List of MusQan Key Performance Indicators (KPI) and their Targets - Dr.
NAVEEN KUMAR KOKCHA
S. No. Key Performance Indicator
Enhanced skills of
mothers/families for
1 discharged successfully
providing optimal care to sick
and small newborns
Median uninterrupted time
2 At least 1 hr or more
given for Kangaroo Mother
Average time lag between
admission and ticket
3 20% reduction from the baseline
uploading online/filling of
admission ticket
4 Child Safety Audit *
SNCU
S.No. Key Performance Indicator
Average waiting time for
1 initial assessment by
physician
2 Patient Satisfaction score
Numerator
Total no. of mothers or families
Total no. of cases
having enhanced skill for
providing optimal care to sick and
from the facility
newborns.
Numerator
Time taken from the moment the
patient entered in SNCU to the
moment the patient's assessment
done by medical officer/physician
Sum of average satisfaction score
of each respondent (Average
Total number of
satisfaction score = sum total of
respondents
scores of attributes/numbers of
total attributes)
Denominator Formula Target Remarks
Total no. of mothers or families
having enhanced skill for
At least 80% or more Only for cases which are
providing optimal care to sick and
mothers/families are trained on successfully discharged from
newborns*100/ Total no. of cases
Family Participatory Care (FPC) the facility
discharged successfully from the
facility
Only for cases which are
medically justified as per GoI
KMC guideline.
Difference between the time of
uploading the ticket online/filling
Within 48 hrs
of admission ticket & admission
time
Child Safety Audit includes
physical safety & security,
environmental safety,
medication & medical
100% achievement of conducting
devices-related safety, HAI
the quarterly Child Safety Audit in
etc. The audit will be
last 6 months
conducted on a quarterly
basis separately in the OPD,
Paediatric ward, SNCU and
NRC
Denominator Formula Target Remarks
Mean of waiting time for the
derived sample observed in time More than 90% cases are seen
motion study done at peak hours within 10 minutes of arrival in the Separately for SNCU
on sample basis (at least 5% facility
patients but not less than 30)
Mean of scores given by each
80% of parent-attendants are
patient in patient satisfaction Separately for SNCU,
either satisfied or highly satisfied
survey for SNCU done each Paediatric OPD, Paediatric
(or Equivalent score > 3.5 on Likert
month on statistically adequate Ward and NRC
scale
sample (at least 30)

3 Follow-up rate
Percentage of low-birth-
weight babies successfully
4 babies successfully discharged
discharged after treatment
from SNCU
5 Referral Rate
6 Mortality Rate
7 LAMA Rate
Percentage of sick newborn
received only breast milk
8 At least 80% or more
(either of mother's own or
DHM) throughout their stay
Number of stock-out days for
9 No stock out
essential paediatric drugs
Hospital acquired infection
10
rate in SNCU
Total number of follow up visits
being done
Number of low-birth-weight
(from SNCU/NBSU)
Total number of patients referred Total admission in
to higher centre Exclude: - LAMA, SNCU/NBSU & Paediatric
Abscond
Total number of deaths among
newborns
Total number of patients left
against medical advice from
SNCU/NBSU & Pediatric Ward
Exclude- Abscond, Referral cases
Total Number of sick newborns
received only breast milk (either
of mother's own or DHM)
throughout their stay
Total Number of Hospital acquired
infections in (SNCU)
Total number of follow up visits
Total number of New born
being done*100 / Total no of
discharged from At least 50% discharged patients Separately for SNCU,
New born discharged from
(SNCU/NBSU, Pediatric report for facility follow-up within Paediatric OPD, Paediatric
(SNCU/NBSU, Pediatric Ward &
Ward & NRC) & New Born one month Ward and NRC
NRC) & New Born consulted in
consulted in OPD.
OPD.
Number of low-birth-weight
babies successfully discharged
Total Number of low-birth-
(from SNCU/NBSU)*100/ Total At least 75% and above success SNCU- Less than 1800 grams
weight babies discharged
Number of low-birth-weight rate infants
(from SNCU/NBSU)
babies discharged (from
SNCU/NBSU)
Total number of patient referred
from SNCU/NBSU & Paediatric
Separately for SNCU and
Ward/Total number of patients 20% reduction from the baseline
Paediatric Ward
Ward admitted in SNCU/NBSU &
Paediatric Ward
Total admission in Total number of newborn
Separately for SNCU and
SNCU/NBSU and Paediatric deaths/Total admission in 20% reduction from the baseline
Paediatric Ward
Ward SNCU/NBSU & Pediatric Ward)
(No. of LAMA Patients from
SNCU/NBSU & Pediatric Separately for SNCU and
Total admission 20% reduction from the baseline
Ward*100/Total no. of admission Paediatric Ward
in SNCU/NBSU & Pediatric Ward)
Total Number of sick newborns
Total number of newborns received only breast milk (either Only for cases which are
admitted in SNCU of mother's own or DHM) medically justified
throughout their stay
Formula – No. of stock out days
Separately for SNCU,
for essential commodities X 100/
Paediatric OPD, Paediatric
Total no. of commodities X days
ward and NRC
in a month
Total Number of Hospital
acquired infections in Less than 5% or at least reduction
Total admissions in (SNCU)
(SNCU)*100/ Total admissions of 30% from the baseline
in(SNCU)
 Total number of days equipment
are not functional during the
Total number of break down days
Number of non-functional month Inclusion: - Radiant Separately for SNCU and
11 added for SNCU/NBSU & 20% reduction from the baseline
equipment days warmer, Phototherapy units, Paediatric Ward
Paediatric Ward
Oxygen concentrator, Pulse
Oximeter, Infusion Pump

12 Rational use of antibiotics Total number of prescriptions Total number of Total number of prescription with 20% reduction from the baseline Separately for SNCU and
13 Turnaround time in diagnostic with rational use of antibiotics prescriptions audited rational usebetween
Difference of antibiotics / Total
the time at At least 30% reduction from Paediatric
For Ward
Paediatric OPD, SNCU
14 services
Case Radiology
Fatality Rate Laboratory which investigation baseline and Paediatric Ward
(a) Pneumonia Total number of deaths due to Total number of deaths Total number of deaths due to At least 10% reduction from For Paediatric OPD, SNCU
(b) Diarrhea particular caseof deaths due to
Total number Total number of deaths particular case/Total
Total number number
of deaths due toof baseline
At least 10% reduction from and Paediatric OPD,
For Paediatric WardSNCU
Pediatric OPD particular case particular case/Total number of baseline and Paediatric Ward
S.No. Key Performance Indicator Numerator Denominator Formula Target Remarks
1 Patient Satisfaction score Sum of average satisfaction score Total number of Mean of scores given by each 80% of parent-attendants are Separately for SNCU,
2 Follow-up rate of each
Total respondent
number (Average
of follow up visits respondents
Total patient
number of New born Total in patient
number satisfaction
of follow up visits either
At leastsatisfied or highly patients
50% discharged satisfied Paediatric OPD,
Separately Paediatric
for SNCU,
3 Number of stock-out days for being done discharged from being done*100
Formula – No. of/stock
Totalout
no of
days report
No forout
stock facility follow-up within Paediatric OPD,
Separately Paediatric
for SNCU,
4 essentialdoor-to-drug
Average paediatric drugs
time in for essential
Difference commodities
between X 100/
the time At least 30% reduction from Paediatric
For OPD,OPD
Paediatric Paediatric
5 the health facility
Percentage of mothers Total number of mothers Total no. of cases from dispensing
Total number of of drug &
mothers baseline
At least in 80% cases Only for cases which are
6 receiving IYCF
Turnaround counselling
time in diagnostic receiving IYCF counselling availing discharged receiving IYCF
Difference counselling
between availing
the time at At least 30% reduction from successfully
For discharged
Paediatric from
OPD, SNCU
7 services
Case Radiology
Fatality Rate Laboratory which investigation baseline and Paediatric Ward
(a) Pneumonia Total number of deaths due to Total number of deaths Total number of deaths due to At least 10% reduction from For Paediatric OPD, SNCU
(b) Diarrhea particular
Total caseof deaths due to
number Total number of deaths particular
Total case/Total
number number
of deaths due toof baseline
At least 10% reduction from and Paediatric
For Paediatric OPD,
WardSNCU
Pediatric Ward particular case particular case/Total number of baseline and Paediatric Ward
S.No. Key Performance Indicator Numerator Denominator Formula Target Remarks
1 Patient Satisfaction score Sum of average satisfaction score Total number of Mean of scores given by each 80% of parent-attendants are Separately for SNCU,
2 Follow-up rate of each
Total respondent
number (Average
of follow up visits respondents
Total patient
number of New born Total in patient
number satisfaction
of follow up visits either
At leastsatisfied or highly patients
50% discharged satisfied Paediatric OPD,
Separately Paediatric
for SNCU,
3 Number of stock-out days for being done discharged from being done*100
Formula – No. of/stock
Totalout
no of
days report
No forout
stock facility follow-up within Paediatric OPD,
Separately Paediatric
for SNCU,
4 essentialof
Number paediatric drugs
non-functional Total number of days equipment for essential
Total numbercommodities
of break downX 100/
days 20% reduction from the baseline Paediatric OPD,
Separately Paediatric
for SNCU and
5 equipment
Rational usedays
of antibiotics are not
Total functional
number during the
of prescriptions Total number of addednumber
Total for SNCU/NBSU &
of prescription with 20% reduction from the baseline Paediatric Ward
Separately for SNCU and
6 Turnaround time in diagnostic with rational use of antibiotics prescriptions audited rational usebetween
Difference of antibiotics / Total
the time at At least 30% reduction from Paediatric
For Ward
Paediatric OPD, SNCU
7 services Radiology
Case Fatality Rate Laboratory which investigation baseline and Paediatric Ward
(a) Pneumonia Total number of deaths due to Total number of deaths Total number of deaths due to At least 10% reduction from For Paediatric OPD, SNCU
(b) Diarrhea particular
Total caseof deaths due to
number Total number of deaths particular
Total case/Total
number number
of deaths due toof baseline
At least 10% reduction from and Paediatric
For Paediatric OPD,
WardSNCU
NRC particular case particular case/Total number of baseline and Paediatric Ward
S.No. Key Performance Indicator Numerator Denominator Formula Target Remarks
1 Patient Satisfaction score Sum of average satisfaction score Total number of Mean of scores given by each 80% of parent-attendants are Separately for SNCU,
2 Follow-up rate of each
Total respondent
number (Average
of follow up visits respondents
Total patient
number of New born Total in patient
number satisfaction
of follow up visits either
At leastsatisfied or highly patients
50% discharged satisfied Paediatric OPD,
Separately Paediatric
for SNCU,
3 Number of stock-out days for being done discharged from being done*100
Formula – No. of/stock
Totalout
no of
days report
No stockforout
facility follow-up within Paediatric OPD,
Separately Paediatric
for SNCU,
essential paediatric drugs for essential commodities X 100/ Paediatric OPD, Paediatric