‫المملكة العربية السعودية‬
‫وزارة الدفاع‬
‫اإلدارة العامة للخدمات الطبية للقوات المسلحة‬
‫إدارة تطوير الجودة و سالمة المرضى‬
Kingdom of Saudi Arabia
Ministry of Defense
Medical Services General Directorate
CQI and PS Department
KEY PERFORMANCE INDICATORS
(KPI)
MANUAL
2018
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
1
2 of 92
TABLE OF CONTENTS
Page No.
SUMMARY
4
KEY PERFORMANCE INDICATORS (KPIs)
WORKLOAD
6
1)
Total Number of Active Patient Files
7
2)
Total Number of Beds
8
3)
Total Available Beds
9
UTILIZATION
11
4)
Bed Occupancy Rate
12
5)
Average Length of Stay
14
6)
Operating Room (OR) Utilization Rate
16
ACCESSIBILITY
19
7)
Average Time To See ED Physician – CTAS Level 3
20
8)
Average Boarding Time
22
9)
Days To Third Next Available Appointment To Specialist Clinic
24
EFFECTIVENESS
10)
Hospital Readmission Percentage
11) Patient Experience Measure
UNDESIRED OUTCOMES
27
28
30
33
12)
Rate of Transfusion Reaction
34
13)
14)
Rate of Adverse Drug Event
Rare of Adverse Event in Procedural Sedation
37
40
15)
16)
Rate of Adverse Event in Anesthesia
Rate of Discrepancies Between Preoperative and Postoperative
Diagnosis
EFFICIENCY
17)
Healthcare Cost per Capita
SAFETY
42
44
46
47
49
18)
Composite Patient Safety Goals Measure (IPSG.1 – IPSG.4.1)
50
19)
Patient Fall
52
20)
Culture of Safety
55
21)
Medication Error Rate
62
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Issue No.
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TABLE OF CONTENTS
Page No.
CLINICAL MEASURES
64
22)
Stroke Thrombolytic Therapy
65
23)
Venous Thromboembolism (VTE) Prophylaxis
68
24)
Pressure Ulcer Prevalence
72
25)
Rate of Diabetic Patient with HBA1C ≤ 7
75
STAFF
77
26)
Staff Turnover Rate (Medical / Nursing)
78
27)
Staff Satisfaction Rate
80
INFECTION CONTROL
28)
29)
82
83
30)
Hand Hygiene Compliance
Central Line Associated Blood Stream Infections (CLABSI)
Measure
Appropriateness Use of Antibiotics
31)
Surgical Infection Rate
89
32)
Multi-Drug Resistant Organism (MDRO) Rate
91
85
87
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Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Issue No.
Page No.
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SUMMARY
Domain
Workload
Utilization
Accessibility
#
INDICATOR
Target
Frequency of
Data
Submission
New
Addition
2018
1
Total Number of Active Patient
Files
N/A
Annual
2
Total Number of Beds
N/A
Annual
3
Total Available Beds
N/A
Annual
4
Bed Occupancy Rate
 85%
Monthly
5
Average Length of Stay
≤ 8.1 days
Quarterly
6
Operating Room (OR) Utilization
Rate
75-80%
Quarterly
7
Average Time To See ED
Physician – CTAS Level 3
≤ 30 minutes
Monthly
8
Average Boarding Time
≤ 24 hours
Monthly
9
Days To Third Next Available
Appointment To Specialist Clinic
10 days
Monthly
10
Hospital Readmission Percentage
≤ 4.49%
Quarterly
11
Patient Experience Measure
≥ 71%
Biannual

12
Rate of Transfusion Reaction
0.07 per 100,000
Quarterly

13
Rate of Adverse Drug Event
≤ 3.5 per 1,000
doses
Quarterly

14
Rate of Adverse Event in
Procedural Sedation
≤ 4.7%
Quarterly

15
Rate of Adverse Event in
Anesthesia
≤ 4.8%
Quarterly

16
Rate of Discrepancies Between
Preoperative and Postoperative
Diagnosis
Annual
Improvement of
Data by 10%
Quarterly

17
Health Care Cost per Capita
Not Applicable
Annual
Modified
Effectiveness
Undesired
Outcomes
Efficiency
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Ministry of Defense
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SUMMARY
Domain
#
INDICATOR
Target
Frequency of
Data
Submission
New
Addition
2018
≥ 95.5%
Quarterly
Modified
≤ 2 per 1,000
patient days
Quarterly
18
Composite Patient Safety Goals
Measure (IPSG.1 – IPSG.4.1)
19
Patient Fall
20
Culture of Safety
AHRQ average
of that year
Annual
21
Medication Error Rate
Annual
Improvement of
Data by 10%
Quarterly

22
Stroke Thrombolytic Therapy
≥ 97.7%
Quarterly

23
Venous Thromboembolism (VTE)
Prophylaxis
≥ 98%
Quarterly
24
Pressure Ulcer Prevalence
 4.5%
Quarterly
25
Rate of Diabetic Patient with
HBA1C ≤ 7
≥ 65%
Quarterly

26
Staff Turnover Rate
(Medical / Nursing)
≤ 3%
Quarterly
Modified
27
Staff Satisfaction Rate
≥ 80%
Annual

28
Hand Hygiene Compliance
≥ 70%
Quarterly
29
Central Line Associated Blood
Stream Infections (CLABSI)
Measure
Annual decrease
by 50%
Quarterly

30
Appropriateness Use of
Antibiotics
≥ 90%
Quarterly

Quarterly

Quarterly

Safety
Clinical
Measures
Staff
Infection
Control
31
Surgical Site Infection Rate
32
Multi-Drug Resistant Organism
(MDRO) Rate
Reduce baseline
by 50% and then
a decrease of
10% every year
N/A, the less
MDRO rate the
best outcome
will be
Kingdom of Saudi Arabia
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MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
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WORKLOAD
1.
2.
3.
Total Number of Active Patient Files
Total Number of Beds
Total Available Beds
1
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Total Number of Active Patient Files
Description
Type of Indicator
Initial Eligible Patient
Population Criteria
Numerator
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The total number of active patient files in the hospital.
Structure
All patient files.
Total number of active patient files in the hospital.
Active Patient Files: files of patients who have received
health care services in the hospital at least once over the
last five years.
All active patient files.
All inactive patient files (files of patients who have NOT
received any health care services in the hospital over the
last five years).
None
Not Applicable
Not Applicable
Not Applicable
N
Medical Record Department
All active patient files. No sampling.
Medical Record Department.
See Page 10
Retrospective
Annually
Not Applicable
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KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Total Number of Beds
Description
Type of Indicator
Initial Eligible Patient
Population Criteria
Numerator
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The total number of beds.
Structure
All patient beds
Total number of patient licensed beds in the hospital.
Licensed beds: an adult beds, pediatric beds, pediatric
bassinets, incubators and cots for premature or ill babies
admitted to nursery or NICU, and beds maintained in
patient care areas for lodging patients in acute, long term
or domiciliary areas of the hospital.
All licensed beds.




Cots of normal newborn babies
Beds in labor rooms
Beds in birthing rooms
Beds
in
post-anesthesia/post-operative/po st
procedure recovery rooms
 Beds in outpatient areas
 Beds in emergency rooms
 Beds in ancillary departments
 Beds in other such areas which are regular ly
maintained and utilized for only a portion of the stay
of patients, primarily for special procedures or not for
inpatient lodging (less than 24 hours)
None
Not Applicable
Not Applicable
Not Applicable
N
Patient affairs department and/or medical administration
All patient beds. No sampling.
Patient affairs department and/or medical administration
See Page 10
Retrospective
Annually
Not Applicable
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KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Total Available Beds
Description
Type of Indicator
Initial Eligible Patient
Population Criteria
Numerator
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The total number of available beds.
Structure
All patient beds
Total number of patient licensed beds in the hospital that
are available and ready to lodge patients.
Available beds: licensed patient beds that are physically
available for use, have the needed staff and support
services (such as food, laundry and housekeeping).
All licensed available beds (as per definition, inclus io n
and exclusion criteria stated in Total Number of Beds
specification manual).
 Non-licensed beds (as per definition, inclusion and
exclusion criteria stated in Total Number of Beds
specification manual).
 Beds that are not physically available or don’t have
the needed staff or support services.
None
Not Applicable
Not Applicable
Not Applicable.
N
Patient affairs department and/or medical administratio n.
All patient available beds. No sampling.
Patient affairs department and/or medical administratio n.
See Page 10
Retrospective
Annually
Not Applicable
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KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Workload Indicators
Hospital:
Year:
Number of Active
Patient Files
Total Number of
Beds
Number of
Available Beds
Percentage of
Available Beds
#DIV/0!
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
UTILIZATION
4.
5.
6.
Bed Occupancy Rate
Average Length of Stay
Operating Room (OR) Utilization Rate
1
11 of 92
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Bed Occupancy Rate
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The rate (percentage) of occupied inpatient beds
Process
All inpatient beds
Total number of inpatient days of care for a month.
Inpatient days of care: sum of all inpatient service days
or occupied bed days.
All inpatient occupied beds
Occupied observation and emergency bed days
Beds days available over the same month
Beds days: The maximum number of inpatient days of
care that would have been provided if all beds were filled
over a month, and is equal to (number of available beds
x number of days in a month)
All inpatient beds
Observation and emergency beds
(N/D)*100
Patient censuses
All inpatient beds
All inpatient areas
See Page 13
Retrospective
Monthly
< 85% (NHS, 2015)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Bed Occupancy Rate
Indicator Name:
Hospital:
Month & Year:
DATE
Number of Occupied
Bed Days
DATE
1
17
2
18
3
19
4
20
5
21
6
22
7
23
8
24
9
25
10
26
11
27
12
28
13
29
14
30
15
31
Number of Occupied
Bed Days
16
Total (Occupied Bed Days)
0
Number of Hospital Beds
Available Bed Days
Monthly BOR
*Varies per Hospital
0
#DIV/0!
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Ministry of Defense
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Average Length of Stay
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The average duration (in days) of a single episode of
hospitalization.
Process
All discharged patients, including deaths, except births,
unless the infant was transferred to the hospital's
neonatal intensive care unit prior to discharge.
Total discharge days over a three month period.
Total discharge days: The sum of the number of days
spent in the hospital for each inpatient who was
discharged during the three month period regardless of
when the patient was admitted.
Admission Date: The date of admission to the hospital.
Date should be entered in the following format:
m/d/yyyy. Example: 7/21/2015.
Discharge Date: The date of discharge from hospital.
Date should be entered in the following format:
m/d/yyyy. Example: 7/21/2015.
All discharged patients, including deaths.
None, Day Case
Total discharges over same three month period.
Total discharges: The number of inpatients released
from the hospital during the three month period.
All discharged patients, including deaths.
None
N/D
Patient registration system and discharge summaries
All discharged patients over the three month period of
study.
All inpatient areas.
See Page 15
Retrospective
Quarterly
≤ 8.1 days (Online Library of Economic Cooperation
and Development – OECD Health Statistics, 2015)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Average Length of Stay
Indicator Name:
Hospital:
Quarter & Year:
#
Discharged Patient
MRN
Specialty
Admission
Date
m/d/yyyy
Discharged
or Death
Date
m/d/yyyy
Length of
Stay
(days)
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
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Operating Room (OR) Utilization Rate
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Rate of patient time (in minutes) it takes to perform all
elective surgical procedures (including preparation of
the patient in the OR, anesthesia induction, and
emergence) plus the total turnover time over three
months.
Process.
All patients operated upon in elective OR.
Sum of patient time (in minutes) it takes to perform all
elective surgical procedures over three months.
Patient time: Patient exit time (from OR) minus Patient
entrance time (to OR) (in MINUTES)
*In elective surgery OR, if the patient exits after the
normal closing time, patient time is calculated as:
Normal closing time minus Patient entrance time (in
MINUTES).
Normal staffed hours: According to OR working hours
for elective surgery.
All elective OR’s.
1. Emergency OR
2. Day Surgery OR
3. Closed OR’s (e.g. because of lack of staff).
4. Induction and recovery rooms.
Total number of working minutes staffed per local
norms, over three months.
Total number of working minutes: “normal” working
hours in the operating room (e.g. from 8 am to 4 pm =
480 minutes for each elective OR) multiplied by number
of working days during the three months’ period of
observation.
Local norms: Hospital regulations. Example: 8 am-4
pm (8 hours/day, 5 days/week) for elective OR.
All elective OR’s.
1. Emergency OR
2. Day Surgery OR
3. Closed OR’s (e.g. because of lack of staff).
4. Induction and recovery rooms.
(N/D)*100
OR registries and medical records.
All patients operated upon in elective OR over the three
month period of study.
Kingdom of Saudi Arabia
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MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
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Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
1
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All OR’s.
See Page 18
Retrospective
Quarterly
75-80% (Strategic Dynamics – KPI Operating Room,
2016)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Operating Room (OR) Utilization Rate
Hospital:
Quarter & Year:
#
Date
Location
MRN
Patient
Entrance
Time
h:mm
Patient Exit Time (or
Operating Room Closing
Time, if patient exits elective
OR after OR closing time)
h:mm
Patient
Time
(minutes)
1
0
2
0
3
0
4
0
5
0
6
0
7
0
8
0
9
0
10
0
11
0
12
0
13
0
14
0
15
0
Quarter
1st month
2nd month
3rd month
0
0
0
Number of Operating Rooms
Number of Working Days in a Calendar Month
Total Number of Working Minutes in a Month
Total Number of Working Minutes in a Quarter
OR Utilization Rate
0
#DIV/0!
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Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
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ACCESSIBILITY
7.
8.
9.
Average Time To See ED Physician –
CTAS Level 3
Average Boarding Time
Days To Third Next Available Appointment
To Specialist Clinic
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Average Time To See ED (ED) Physician – CTAS Level 3
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
*ED – Emergency Department
Average duration of time (in minutes) for patients
categorized as CTAS level 3 presenting to see ED
physicians.
Process
All patients registered and categorized as CTAS level 3
in ED and were seen by ED physicians.
Sum of durations (in minutes) for patients who
registered in ED and categorized as CTAS level 3 to see
ED physicians over a month.
Duration to see ED physicians: the difference (in
minutes) between the patient registration date and time
and date and time the patient was seen by an ED
physician. Date and time should be entered in the
following format: m/d/yyyy h:mm. Example: 7/21/2015
23:55.
All patients registered and categorized as CTAS level 3
in ED department and were seen by ED physicians.
Patients who registered and categorized as CTAS level
3 but for any reason left the ED before being seen by the
ED physician.
Total number of patients who were registered and
categorized as CTAS level 3 in ED whom were seen by
ED physician over the same month.
None
All patients who were registered and categorized as
CTAS level 3 in ED and were seen by ED physician.
Patients who registered and categorized as CTAS level
3 but for any reason left the ED before being seen by the
ED physician.
N/D
Patient registration system and patients’ census.
ER encounter form.
All patients presenting to ED over a month.
ED.
See Page 21
Retrospective
Monthly
≤ 30 minutes (CTAS)
*CTAS – Canadian Triage and Acuity Scale
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Average Time To See ED Physician CTAS Level 3
Hospital:
Month & Year:
#
MRN
Registration
Date/Time
m/d/yyyy h:mm
Date/Time Seen
by ED Physician
m/dd/yyyy h:mm
Duration
(minutes)
1
0.00
2
0.00
3
0.00
4
0.00
5
0.00
6
0.00
7
0.00
8
0.00
9
0.00
10
0.00
11
0.00
12
0.00
13
0.00
14
0.00
15
0.00
16
0.00
17
0.00
18
0.00
19
0.00
20
0.00
Calculated
Result
#DIV/0!
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Ministry of Defense
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Controlled Document
Issue No.
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Average Boarding Time
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
*ED – Emergency Department
Average duration of time in hours from admit decision
time to time of patient departure from ED to be admitted
to inpatient status.
Process
All patients admitted through ED.
Sum of boarding times (in hours) of all admitted patients
over one month period.
Boarding time: the difference (in hours) between the
date and time of the physician’s admission order and the
date and time of either the actual transfer of the patient
from ED to an inpatient bed or the discharge from ED.
Date and time should be entered in the following format:
m/d/yyyy h:mm.
Example: “Type” 7/21/2015 23:55.
All patients admitted through ED.
Patients who left or were discharged against medical
advice before being admitted.
Number of patients who were admitted through ED over
the same month.
Admitted patients: patients who had physicia n’s
admission order and were transferred from ED to
inpatient beds or discharged while still in ED awaiting
admission.
All patients admitted through ED.
Patients who left or were discharged against medical
advice before being admitted.
N/D
Medical records and patients’ censuses
All patients admitted through ED.
ED and inpatient wards.
See Page 23
Retrospective
Monthly
≤ 24 hours (The Joint Commission White Paper, 2013)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Average Boarding Time
Indicator Name:
Hospital:
Month & Year:
#
MRN
Specialty
Patient
Disposition
Admission
Order
Date/Time
m/d/yyyy
h:mm
Date/Time
Transferred
to Inpatient
Bed or
Discharged
m/d/yyyy
h:mm
Boarding
Time
(hours)
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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Days To Third Next Available Appointment To Specialist Clinic
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Average length of time in days (including weekends)
between the day a patient makes a request for an
appointment with a specialty clinic and the third
available appointment for a new patient physical, routine
exam, or return visit exam.
Process
All specialty clinics
Average length of time in days (including weekends)
between the day a patient makes a request for an
appointment with a specialty clinic and the third
available appointment for a new patient physical, routine
exam, or return visit exam.
Average length of time in days (including weekends)
between the day a patient makes a request for an
appointment with a specialty clinic and the third
available appointment for a new patient physical, routine
exam, or return visit exam.
For each specialty do the following:
1. Select one day each week to serve as your reference
day.
2. Using either manual or electronic methods, count the
number of calendar days (including weekends) from
that day to the day when the third next availab le
appointment slot is available for a non-urgent office
visit for each specialty.
3. Calculate the value for the month (based on the
weekly averages of days) for each specialty.
4. Calculate the average of all specialties.
Specialty clinics
Anesthesiology and pathology
None
Not Applicable
Not Applicable
Not Applicable
N
Manual or electronic appointment system
All specialties. No sampling
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Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Registration/appointment offices
See Page 26
Concurrent
Monthly
10 days (MSD Data)
1
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Days To Third Next Available
Appointment To Specialist Clinic
Indicator Name:
Hospital:
Month & Year:
Note: Please keep Number of calendar days “0” if no data entry.
#
OPD
Week Number of calendar days
Monthly
Specialty
(including weekends) to
Average
the third next available
appointment
1
0
2
0
3
0
4
0
1
0
2
0
3
0
4
0
1
0
2
0
3
0
4
0
1
0
2
0
3
0
4
0
1
0
2
0
3
0
4
0
1
0.00
2
0.00
3
0.00
4
0.00
5
0.00
Calculated
Result
#DIV/0!
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EFFECTIVENESS
10. Hospital Readmission Percentage
11. Patient Experience Measure
1
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10. Hospital Readmission Percentage
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The percentage of patients discharged from the hospital
who are readmitted to the hospital within 30 days.
Outcome
All patients discharged from the hospital every month.
Number of discharged patients readmitted to the hospital
within 30 days of their discharge over a quarter.
Readmitted patients: patients who were readmitted
based on a physician’s admission order and stayed in the
hospital for at least 24 hours.
All discharged patients who were readmitted to the
hospital within 30 days of their discharge.
Planned readmissions and False labor patients
Number of patients discharged from the hospital over
the same quarter.
Discharged patients: patients who were sent home after
completion of management course.
All patients discharged from the hospital.
Patients who left the hospital or were discharged against
medical advice or those who were transferred to another
healthcare facility.
(N/D)*100
Medical records and admission/discharge registries.
All discharged patients every month.
All
See Page 29
Retrospective
Quarterly
≤ 4.49% (IHI white paper “Whole System” Measures,
2016)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Hospital Readmission Percentage
Hospital:
Quarter & Year:
#
Date
Discharged
Patient
MRN
Disposition
Readmitted
Mode of
Within 30 Readmission
Days?
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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11. Patient Experience Measure
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
 The rate of patients whom scored the hospital ≥ 9
 The rate of patients whom reported that they would
recommend the hospital
Outcome
Adult discharge patient
 Number of patients whom scored the hospital ≥ 9 in
Question #29 of the questionnaire
 Number of patients whom answered Definitely Yes
in Question #30 of the questionnaire
Not Applicable
Completed surveys with answered questions (#29 and
#30)
 Surveys with unanswered questions (#29 and #30)
 Psychiatric patients
Total number of completed surveys
Completed surveys: are surveys in which the patient
answers at least 50% of the questions in the
questionnaire. Surveys that do not meet the required
50% are considered incomplete. There must be no
evidence that the patient is ineligible. (According to
MSD Policy No. MSD-H-1-QPS-006)
 All patients discharged in each month
 At least one night admission
 Alive at discharge
 Age of patient above 18 and less than 80 years
 Time of Discharge: from 48 hours to 30 days after
discharge
 Patient under the age 18 years and older than 80
years
 Proxy patient (relatives or family members)
 Patients with illness, which affects judgments, like
Dementia, Alzheimer’s disease, etc.
 Psychiatric patients
 Patient discharged to other level of care in another
organization
 Refusal to participate
 Female patients who can’t be reached personally
 Multiple discharges in the same month
 No financial incentive or special
 Employee of hospital or their families
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Data Source
Target Sample and Sample
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Organization Areas of
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Data collection tool
Data collection methodology
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(N/D)*100
Questionnaire for Inpatients Experience in MSD
Hospitals. (Appendix-1 of MSD Policy No. MSD-H-1QPS-006)
 Source of sample: Discharge patient registry
 Type of sample: Random sample on monthly basis.
 Sample size: Calculate 10% of discharged patient
with a minimum response rate for data collected
75%.
Discharged patient between 2 days and 30 days.
Frequency of Data Analysis
See Page 32
Retrospective: Through Phone Call by the Patient
Experience Officer from the third day until 30 days after
the patient is discharged.
Biannual
Measure Target and/or
Threshold
≥ 71% (Data from CMS' Hospital compare web site,
2016)
10
Discharged
Patient
MRN
Interview
Date
Time
Discharged
Date
Diagnosis
Specialty/
Department
 1st Half
Question
#29
Question
#30
 2nd Half
Patient Experience Measure
#DIV/0!
Q #30
Result
#DIV/0!
Q#29
Result
Issue No.
Page No.
9
8
7
6
5
4
3
2
1
#
Year:
Hospital:
Indicator Name:
Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
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UNDESIRED OUTCOMES
12.
13.
14.
15.
16.
Rate of Transfusion Reaction
Rate of Adverse Drug Event
Rate of Adverse Event in Procedural Sedation
Rate of Adverse Event in Anesthesia
Rate of Discrepancies Between Preoperative and
Postoperative Diagnosis
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12. Rate of Transfusion Reaction
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Rate of transfusion reactions period per 100,000
transfused units of blood/blood components over three
month.
Outcome
Patients whose age is 18 years and older with a
transfusion of blood or blood components done in the last
3 months.
Number of transfusion reactions.
 Transfusion Reaction: an unexpected and untoward,
response to a blood transfusion, manifested by the
following signs and/or symptoms (mentioned below)
 Blood Transfusion Reactions Classification:
 ALLERGIC (MILD)
o Sign & Symptom: Pruritus, Urticaria (hives)
o Etiology: Antibodies to plasma proteins
 ALLERGIC (SEVERE) OR FEBRILE
o Sign & Symptom: Anxiety, pruritus, fever,
chills,
agitation,
flushing,
hives,
tachycardia, mild dyspnea, hypotensio n,
anaphylaxis.
o Etiology: Antibodies to WBC, platelets,
plasma proteins, including antibodies to IgA
 ACUTE HEMOLYTIC
o Sign & Symptom: Anxiety, chest pain, flank
pain, headache, dyspnea, chills, fever,
agitation, shock, hypotension, unexpla ined
bleeding, hemoglobinemia, hemoglobinur ia
cardiac arrest.
o Etiology:
Intravascular
hemolytic
transfusion reaction (usually due to ABO
incompatibility).
 SEPTIC / TOXIC
o Sign & Symptom: Chills, fever, hypotensio n
o Etiology: Gram-negative sepsis from blood
transfusion.
Patients whose age is 18 years and older with a
transfusion of blood or blood components done in the last
3 months.
Cases with a principal diagnosis of transfusion reaction
or cases with a secondary diagnosis of transfus io n
reaction that is present on admission in any of the above
blood transfusion reactions classifications.
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Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
1
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Total number of blood and blood components transfused.
Not Applicable
Patients whose age is 18 years and older with a
transfusion of blood or blood components done in the last
3 months.
Cases with a principal diagnosis of transfusion reaction
or cases with a secondary diagnosis of transfus io n
reaction that is present on admission.
(N/D)*100,000
Blood bank logs & blood transfusion reaction forms.
All blood and blood components transfusions to patients
whose age is 18 years and older in last 3 months.
Blood bank, Nursing, Medical Departments.
See Page 36
Retrospective document review.
Quarterly
0.07 observed rate per 100,000 (AHRQ Patient Safety
Indicator Benchmark Data Tables, 2017)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Rate of Transfusion Reaction
Hospital:
Quarter & Year:
Total Number of Blood and Blood Components Transfused:
#
MRN
Age
Date of
Transfusion
Transfusion
Reaction
Classification
Blood
Component
Transfused
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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13. Rate of Adverse Drug Event
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Rate of adverse events error doses per 1,000 doses over
three month period.
Outcome
All inpatient medication doses.
Number of adverse events error doses in last 3 months.
 An adverse drug event ADE is “an injury resulting
from the use of a drug. Under this definition, the term
ADE includes harm caused by the drug (adverse drug
reactions ADR) and harm from the use of the drug.
 Adverse Drug Reaction (ADR): any unexpected,
unintended, undesired, or excessive response to a
drug that;
 Requires discontinuing the drug (therapeutic or
diagnostic),
 Requires changing the drug therapy,
 Requires modifying the dose (except for minor
dosage adjustments),
 Prolongs stay in a health care facility,
 Necessitates supportive treatment,
 Significantly complicates diagnosis,
 Negatively affects prognosis, or
 Results in temporary or permanent harm,
disability, or death.
 Consistent with this definition, an allergic reaction
(an immunologic hypersensitivity, occurring as the
result of unusual sensitivity to a drug) and an
idiosyncratic reaction (an abnormal susceptibility to
a drug that is peculiar to the individual) are also
considered ADRs.
All inpatient medication doses in last 3 months.
Outpatient/ER medication doses.
Total number of medications doses administered in last 3
months.
Not Applicable
All inpatient medication doses in last 3 months.
Outpatient/ER medication doses.
(N/D)*1,000
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Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
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Frequency of Data Analysis
Measure Target and/or
Threshold
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Medication sheets & clinical pharmacist follow up sheet.
All inpatient medication doses.
Pharmacy Department.
See Page 39
Concurrent & retrospective medical record review.
Quarterly
≤ 3.5 per 1,000 doses (Medication Errors and Adverse
Drug Events Medscape - Jan 19, 2000)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Rate of Adverse Drug Event
Indicator Name:
Hospital:
Quarter & Year:
Total Number of Administered Doses:
#
MRN
Age
Date of
Event
Name
DRUG
Dose
Duration
Diagnosis
Patient
Reaction
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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14. Rate of Adverse Event in Procedural Sedation
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of procedural sedation related adverse events over
three month period.
Outcome
All procedures requiring procedural sedation.
Number of procedural sedation related adverse events in
last 3 months.
 Procedural sedation: the technique of administer ing
sedatives or dissociative agents with or without
analgesics to induce an altered state of consciousness
that allows the patient to tolerate painful or
unpleasant
procedures
while
preserving
cardiorespiratory function.
 Adverse event in procedural sedation are all events
that result in an intervention or a change in condition
after sedation.
All procedures requiring procedural sedation.
Not Applicable
Number of all procedures requiring procedural sedation
in last 3 months.
Not Applicable
All procedures requiring procedural sedation.
Not Applicable
(N/D)*100
Medical records and incidence reporting system.
All procedures requiring procedural sedation in last 3
months
Anesthesia and all areas where procedural sedation
can occur.
See Page 41
Retrospective document review
Quarterly
≤ 4.7% (The Royal College of Emergency Medicine, UK,
Procedural Sedation Clinical Audit report, 2015-16)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Rate of Adverse Event in Procedural Sedation
Hospital:
Quarter & Year:
Total Number of Procedural Sedation:
#
MRN
Age
Diagnosis
Procedure
Name
Location
Adverse
Event
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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15. Rate of Adverse Event in Anesthesia
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of anesthesia related adverse events over three
month period.
Outcome
All surgeries/procedures requiring general or major
regional (including spinal, epidural) anesthesia.
Number of anesthesia related adverse events in last 3
months.
 Consists of general anesthesia including spinal or
major regional anesthesia. It doesn’t include local
anesthesia. (JCI Definition)
 Adverse event during anesthesia is defined as an
event that may result in the emergence of
complications, and occurs due to human error, failure
of the apparatus, the selected anesthetic techniques
and the individual reaction of the patient.
All surgeries/procedures requiring general or major
regional (including spinal, epidural) anesthesia.
All cases of local anesthesia.
Number of all surgeries/procedures requiring general or
major regional (including spinal, epidural) anesthesia in
last 3 months.
Not Applicable
All surgeries/procedures requiring general or major
regional (including spinal, epidural) anesthesia.
All cases of local anesthesia.
(N/D)*100
OR logs, medical records and incidence reporting
system.
All surgeries/procedures requiring general or major
regional (including spinal, epidural) anesthesia in last 3
months
Anesthesia, OR and all areas requiring general or
major regional anesthesia.
See Page 43
Retrospective document review
Quarterly
≤ 4.8% (National Anesthesia Clinical Outcomes
Registry, 2016)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Rate of Adverse Event in Anesthesia
Hospital:
Quarter & Year:
Total Number of Surgeries/ Procedures:
#
MRN
Age
Date of
Procedure
Diagnosis
Procedure
Name
Type of
Anesthesia
Adverse
Event
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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16. Rate of Discrepancies Between Preoperative and Postoperative Diagnosis
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of all significant discrepancies between
preoperative and post-operative diagnosis, includ ing
pathologic diagnoses over three month period.
Outcome
Patients who underwent surgeries except exploratory
laparotomy/laparoscopy.
Number of all significant discrepancies between
preoperative and post-operative diagnoses, includ ing
pathologic diagnoses in last 3 months.
“If the postoperative diagnosis is known to be differe nt
from the preoperative diagnosis at the time the diagnosis
is confirmed.”
All patients who underwent surgeries in last 3 months.
Patients who had exploratory laparotomy/laparoscopy.
All patients who underwent surgeries in same 3 months.
Not applicable
All patients who underwent surgeries in last 3 months.
Patients who had exploratory laparotomy/laparoscopy.
(N/D)*100
Patients Medical Records & OR logs.
10% of the surgeries done in the last 3 months, selected
by systematic random sampling.
All surgeries.
See Page 45
Retrospective medical record & OR logs document
review.
Quarterly
Annual Improvement of Data by 10% (MSD)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Rate of Discrepancies Between Preoperative
and Postoperative Diagnosis
Indicator Name:
Hospital:
Quarter & Year:
Total Number of Surgeries/ Procedures:
#
MRN
Age
Date of
Procedure
Preoperative
Diagnosis
Postoperative
Diagnosis
Operation
Name
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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EFFICIENCY
17. Healthcare Cost Per Capita
1
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17. Health Care Cost per Capita
Description
Type of Indicator
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The average health care expenditures for the number of
active patient files of the hospital
Structure
All health care expenditures
The annual budget of the hospital
The annual budget of the hospital: the amount of
money (in Saudi Riyals) assigned and given by MSD to
the hospital.
All annual budget
None
Number of active files in the same year
Active Patient Files: files of patients who have
received health care services in the hospital at least once
over the last five years
All active patient files
All inactive patient files (files of patients who have
NOT received any health care services in the hospital
over the last five years)
N/D
Patient registry and Finance department
Not applicable
Not applicable
See Page 48
Retrospective
Annually
Not Applicable
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Healthcare Cost per Capita
Hospital:
Year:
The annual budget of
the year
Number of active
patient files in the same
year
Healthcare Cost per
Capita
#DIV/0!
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
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SAFETY
18. Composite Patient Safety Goals Measure
(IPSG.1 - IPSG.4.1)
19. Patient Fall
20. Culture of Safety
21. Medication Error Rate
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Composite Safety Measure (IPSG.1 – IPSG.4.1)
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The average percentage of the results of IPSG.1 –
IPSG.4.1
Process
Not Applicable
The sum of the results (in percentage) of IPSG.1 –
IPSG.4.1 measurements.
Results: the achieved compliance with IPSG, in
percentage, as measured by the hospital using
specification manuals of individual IPSG’s.
IPSG.1, IPSG.2, IPSG.2.1, IPSG.2.2, IPSG.3, IPSG.3.1,
IPSG.4, IPSG.4.1
IPSG.5 & IPSG.6
Eight (number of all IPSG’s excluding IPSG.5 & IPSG.6)
Not Applicable
Not Applicable
Not Applicable
N/D
The results of individual IPSG’s
Not Applicable
Not Applicable
See Page 51
Retrospective
Quarterly
≥ 95.5% (JCI Average for all IPSGs)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Composite Safety Measure
Hospital:
Quarter & Year:
IPSG
COMPLIANCE (%)
IPSG.1
#DIV/0!
IPSG.2
#DIV/0!
IPSG.2.1
#DIV/0!
IPSG.2.2
#DIV/0!
IPSG.3
#DIV/0!
IPSG.3.1
#DIV/0!
IPSG.4
#DIV/0!
IPSG.4.1
#DIV/0!
Composite Safety Measure
#DIV/0!
1
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19. Patient Fall
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
All documented falls with or without injury, experienced
by in-patients in a calendar month per 1,000 patient days
(per unit and overall).
Outcome
Patients admitted to the hospital for inpatient acute care
in an eligible unit type AND a Patient Age (Admiss io n
Date minus (–) Birthdate) greater than or equal to 18
years of age.
Total number of patient falls (with or without injury to
the patient) during the calendar month.
Admission Date: the Gregorian date of patient admissio n
to hospital. Date should be entered in the following
format: m/d/yyyy. Example: 7/21/2015.
Birthdate: the Gregorian date of patient birth. Date
should be entered in the following format: m/d/yyyy.
Example: 7/21/2015.
Date of Fall: the Gregorian date in which the patient fell
down. Date should be entered in the following format:
m/d/yyyy. Example: 7/21/2015.
Number of Patient Falls:The total number of patient
falls that occurred on the eligible reporting unit during the
calendar month.
Location: the hospital unit in which the patient fell down.
 Patient falls occurring while on an eligible reporting
unit (See Attached Data Collection Tool)
 Assisted falls
 Repeat falls
 Visitors
 Students
 Staff members
 Patients from eligible reporting units, however patient
was not on unit at time of fall (e.g., patients falls in
radiology department)
 Falls on other unit types (e.g., pediatric, obstetrical,
rehab, etc.)
Patient days by Type of Unit during the calendar month.
Month: The 2 digit month during which the fall occurred
(e.g. 01= January).
Patient Days: The total number of patient days, per unit,
for a month.
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Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
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Type of Unit: Unit type reflects the patient populatio n
and the service line. It is used in risk stratification, so that
reporting occurs for similar units.
Year: The 4-digit year during which the fall occurred.
 Inpatients, short stay patients, observation patients
and same day surgery patients who receive care on
eligible inpatient units for all or part of a day.
 Adult critical care, step-down, medical, surgica l,
medical-surgical combined, and mixed acuity units.
 Any age patient on an eligible reporting unit is
included in the patient day count.
Other unit
types (e.g., pediatric,
obstetrical,
rehabilitation, etc.)
(N/D)*1,000
Medical Records and Incident Reports
All fall incident reports
Medical Ward, Surgical Ward, Emergency Department,
Out Patient Clinic, Critical Care Unit, Operating Theater
See Page 54
Retrospective
Quarterly
≤ 2 per 1,000 patient days (Nursing-Sensitive
Benchmarks for Hospitals to Gauge High-Reliability
Performance, 2010)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Patient Fall
Hospital:
Quarter & Year:
Number of Patient Falls
Location (Unit)
1st month
2nd month
3rd month
0
0
0
Critical Care Units – Adult
Step Down – Adult
Medical – Adult
Surgical – Adult
Medical-Surgical – Combined
Mixed Acuity
Total
Number of Patient Days per Unit
Location (Unit)
1st month
2nd month
3rd month
0
0
0
1st month
2nd month
3rd month
#DIV/0!
#DIV/0!
#DIV/0!
Critical Care Units – Adult
Step Down – Adult
Medical – Adult
Surgical – Adult
Medical-Surgical – Combined
Mixed Acuity
Total
Patient Fall Rate per month
Result (Quarter)
#DIV/0!
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20. Culture of Safety
Measuring Culture of Safety Project Instructions
Form a Project Team
The







project team is responsible for:
Planning
Selecting a sample
Establishing department-level contact persons
Preparing survey materials
Distributing and receiving survey materials
Tracking survey responses and response rates
Handling data entry, analysis, and report preparation
Sample Selection
Sampling Methods:
A subset of staff from all areas/units, using Systematic Sampling.
Sample Size:
Sample size should be at least twice the number of desired responses. The desired number of
responses should be 5% of your staff number, but minimum of 100 responses.
Compile Your Sample List
After you determine your sample size, compile a list of the staff from which to select your sample.
When compiling your sample list, include several items of information for each staff member:

First and last name,

Hospital area/unit, and

Staffing category or job title
Data Collection Method
Distributing Surveys
Surveys should be distributed in sealed envelopes together with the cover letter and another
envelope to return completed surveys. Surveys should NOT contain respondent’s identifiers (e.g.
name or code number). Allow staff to complete the survey during work time to emphasize
hospital administration’s support for the data collection effort.
Returning Surveys
Instruct staff to return completed surveys to a drop box in a public place in the hospital.
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Establish Points-of-Contact within the Hospital
Train and educate nurses in charge of each unit/ward/department (on the survey structure/conte nt
and process) to act as the points-of-contact and help answer questions about the survey. A main
point-of-contact (from the project team) should be appointed as a reference.
Data Collection Procedure
Maximize Your Response Rate
An overall response rate of 50 percent or more should be your minimal goal. Do the following to
maximize the response rate:
1.
Pre-notification letter. Before administering the survey, create a letter signed by your
hospital’s director on hospital letterhead. The letter will inform all the staff in your sample
that they will be receiving a survey and that hospital administration is in full support of the
survey effort. It will also describe the purposes of the survey and the completio n
instructions.
2.
First survey. About 1 week later, send the survey to all staff in your sample group. Include
a supporting cover letter similar in content to the pre-notification letter and instructions for
completing and returning the survey. Please use the following template for the cover letter:
“The enclosed survey is part of our hospital’s efforts to better address patient safety. The
survey is being distributed to a subset of staff from all areas/units. It will take about 10 to
15 minutes to complete and your individual responses will be kept confidential. Only group
statistics will be prepared from the survey results. Please complete your survey and return
it WITHIN THE NEXT 7 DAYS. (Do not provide a specific date) When you have completed
your survey, please return it to the designated drop box located in (provide the location of
drop box). Please contact [contact name and job position] if you have any questions
[provide phone number and email address]. Thank you in advance for your participation
in this important effort.”
3.
First reminder letter. Approximately 2 weeks after sending the survey, send a reminder
letter to the sample group thanking those who have already responded and reminding others
to please respond.
4.
Second survey. Two weeks after sending the first reminder, send a second survey to the
sample group, including a cover letter thanking those who have already responded and
reminding others to please complete the second survey. Ask staff to disregard the second
survey if the first survey was completed and dropped in the drop box.
5.
Second reminder letter. Approximately 1 week after sending the follow-up survey, you
may choose to send a second and final reminder.
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Closing out Data Collection
Allow 8 weeks from the pre-notification letter to your data collection period closeout. If you had
less than 50% response rate, you may extend the data collection period closeout date for another
2 weeks.
Calculating Your Response Rate
Number of complete, returned surveys
Number of surveys distributed – Incomplete surveys
Preparing and Analyzing Data, and Producing Reports
Identify Complete and Incomplete Surveys
Incomplete surveys are those which fulfill one of the following criteria:

The respondent answered less than one entire section of the survey (i.e. all sections are
incomplete).

The respondent answered fewer than half of the items throughout the entire survey (in
different sections).

The respondent answered every item the same (e.g., all “4”s or all “5”s). If every answer is
the same, the respondent did not give the survey their full attention. The survey includes
reverse worded items that exercise both the high/positive and low/negative ends of the
response scale to provide consistent answers.
Exclude incomplete surveys.
Code and Enter the Data
Coding involves decision making with regard to the proper way to enter ambiguous responses.
Respondents may provide responses that cannot be read easily or, in some cases, their intended
answer may be difficult to determine. For example, a respondent may write in an answer such as
3.5, when they have been instructed to circle only one numeric response. Or, they may circle two
answers for one item. The coding rule that should be used is to mark all of these types of
inappropriate responses as missing. Once surveys have been coded as necessary (most surveys
will not need to be coded), the data can be entered into an electronic file using a Microsoft Excel®
spreadsheet.
Check and Electronically Clean the Data
The data file may contain errors. You can check and clean the data file electronically by producing
frequencies of responses to each item and looking for out-of-range values or values that are not
valid responses.
Most items in the survey require a response between 1 and 5. Check through the data file to ensure
that all responses are within the valid range (e.g., that a response of “7” has not been entered for
a question requiring a response between 1 and 5). If out-of-range values are found, return to the
original survey and determine the response that should have been tallied.
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Analyze the Data and Produce Reports of the Results
1.
Frequencies of Response

A Microsoft PowerPoint® presentation with modifiable feedback report templates is
provided to be used to present and communicate results from the Hospital Survey on
Patient Safety Culture. The feedback report template groups survey items according
to the safety culture dimension each item is intended to measure. You can easily adapt
the PowerPoint template by inserting your hospital’s survey findings in the charts to
create a customized feedback report. You can also customize the report to display unit
level data, in addition to hospital- level data.

To make the results easier to view in the report, the two lowest response categories
have been combined (Strongly Disagree/Disagree and Never/Rarely) and the two
highest response categories have been combined (Strongly Agree/Agree and Most of
the time/Always). The midpoints of the scales are reported as a separate category
(Neither or Sometimes).

The percentage of answers corresponding with each of three response categories then
are displayed graphically—see the example below.

2.
Because each survey item most likely will have some missing data, missing responses
are excluded from the total (or denominator) when calculating these percentages. In
the example shown, assume there were 200 total survey respondents. Twenty people
did not answer this particular item, however, so the total number of people who
responded to the item was 180. The percentage of respondents who Strongly
Agreed/Agreed was 50 percent or 90/180. The percentage of respondents who either
Strongly Disagreed/Disagreed or responded “Neither” was 25 percent or 45/180.
Excluding missing data from the total allows the percentages of responses within a
graph to sum to 100.
Composite Frequencies of Response

The survey items can be grouped into dimensions of safety culture, and so it can be
useful to calculate one overall frequency for each dimension. One way of doing this
is to create a composite frequency of the total percentage of positive responses for
each safety culture dimension. Composites can be computed for individual units or
sections of a hospital, or for the hospital as a whole.
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For example, a composite frequency of 50 percent on Overall Perceptions of Safety
would indicate that 50 percent of the responses reflected positive opinions regarding
the overall safety in the unit or hospital.
To create an overall composite frequency on a safety culture dimension:

Step 1.Determine which items are related to the dimension in which you are
interested, and which items related to that are reverse worded (negative ly
worded). Items are grouped by dimension in an attached document titled as:
(Hospital Survey on Patient Safety Culture: Items and Dimensions) which also
identifies the items that are reverse worded. There are three or four items per
dimension.

Step 2. Count the number of positive responses to each item in the dimensio n—
“Strongly Agree/Agree” or “Most of the time/Always” are positive responses for
positively worded items. For reverse worded items, disagreement indicates a
positive response, so count the number of “Strongly Disagree/Disagree” or
“Never/Rarely” responses.

Step 3. Count the total number of responses for the items in the dimension (this
excludes missing data).

Step 4. Divide the number of positive responses to the items (answer from step
2) by the total number of responses (answer from step 3).
Number of positive responses to the items in the dimension
Total number of responses to the items (positive, neutral, and negative) in the dimension


The resulting number is the percentage of positive responses for that particular
dimension.
Here is an example of computing a composite frequency percentage for the Overall
Perceptions of Safety dimension:

There are four items in this dimension - two are positively worded (A15) and
(A18), and two are negatively worded (A10) and (A17). Keep in mind that
disagreeing with the negatively worded items indicates a positive perception of
safety.

To count the total number of positive responses, complete the following Table:
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The composite frequency percentage is calculated by dividing the total number
of positive responses on all four questions (numerator) by the total number of
responses to all four questions excluding missing responses (denominator).
There was 500 positive responses, divided by 1,000 total responses, which
results in a composite of 50 percent positive responses for Overall Perceptions
of Safety.
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21. Medication Error Rate
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of medication error observed per 1,000 medicatio n
doses.
Outcome
All inpatient medication doses.
Number of medication error observed.
Any preventable event that may cause or lead to
inappropriate medication use or patient harm while the
medication is in the control of the healthcare professiona l,
patient or consumer. Such events may be related to
professional practice, healthcare products, procedures and
systems, including: prescribing, order communicatio n,
product labeling,
packaging
and nomenclature,
compounding, dispensing, distribution, administratio n,
education, monitoring and use. (Adopted by ISMP
&WHO)
All inpatient medication doses.
Outpatient/ER medication doses.
Total number of medications dispensed.
Not Applicable
All inpatient medication doses.
Outpatient/ER medication doses.
(N/D)*1,000
Medication sheets & incident report/ pharmacist follow up
sheet.
All inpatient medication doses.
Pharmacy/ QI Department.
See Page 63
Concurrent & retrospective medical record review.
Quarterly
Annual Improvement of Data by 10% (MSD)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Medication Error Rate
Indicator Name:
Hospital:
Quarter & Year:
Total Number of Medications Dispensed:
#
MRN
Age
Diagnosis
Medication
Name
Dose
Duration
Date of
administering
1 st dose
Error
Type
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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CLINICAL MEASURES
22. Stroke Thrombolytic Therapy
23. Venous Thromboembolism (VTE)
Prophylaxis
24. Pressure Ulcer Prevalence
25. Rate of Diabetic Patient with HBA1C ≤ 7
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22. Stroke Thrombolytic Therapy
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Rate of acute ischemic stroke patients who arrive at this
hospital within 2 hours of time last known well and for
whom IV t-PA was initiated at this hospital within 3 hours
of time last known well over three month period.
Process
All acute ischemic stroke patients whose Time Last
Known Well to arrival in the emergency department less
than 2 hours.
Acute ischemic stroke patients for whom IV thrombolytic
therapy was initiated at the hospital within 3 hours (less
than or equal to 180 minutes) of time last known well.
 Date Last Known Well
 IV Thrombolytic Initiation
 IV Thrombolytic Initiation Date
 IV Thrombolytic Initiation Time
 Time Last Known Well
Not applicable
None
Acute ischemic stroke patients whose time of arrival is
within 2 hours (less than or equal to 120 minutes) of time
last known well.
Admission Date, Arrival Date, Arrival Time, Birthdate,
Clinical Trial, Date Last Known Well, Discharge Date, ED
Patient, Elective Carotid Intervention, ICD-10-CM
Principal Diagnosis Code, Last Known Well, Reason for
Extending the Initiation of IV Thrombolytic, Reason for
Not Initiating IV Thrombolytic, Time Last Known Well
Discharges with an ICD-10 Principal Diagnosis Code for
ischemic stroke
Patients less than 18 years of age, Patients who have a
Length of Stay greater than 120 days, Patients enrolled in
clinical trials, Patients admitted for Elective Carotid
Intervention, Time Last Known Well to arrival in the
emergency department greater than 2 hours, Patients with
a documented Reason For Extending the Initiation of IV
Thrombolytic, Patients with a documented Reason For Not
Initiating IV Thrombolytic
(N/D)*100
Medical Record Review, Emergency Room sheets
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Target Sample and Sample
Size
Average quarterly
initial patient population
> or equal 1551
391 – 1550
78 – 390
6 – 77
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
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Minimum required
sample size
311
20% of the initial patient
population
78
No sampling; 100% of the
initial patient population
Emergency Room
See Page 67
Retrospective data sources for required data elements
include administrative data and medical records. Some
hospitals may prefer to gather data concurrently by
identifying patients in the population of interest. This
approach provides opportunities for improvement at the
point of care/service. However, complete documentatio n
includes the principal or other ICD-10 diagnosis and
procedure codes, which require retrospective data entry.
Quarterly
≥ 97.7% (The Joint Commission’s Annual Report, 2015)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Stroke Thrombolytic Therapy
Hospital:
Quarter & Year:
#
MRN
Date/Time of
Last Known
Well
m/d/yyyy h:mm
Date/Time of
Arrival to ER
IV Thrombol ytic
Initiation
m/d/yyyy h:mm
m/d/yyyy h:mm
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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23. Venous Thromboembolism (VTE) Prophylaxis
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Rate
of
patients
who
received
Venous
Thromboembolism(VTE) prophylaxis on the day of or day
after hospital admission or surgery end date for surgeries
that start the day of or the day after hospital admissio n
over three month period.
Process
 Patients admitted to the hospital for inpatient acute
care with any ICD Principal Diagnosis or Other
Diagnosis Code or Diagnosis AND a Patient Age
(Admission Date minus Birthdate) greater than or
equal to 18 years.
 All inpatients who do NOT have an ICD Principal or
Other Diagnosis Code or diagnosis of Obstetrics or
VTE, as defined in Appendix A, Table 7.02, 7.03, or
7.04 AND an age greater or equal to 18 years old. (IVTE-MeasureSetSpecManualV2.0).
Patients who received VTE prophylaxis on:
 the day of or the day after hospital admission
 the day of or day after surgery end date for surgeries
that start the day of or day after hospital admission
Reason for No VTE Prophylaxis – Hospital Admission:
Documentation why mechanical or pharmacologic VTE
prophylaxis was not administered at hospital admission.
Surgery End Date: The date the surgical procedure
ended after hospital admission. Date should be entered in
the following format: m/d/yyyy. Example: 7/21/2015.
Surgical Procedure:
A surgical procedure was
performed using general or neuraxial anesthesia the day of
or the day after hospital admission.
VTE
Prophylaxis:
The
type of venous
thromboembolism (VTE) prophylaxis documented in the
medical record.
VTE Prophylaxis Date: The day, month, and year that
the initial VTE prophylaxis (mechanical and/or
pharmacologic) was administered after hospital admissio n
Date should be entered in the following format: m/d/yyyy.
Example: 7/21/2015.
Not Applicable
None
All patients admitted.
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Data Elements
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Admission Date: The day, month, and year of admissio n
to acute inpatient care. Date should be entered in the
following format: m/d/yyyy. Example: 7/21/2015.
Birthdate: The day, month, and year the patient was born.
Date should be entered in the following format: m/d/yyyy.
Example: 7/21/2015.
Discharge Date: The day, month and year the patient was
physically discharged from the hospital, left against medical
advice (AMA) or expired. Date should be entered in the
following format: m/d/yyyy. Example: 7/21/2015.
ICD Other Diagnosis Code(s):
The Internationa l
Classification of Diseases, Sixth Revision, Ninth Revision,
Clinical Modification or Tenth Revision codes associated
with the diagnosis for this hospitalization.
ICD Principal Diagnosis Code: The Internationa l
Classification of Diseases, Sixth Revision, Ninth Revision,
Clinical Modification or Tenth Revision code associated
with the diagnosis established after study to be chiefly
responsible for occasioning the admission of the patient for
this hospitalization.
ICU Admission Date: The date that the patient was a direct
admission or transfer (from a lower level of care) to the
intensive care unit (ICU) for more than one day AND was
physically admitted to a bed in an ICU. Date should be
entered in the following format: m/d/yyyy. Example :
7/21/2015.
ICU Admission or Transfer: Documentation that the
patient was admitted or transferred to the intensive care unit
(ICU) at this hospital.
ICU Discharge Date: The day, month and year the patient
was physically discharged from the intensive care unit
(ICU), left against medical advice (AMA) or expired. Date
Inclusions to the
population
Exclusions from the
population
should be entered in the following format: m/d/yyyy.
Example: 7/21/2015.
Not applicable
 Patients less than 18 years of age.
 Patients with a hospital length of stay less than 2 days.
 Patients who are direct admits to the Intensive Care
Unit (ICU) or transferred to ICU the day of or the day
after hospital admission AND ICU length of stay
greater or equal to 1 day.
 Patients with an ICD Principal diagnosis code of
Mental Disorders, as defined on Table 7.01
(I-VTE-MeasureSetSpecManualV2.0).
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
1
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 Patients with an ICD Principal or other diagnosis code
or diagnosis of Obstetrics as defined in Appendix A,
Tables 7.02 or 7.04, or VTE as defined on Table 7.03
(I-VTE-MeasureSetSpecManualV2.0).
 Patients with an ICD Principal or other diagnosis code
or diagnosis of Stroke as defined in Appendix A,
Tables 8.1 and 8.2.
(I-VTE-MeasureSetSpecManualV2.0).
 Patients with an ICD Principal Procedure Code or
Principal Procedure of Hip or Knee Arthroplasty as
defined in Appendix A, Tables 5.04 and 5.05.
(I-VTE-MeasureSetSpecManualV2.0).
(N/D)*100
Medical Records
5% of all inpatients (not less than 50 patients).
All inpatient areas
See Page 71
Retrospective
Quarterly
≥ 98% (The Joint Commission’s Annual Report on
Quality and Safety, 2013)
10
MRN
Admission
Date
Discharged
Date
ICD
Principal
Diagnosis/
Procedure
Code
ICU
Initial
Admission ICU Day
or Transfer
ICU
Length of
Stay
Reason for
VTE
Initial
Surgical
Initial
no VTE
Prophylaxis* Prophylaxis Procedure
Surgical
Prophylaxis
Day
Prophylaxis
Day
#DIV/0!
Calculated
Result
Venous Thromboembolism Prophylaxis (VTE)
Issue No.
Page No.
9
8
7
6
5
4
3
2
1
#
Quarter & Year:
Hospital:
Indicator Name:
Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
1
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Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
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24. Pressure Ulcer Prevalence
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Rate of patients that have hospital-acquired (nosocomia l)
Category/Stage II or greater pressure ulcer(s) on the day
of the prevalence study.
Outcome
Patients admitted to the hospital for inpatient acute care in
an eligible unit type (Critical Care Units – adult, Stepdown – adult, Medical – adult, Surgical – adult, Med –
Surgical Combined – adult, Mixed acuity – adult) AND a
Patient Age (Admission Date minus (–) Birthdate) greater
than or equal to 18 years of age.
Patients that have at least one Category/Stage II or greater
hospital-acquired pressure ulcer(s) on the day of the
prevalence study.
Observed Pressure Ulcer:
Documentation that a
pressure ulcer was or was not observed at the time of the
prevalence study.
Observed Pressure Ulcer – Category/Stage:
Documentation of the category/stage for the observed
pressure ulcer using the NPUAP / EPUAP Pressure Ulcer
Classification System. Allowable Values:
1. Category/stage I - Non-blanchable erythema
2. Category/stage II– Partial thickness skin loss
3. Category/stage III– Full thickness skin loss
4. Category/stage IV– Full thickness tissue loss
5. Unstageable/ Unclassified– Full thickness skin or
tissue loss – depth unknown
6. Suspected deep tissue injury– depth unknown
7. There is no documentation of category/stage or Unable
to Determine from the documentation
Observed Pressure Ulcer – Hospital-Acquire d:
Documentation that the observed pressure ulcer meets the
criteria for hospital-acquired (nosocomial).
Hospital-acquired ulcers are those discovered or
documented after the first 24 hours from the time of
inpatient admission.
 Hospital-acquired pressure ulcers (ulcers discovered
or documented after the first 24 hours from the time of
inpatient admission)
 Category/Stage II or greater pressure ulcers
 Unstageable/unclassified pressure ulcers
 Suspected deep tissue injury
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Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
1
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None
All patients surveyed for the study who are > = 18 years.
Admission Date: The day, month, and year of admissio n
to acute inpatient care. Date should be entered in the
following format: m/d/yyyy. Example: 7/21/2015.
Birthdate: The day, month, and year the patient was
born. Date should be entered in the following format:
m/d/yyyy. Example: 7/21/2015.
Prevalence Study Date: The date of the prevalence study.
Date should be entered in the following format: m/d/yyyy.
Example: 7/21/2015.
Sex: Patient Gender.
Type of Unit: Unit type reflects the patient populatio n
and the service line. It is used in risk stratification, so that
reporting occurs for similar units.
Patients surveyed who are ≥ 18 years.
 Patients less than 18 years of age
 Patients who refuse to be assessed
 Patients who are off the unit at the time of the
prevalence study, i.e. surgery, X-ray, physical therapy,
etc.
 Patients who are medically unstable at the time of the
study for whom assessment would be contraindica ted
at the time of the study, i.e. unstable blood pressure,
uncontrolled pain, or fracture waiting repair.
 Patients who are actively dying and pressure ulcer
prevention is no longer a treatment goal.
(N/D)*100
Observation & medical record review
All patients admitted to the hospital (in the day of
prevalence study) for inpatient acute care in an eligib le
unit type AND a Patient Age greater than or equal to 18
years of age.
Adult Critical Care, Adult Step-down, Adult Medical,
Adult Surgical, Adult Medical-Surgical Combined, Adult
Mixed acuity.
See Page 74
Concurrent
Quarterly
 4.5% (National Medicare Patient Safety Monitoring
System Study)
*NPUAP – National Pressure Ulcer Advisory Panel
*EPUAP – European Pressure Ulcer Advisory Panel
10
MRN
Admission
Date
Birthdate
Type of
Unit
Prevalence Number of Observed
Study
Pressure Ulcer(s) in
Date
the Day of Prevalence
Study
Category/ Stage of
Most Advanced
Observed Pressure
Ulcer
Pressure Ulcer (at least one)
Discovered or Documented in the
Chart after the 1 st 24 hours from
the time of inpatient admission?
Pressure Ulcer Prevalence
#DIV/0!
Calculated
Result
Issue No.
Page No.
9
8
7
6
5
4
3
2
1
#
Quarter & Year:
Hospital:
Indicator Name:
Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
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Controlled Document
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25. Rate of Diabetic Patient with HBA1C ≤ 7
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of diabetic outpatients ≥ 18 years of age with
diabetes who had hemoglobin HBA1C ≤ 7 over three
month period.
Outcome
Patients aged ≥ 18 years diagnosed with Diabetes Type II
who are enrolled in the diabetes clinic (excluding
gestational diabetes)
Number of the diabetic outpatients who had HBA1C ≤ 7
in 3 months.
 The indicator determines the percentage (%) of the
diabetic patients (Type II) who had good controlled
blood sugar level every 3 months.
 Controlled blood sugar level: HBA1C ≤ 7
Patients aged ≥ 18 years diagnosed with Diabetes Type II.
 Female patients with gestational diabetes.
 Patients diagnosed as Type I diabetes (tighter
glycemic control is advised).
 Patients aged < 18 years.
All diabetic outpatients surveyed for the study who are ≥
18 years over same 3 months.
Not Applicable
Patients aged ≥ 18 years diagnosed with Diabetes Type II.
 Female patients with gestational diabetes.
 Patients diagnosed as Type I diabetes (tighter
glycemic control is advised).
 Patients aged < 18 years.
(N/D)*100
Medical record review
All Diabetic Type II patients who are enrolled in the
diabetes clinic and had their HBA1C results in the last 3
months and the patient age is greater than or equal to 18
years of age.
Diabetes Clinic.
See Page 76
Retrospective
Quarterly
≥ 65% of patients with HBA1C assay ≤ 7 (American
Association of Diabetes Project, AHRQ 2001)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Rate of Diabetic Patient with HBA1C ≤ 7
Hospital:
Quarter & Year:
#
MRN
Age
HBA1C
Diabetes
Type
Gestational
Diabetes
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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Ministry of Defense
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Issue No.
Page No.
STAFF
26. Staff Turnover Rate (Medical / Nursing)
27. Staff Satisfaction Rate
1
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26. Staff Turnover Rate (Medical / Nursing)
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
 Rate of total separations to the average number of
physicians.
 Rate of total separations to the average number of
nurses.
Outcome
All Physicians / Nurses.
Total number of Physicians / Nurses separations over a
three month period.
Total number of separations: Total number of
physicians / nurses who has voluntarily left the hospital
over a three month period.
All physicians / nurses who voluntarily left the hospital
over a three month period.
Those physicians / nurses who has involuntarily left the
hospital, such as those who were dismissed or fired.
Average number of physicians / nurses during the same
three month period.
Average number of physicians / nurses: Total number
of physicians / nurses on the payroll over the same three
months divided by three.
All full time physicians / nurses currently employed by
the hospital.
Part time or visiting physicians / nurses
(N/D)*100
Human Resources Department registries
All full time physicians / nurses currently employed by
the hospital.
All
See Page 79
Retrospective
Quarterly
≤ 3% (MSD Data, 2016)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Staff Turnover Rate (Medical / Nursing)
Hospital:
Quarter & Year:
#
Category of Staff who
voluntarily left
(Physician / Nurse)
Month of Leaving the
Hospital
Years of Employment
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Average
number of
staff
employed
over 3
months
Total
number of
separations
over the
same 3
months
Staff
Turnover
Rate
PHYSICIANS
#DIV/0!
0
#DIV/0!
NURSES
#DIV/0!
0
#DIV/0!
Number of Staff
Staff Category
1st month
2nd month
3rd month
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27. Staff Satisfaction Rate
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
The rate of staff satisfaction about hospital.
Outcome
Hospital staff
Number of Promoters – Number of Detractors
 Each staff surveyed should have a total average
percentage score.
 Net Promoter Score (NPS) will be used to measure
staff satisfaction.
 Staff with a total average percentage score ≥ 90%
are Promoters.
 Staff with a total average percentage score
between 70-80% are Passives.
 Staff with a total average percentage score ≤ 60%
are Detractors.
Surveys with at least 50% answered questions.
Surveys with ≥ 50% unanswered questions.
Total number of completed surveys
 Completed surveys: are surveys in which the staff
answers at least 50% of the questions in the
questionnaire. Surveys that do not meet the required
50% are considered incomplete.
 Response Rate ≥ 70%.
All hospital staff
Not Applicable
(N/D)*100
Self-administered questionnaire.
Sampling method is simple random sample.
All Hospital areas
See Page 81
Retrospective
Annually
≥ 80% (MSD Data)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Staff Satisfaction Rate
Hospital:
Year:
Enter Staff
Satisfaction
Rate
Total Number of Completed
Surveys
Total Number of Surveys
Distributed
Response Rate
#DIV/0!
#DIV/0!
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
INFECTION CONTROL
28. Hand Hygiene Compliance
29. Central Line Associated Blood Stream
Infections (CLABSI) Measure
30. Appropriateness Use of Antibiotics
31. Surgical Site Infection
32. Multi-Drug Resistant Organism (MDRO)
Rate
1
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28. Hand Hygiene Compliance
Description
Type of Measure
Initial Eligible Population
Criteria
Numerator
Data Elements
Inclusion criteria
Exclusion criteria
Denominator
Data Elements
Inclusion criteria
Exclusion criteria
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of compliance to WHO standardized Hand Hygiene
method.
Process
20 mts (± 10) direct observation session to be assigned
randomly.
The total number of times an HCW was observed to have
appropriately washed/rubbed his or her hands.
Number of appropriate actions observed in compliance of
Hand Hygiene method.
Any HCW has been monitored to have appropriate hand
washing/rubbing within the hand hygiene observation
session.
Any HCW has been monitored to have appropriate hand
washing/rubbing out of the hand hygiene observation
session.
The total number of opportunities observed.
Number of opportunities observed.
Any hand hygiene opportunity observed within the hand
hygiene observation session.
Any hand hygiene opportunity observed out the hand
hygiene observation session.
(N/D)*100
Infection control or other HCWs observations.
200 opportunities per observation period and per unit of
observation (ward, department, healthcare category etc.).
All clinical impatient and outpatient locations based on
hospital surveillance plan.
See Page 84
Direct observation method
Quarterly
 ≥ 70% (MSD Data, 2016)
 MSD - CIPC Definition, Policy No: IPC-IV-01,
pp. 34-45
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Hand Hygiene Compliance
Indicator Name:
Hospital:
Quarter & Year:
#
Date
Location
Opportunities
/ Indicators
Hand
Hygiene
Practice
Correct
Hand
Hygiene
Practice?
Life
Threatening
Situations?
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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29. Central Line Associated Blood Stream Infection (CLABSI) Measure
Description
Type of Measure
Initial Eligible Population
Criteria
Numerator
Data Elements
Inclusion criteria
Exclusion criteria
Denominator
Data Elements
Inclusion criteria
Exclusion criteria
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Central Line Associated Blood Stream Infectio n
(CLABSI) rate per 1,000 central line days.
Outcome
Positive blood culture with a significant pathogen and
central line in place >2 calendar days on the date of event.
Number of CLABSI cases in each unit assessed
CLABSIs are identified during the month of surveilla nce
All Patients with central line in the selected location or
transferred to other department within the last 48 hours
If the date of event for a CLABSI is the day of transfer or
discharge, or the next day, the infection is attributed to
the transferring location
Total number of central line– days in each unit assessed
Patients with one or more central line at time of counting
All Patients with one or more central line at time of
counting in the selected location
N/A
(N/D)*1,000
Medical Records
All Patients met the definition of CLABSI in the selected
area
At least one critical care area
See Page 86
Manual data collection by infection control practitioner
Quarterly
 Annual Decrease by 50% (Canadian Patient Safety
Institute, 2015)
 MSD - CIPC Definition, Policy No: IPC-XI-02,
pp. 245-262
10
MRN
Location
Age
Date of
Admission
Date of
Central Line
Insertion
Date of
Central Line
Removal
Date of
Specimen
Collection
Confirmed
Blood Stream
Infection
#DIV/0!
Calculated
Result
Central Line Associated Blood Stream Infection (CLABSI)
Issue No.
Page No.
9
8
7
6
5
4
3
2
1
#
Quarter & Year:
Hospital:
Indicator Name:
Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
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Ministry of Defense
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KEY PERFORMANCE INDICATORS (KPI) MANUAL
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1
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Issue No.
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30. Appropriateness Use of Antibiotics
Description
Type of Measure
Initial Eligibility Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Percentage of appropriateness use of antibiotic
(according to antibiotic stewardship guidelines) in
inpatients over three month period.
Process
Patients admitted to the hospital for inpatient acute care
according to ICD-10
Total number of admitted patients who receive
appropriate
antibiotic
(according
to antibiotic
stewardship guidelines)
Number of patients receiving antibiotic
Any patient receiving antibiotic
Outpatients
All number of admitted patients receiving antibiotic.
Total number of patients receiving antibiotic
Patients admitted to the hospital for inpatient acute care
and received antibiotic
Patient who did not receive antibiotic
(N/D)*100
Administration Drug Record (ADR sheet)
All admitted patients receiving antibiotics
Wards, ICU and NICU
See Page 88
Retrospective
Quarterly
≥ 90% (MSD Data)
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Appropriateness Use of Antibiotics
Indicator Name:
Hospital:
Quarter & Year:
#
MRN
Diagnosis
ANTIBIOTIC
Prescribed
Dose
Prescription
Duration
Culture
S ensitivity
Result
Compliant
with
Antibiotic
S tewardship
Guidelines?
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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Ministry of Defense
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Controlled Document
Issue No.
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31. Surgical Site Infection Rate
Description
Type of Measure
Initial Eligible Patient
Population Criteria
Numerator (N)
Data Elements
Inclusions to the
population
Exclusions from the
population
Denominator (D)
Data Elements
Inclusions to the
population
Exclusions from the
population
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of clean and clean contaminated surgical patients
with surgical infections.
Outcome
Signs and symptoms of SSI
Number of SSI cases for specific operative procedure
Number of SSI
Any SSI developed after the operative procedure within
its specific surveillance period and was not present at
time of surgery
Any SSI presented at time of surgery or developed after
its specific surveillance period, or ASA score of 6.
ASA Score 6: A declared brain dead patient whose
organs are being removed for donor purposes.
Total number of specific operative procedures
Number of operative procedure
Any operative procedure listed in the surveillance plan
Any operative procedure not listed in the surveilla nce
plan
(N/D) *100
Medical records, Nurses Survey, Surgeon surveys,
Patient surveys
All SSI cases for specific operative procedure listed in
surveillance plan
Any inpatient and/or outpatient setting where the selected
operative procedure(s) are performed.
See Page 90
Active, patient-based, prospective, post-discharge and
ante-discharge surveillance
Quarterly
 Reduce Baseline by 50% and then a decrease of 10%
every year (Canadian Patient Safety Institute)
 MSD - CIPC Definition, Policy No: IPC-XI-01,
pp. 230-244
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Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Surgical Site Infection Rate
Indicator Name:
Hospital:
Quarter & Year:
Total Number of Operations:
#
MRN
Age
Diagnosis
Procedure
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!
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Ministry of Defense
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Issue No.
Page No.
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32. Multi-Drug Resistant Organism (MDRO) Rate
Description
Type of Measure
Initial Eligible Population
Criteria
Numerator
Data Elements
Inclusion criteria
Exclusion criteria
Denominator
Data Elements
Inclusion criteria
Exclusion criteria
Formula Used
Data Source
Target Sample and Sample
Size
Organization Areas of
monitoring
Data collection tool
Data collection methodology
Frequency of Data Analysis
Measure Target and/or
Threshold
Rate of Multi-Drug Resistant Organism (MDRO) per
1,000 patient days.
Outcome
Any specimen, obtained for clinical decision making,
testing positive for an MDRO mentioned above.
All non-duplicate MDRO isolates from any specimen
source for specific location in a period of time.
Number of MDROs isolates. Hospitals need to monitor
the following MDROs: MRSA, ESBLs, VRE, CRE,
multidrug resistant Acinetobacter spp., and MDR
pseudomonas aeruginosa.
MDRO specimen collected >3 days after admission to the
facility (i.e., on or after day 4).
MDRO Specimen collected in an outpatient location or
an inpatient location ≤3 days after admission to the
facility.
Patient days
Total number of patients in specific location over a period
of time
All presented patient need to be counted each day at the
same time
N/A
(N/D)*1,000
Laboratory reports, medical record
N/A
According to surveillance plan
- Facility-wide by location.
- Selected locations within the facility (1 or more)
See Page 92
Active surveillance
Quarterly
 N/A, the less MDRO rate the best outcome will be.
 MSD - CIPC Definition, Policy No: IPC-VII-01,
pp. 99-100
Kingdom of Saudi Arabia
Ministry of Defense
MEDICAL SERVICES GENERAL DIRECTORATE
KEY PERFORMANCE INDICATORS (KPI) MANUAL
Controlled Document
Issue No.
Page No.
1
92 of 92
Medical Services General Directorate
Continuous Quality Improvement and Patient Safety Department
Data Collection Sheet
Indicator Name:
Multi-Drug Resistant Organism (MDRO) Rate
Hospital:
Quarter & Year:
Patient Days:
#
MRN
Age
Date of
Admission
Date of
Specimen
Collection
Specimen
Result
Calculated
Result
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
#DIV/0!