr-10 7-May-10 24-May-10 31-May-10 10-Jun-10 14-Aug-10 8-Aug-10 14-Aug-10 26-Aug-10 28-Aug-10 30-Sep-10 25-Sep-10 27-Sep-10 16-Oct-10

1 day 1 day Within 24 hours 2 days 8 days 37 days 2 days 2 days 10 days 1 day 8 days 1 day 1 day 1 day >8 Days 3 2

Break Down Time No. Of Equipments

1 Day 6

2-4 Days 3

4-8 Days

Equipment Down Time

6 5 4 No. of 3 Equipments 2 1 0 <24 Hours 1 Day 2-4 Days Down Time 4-8 Days >8 Days 3 3 3 2 6

No. of Equipments 7 6 5 4 3 3 2 1 0 <24 Hours

Equipment Down Time

6

3 2

1 Day

2-4 Days

4-8 Days

>8 Days

Down Time

DOCTOR/ OPTOMETRIST PATIENT RATIO

DOCTOR PATIENT RATIO DOCTOR PATIENT

1 30

DO CTO PA R TIENT RA TIO

35 30 25 20 15 10 5 0 D CO O T R PAT T IEN Series1

OPTOMETRIST PATIENT RATIO OPTOMETRIST 1 PATIENT 15

O PTO ETRIST PA M TIENT RA TIO

16 14 12 10 8 6 4 2 0 O O ET IST PT M R PAT T IEN Series1

K. PERFORMANCE INDICATORS SUITABLE TO PATIENT'S SATISFACTION WHICH ALSO INCORPORATES WAITING TIME FOR SERVICES

1. Patient satisfaction Index 2. Waiting time for services for OPD FEEDBACK FORM ANALYSIS-PATIENT SATISFACTION

Jun-2010 to Aug 2010 % Needs Improvement 2 3 1 % No Comments 1 2 4

Services & Facilities Helpfulness of the staff Cleanliness & Hygiens

% Satisfied 97 95 95

PATIENTS SATISFACTION LEVEL- September, 2010

120 100 80 60 40 20 0 Serv ices & Facilities Helpfulness of the staff Cleanliness & Hygiens % Satisfied % Needs Improv ement % No Comments

PATIENTS SATISFACTION MEDICAL ASPECT

Patient satisfaction level(Jun-Aug 2010)

98 97 96 95 94 93 92 97 95 94 95

Jun-10 Jun-10 Series1 94

Jul-10 Jul-10 95

Aug-10 Aug-10 95

Sep-10 Sep-10 97

Level of patient satisfaction is continuously increasing.

Level of patient satisfaction

97.5 97 96.5 96 95.5 95 94.5 94 93.5 93 92.5

97

95 94

95

Jun-10

Jul-10

Aug-10

Sep-10

RATING OF SERVICES BY PATIENTS:

Rating 6 7 8 9 10 No Comments Total

% of people 3 11 31 23 13 19 100

Most of the patients have rated us 8 or above. (75%)

Rating by patients (Jun-2010 to Aug 2010)

19%

3%

11%

13% 23%

31%

10

No Comments

L. PERFORMANCE INDICATORS-EMPLOYEE SATISFACTION 1. Employee satisfaction

2. Employee attrition rate 3. Employee absenteeism rate

ATTRITION RATE
Attrition Rate(April 2009-March 2010) S. No 1 2 3 4 5 6 7 8

Category Billing Doctors Counsellors Front Office IT OPD Attendant Medical Transcriptionist Optometrist

Attrition Rate % 28 20 30 28 25 18 28 15

35 30 25 20 15 10 5 0
O IT PD M ed At ic te al nd Tr an an t sc rip tio ni st O pt om et ris t Do ct or s Co un se llo rs Fr on tO ffi ce Bi lli ng

S rie e s1

ATTRITION RATE MONTH WISE

New Joinees at SJE July August September

4 5 8

New Joinings
9 8 7 6 5 4 3 2 1 0 July August September 4 5

9 8 7 6 5 4 3 2 1 0 July August September

Attrition Rate

Attrition Rate Month July August September No of Employees 5 3 2

Attrition rate
6 5 4 3 2 1 0 July August September 5

3 2

Attrition rate
6 5 4 3 2 1 0 July August September 3 2 5

J. PERFORMANCE INDICATORS SUITABLE TO ADVERSE EVENTS & NEAR MISSES

1. 2. 3.

No of sentinel events Percentage of near misses No of security related incidents including theft

NEAR MISSES
Total Surgeries Near misses Aug-10 503 0 Sep-10 522 0

NEAR MISSES AUGUST

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Near misses Series1

NEAR MISSES SEPTEMBER

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Near misses Series1

SENTINAL EVENTS
Aug-10 503 0 Sep-10 522 0

Total Surgeries Sentinal Event

AD V E R S E S E N TIN AL E V E N T AU GU S T
600 500 No OF CASES 400 300 200 100 0 Total S urgeries S entinal E vent S eries 1

ADVERSE SENTINAL EVENT SEPTEMBER

600 500 No OF CASES 400 300 200 100 0 Total Surgeries Sentinal event Series1

THEFTS
AUGUST 2010 SEPTEMBER 2010 0 0

THEFTS
1 No OF CASES 0.8 0.6 Series1 0.4 0.2 0 AUGUST MONTHS 2010 SEPTEMBER