HOSPITAL WIDE QUALITY INDICATORS - 2022

№ Category Name Definition Rationale Type of measures Numerator Denumerator Method of data Data aggregation and analysis Responsible Frequency and Target Internal Benchmarking National International
collection Department time frame Benchmarking Benchmarking

Number of inpatient cases Collect data from HIS (number of inpatient Propo
Inpatient‘s pathogenic To control and track rational use of having pathogen test Total number of inpatient received antibiotic treatment and compare sal: >50%
1 Strategic detection rate prior to antibiotics as per AB policy Process
specimens sent prior to cases prescribed antibiotics
Retrospective
to number of patient who has pathogen
QAS Monthly >80% 80% >7.2% Target
antibiotic treatment (Mongolia benchmark 7.2%)
antibiotics test specimens) >20%

Percentage of policy Sampled number of

compliance using inpatients who received Average rate of AB prescription policy Ped, Internal
checklist antibiotics medicine
Antibiotic prescription policy To improve AB prescription policy compliance rate of Pediatric and Internal
2 Strategic
compliance rate compliance
Process Retrospective
medicine departments, Cardiology center
departments, Monthly >95% 95% N/A Varies
and ICU Cardiology
Rational use of center, ICU
Antibiotic (AB)
Прокалцитонин Нийт сонгогдсон өвчтний
To improve antibiotic prescription хэмжээг /анх удаа болон түүхийн тоо / антибиотик
давтан хэмжсэн/ тоо эмчилгээ хийж эхэлсэн Тухайн сонгогдсон тасгийн /эрчимт
policy compliance guided by эмчилгээ, мэс засал, хүүхэд, дотор г.м/
procalcitonin өвчтний түүх болон давтан
Procalcitonin policy прокалцитонин үзэгдсэн антиотик эмчилгээ хийгдсэн өвчний AB stewarship
3 Strategic compliance Прокальцитонины хэмжээг хөтөч Process Retrospective түүхүүдээс мэдээллийг цуглуулна. committee Semi-annual >80% 80% NA NA Tsolm
болгосон антибиотик эмчилгээ өвчний түүхийн тоо/
удирдамжийн хэрэгжилтийг
/прокалцитонин үзсэн эсэх, хариу гарсан on.b:
хангах, сайжруулах цаг г.м/ Chavali
S,
Menon
Total number of V,
Hand hygiene is one of the most Total number of opportunities where hand Determine hospital wide data based on Shukla
3 Strategic Hand hygiene compliance rate important ways to prevent the Process opportunity where hand hygiene could have been Concurrent unit data QAS Monthly > 90% 90% N/A 78% overall in ICU, India*
U.
spread of infections. hygiene is performed
performed Hand
hygien
Infection control e
3.2–24.7 NSIs
Total exposed population per 100 occupied compli
To create a safe environment for Not sufficient data
4 Strategic Employee needle stick case patients, families and staffs. Outcome Every case number (technicians, midwives, nurses Concurrent Total number of needle stick injuries QAS Monthly <1 <1 per month availabla beds annually. 4.7 needle ance
and doctors) stick injuries per 1,000 among
HCW healthc
are
worker
To improve the hospital healthcare
Patient and family service by engaging the patients Total percentage of Total number of patients Concurrent and Determine mean level of IPD and OPD s in an
5 Strategic Patient experience IPD/OPD Outcome patients who scored 9 or PA Monthly >85% 85% 75% Varies accredi
satisfaction through actively reviewing the above participated in the survey Retrospective patient satisfaction
patient experience survey ted
tertiary
To improve staff satisfaction and HR team maintain data set and regularly care
reduce turnover rate calculates for all staff <1.875% per hospita
Number of employees
6 Strategic Human resources Staff turnover rate Outcome who left Average number of employees Retrospective HR Monthly <1% 1% per month month, MCS 14.2% per year, USA 2015 l.
Groupwide Indian
Timely follow-up and risk reduction Process Collect events from hospital 'Event J Crit
action paln Number of level 3 events reporting system' Determine total number Care
Percentage of follow up Total number of events of followed up events from total number Med.
7 Strategic events that have been followed registered as level 3 or above Retrospective QAS Monthly >95% 95% N/A N/A
up. of registered events 2014;1
Risk 8(10):6
Process 89–
Number of medication events Total number of Collect medication related events from 693.
8 Strategic (near misses, adverse drug To improve medication safety medication events NA Retrospective hospital 'Event reporting system. QAS Monthly 0 0 N/A 12%, PMC, UK doi:10.
reactions) 4103/0
To reduce and prevent risks resulted Process 972-
Number of occurrences Total number of events Collect events related to patient
9 Strategic regarding incorrect patient from patient misidentification. regarding to patient NA Retrospective misidentification from hospital 'Event QAS Monthly 0 0 N/A 0, WHO
5229.1
42179
identification identification reporting system.
Process Determine average level reported
To improve safe and quality Laboratory and Radiology department
Critical values reported back healthcare by ensuring timely Number of critical values Total number of critical value Concurrent and
10 Strategic reported within time critical value QAS Monthly 100% 100% N/A 100% within 1 hour
within time frame (Lab&Rad) communication on critical values frame results Retrospective
reports.

Safety storage and use of To improve the safety of LASA Total number of LASA Pharmacy team collects data by regular
11 Strategic LASA medicaton in patient medications Process medication events NA Retrospective monthly audit QAS & Pharmacy Monthly 0 0 N/A 0, WHO
care areas

Surgical sites marking

excluding single organ, c/s,
infant surgery and other
exceptions as per the
Patient Safety Universal Protocols - correct To provide safe healthcare service by Number of surgical cases Total number of surgical cases
measures Site marking registry from Operation
12 Strategic symbol ensuring correct site, correct patient, Process that have correct site that need site marking as per Retrospective
Theater
Surgery Monthly 100% 100% N/A 100%, WHO
(IPSG) - done before entering OR and correct procedure. marking policy
- done by
surgeon
- visible after drape
/Surgery Safety Checklist/

Nosocomial infection rates: 43.7/1000 MV 12.2/1000 MV days

13 Strategic • Ventilator associated VAP patient number Ventilator days Retrospective <13.1 13.1
pneumonia rates per 1000 days, 2015 (INICC)
MV days(VAP)
14 Strategic • Urinary tract infection (UTI) CAUTI patient number Urinary catheter days Retrospective INICC and National registry (INICC <5.07 5.07 15.7/1000 4.82/1000 catheter days
To minimize the risk of hospital QAS (infection
• Central line-associated acquired infection
Outcome becnhmarking (INICC international report
control)
Monthly catheter days (INICC)
Blood stream infection (IPSG "2010-2015")
15 Strategic 5) per 1000 CL days CLABSI patient number Central-line days Retrospective <4.11 4.11 19.7/1000 CL days 4.19/1000 CL days (INICC)
• Surgical site infection (SSI)
16 Strategic from Class I surgical wounds Number of SSI cases Surgery number Retrospective <3.5% 3.50% N/A 1.9%2 (NHSN, US)
To create a safe environment for Number of patient falls x Events registry at OSH and hospital 'event
17 Strategic Fall rate in hospitals patients, visitors and staff. Outcome 1000 Patient days of each month Retrospective reporting system' QAS Monthly 0 0 N/A 3.56/1000 bed days

Total number of sampled QAS team designates a team of doctors

18 Strategic Closed Medical Record (MR) Process MRs fully met policy Total number of sampled Retrospective who evaluates quality of MR using check QAS Quarterly ≥90% 90% N/A 100%, WHO
quality and completeness closed medical records
requirements (checklist) list

The number of open

20 Strategic Open medical record Process medical record that fully Total number of sampled Concurrent MR unit regularly collects completeness QAS Monthly ≥95% 95% N/A 100%, WHO
completeness met policy requirement open medical records data using check list on daily basis
(checklist)

Medical record To improve clinical documentation

 The number of outpatient Sampled medical record disseminated by
Outpatient medical record medical record that fully Total number of sampled
21 Strategic quality and completeness Process met policy requirement outpatient medical records Retrospective medical record unit. Compliance checked QAS Quartetly >90% >90% N/A N/A
(checklist) against checklist
Medical record To improve clinical documentation

The sampled ER form that Sample randomly selected from the total
22 Strategic ER form completeness Process fully completed NA Retrospective number of patient that visited ER in ER monthly >90% >90% N/A N/A
respective month

The log file used by the “copy and paste”

Copy and Paste function function is saved, a database is created, Health Statistics
improper use Number of texts were Total number selected copy and the resulting database is used for Unit and 23%
23 Strategic (Percentage of unchanged Structure
not changed and paste texts Retrospective calculations. Thirty patient’s charts will be Information Quarterly <20% <20% N/A
texts in selected medical randomly selected and reviewed to Technology
record) evaluate whether any changes have been Department
made.

Number of cases of drug & Number of events of

24 Strategic Supрly chain consumable stock out To maintain contineous supply Structure shortage for each NA Retrospective Procurement registry Procurement Monthly <4 <4 N/A N/A
categories

QAS team performs audit on the sampled

Compliance of clinical Number of MRs that met Total number of MRs with MRs. Data will be collected for each CPG
25 Strategic Clinical indicator
guidelines
To reduce variation in clinical care Process
CPG indicators respective diagnosis
Retrospective
with questionnaire regarding to respective
QAS Quarterly >80% 80% N/A N/A
diasnosis

Patients with elective vaginal Number of women with

deliveries or elective cesarean To monitor delivery and improve elective deliveries < 39 Number of women delivering Delivery registry. Retrospective data 4.6% Leapfrog group,
26 Strategic
sections at >= 37 and < 39 perinatal care
Outcome weeks of gestation newborns with < 39 weeks of Retrospective sources for required data elements include OBGYN Monthly <30% 30% 25.6%, 2017 2013
completed without gestation administrative data and medical records
weeks of gestation completed indication

Nulliparous women with a Number of nulliparous Total number of nulliparous

Perinatal care term, singleton baby in a To monitor delivery and improve women with a term, women with a term, singleton Retrospective Delivery registry. Retrospective data 26.7% (Target for 2020,
27 Strategic
(Library of Measure) vertex position delivered by perinatal care
Outcome singleton baby in a vertex
baby in a vertex position
sources for required data elements include OBGYN Monthly <30% 30% N/A Joint commision, US)
cesarean section position delivered by delivery administrative data and medical records
cesarean section

Exclusive Breast Feeding

(Exclusive breast milk feeding Newborns that were fed Total number of single term Delivery registry. Retrospective data
28 Strategic during To improve perinatal care Outcome newborns discharged from
breast milk only since birth the hospital
Retrospective sources for required data elements include OBGYN Monthly >80% 80% N/A 100%, WHO
the newborn's entire administrative data and medical records
hospitalization)
 IH - HOSPITALWIDE QUALITY INDICATOR 2023
Jan Feb Mar Apr May June Jul Aug Sep Oct Nov Dec

61 45 71 89 65 66 Мөнхтуяа
Inpatient‘s pathogen detection rate prior to
351 276 352 333 364 351 Ариунаа
1 antibiotic treatment
17.4% 16.3% 20.2% 26.7% 17.9% 18.8% #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0! #DIV/0!

ANTIBIOTIC Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
1 STEWARDSHIP
PROGRAM Antibiotic prescription policy compliance 82.5% 93.3% 92.7% 89.5%
2 rate (IM & Ped) Дотор1-3, Зүрхний төв, Хүүхдийн тасгийн дундж
Target>95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
Procalcitonin policy compliance Ariunaa
3
Target >95% 95% 95%
Staff hand hygiene compliance rate 96.5% 96.0% 97.0% 98.0% 99.0% 97.0% 97.3% Мядагмаа
7
Target>90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
2 Infection control
Needle sticks rate of employees 0.0% 0.5% 0.2% 9.0% 0.5% 0.0% 1.70% Мядагмаа
8
Target<1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%
PATIENT AND Patient satisfaction IPD/OPD 85% 85.2% 88.2% 84.4% 89.0% 88.3% 86.7% Ундрал/Regzedmaa
3 9 FAMILY
SATISFACTION Target>85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85% 85%

Turnover rate 2.9% 1.7% 1.8% 3.0% HR Золоо

Physician 1.3% 2.2% 0.0% 0.9%
STAFF Nurses, Midwives, Technicians 2.9% 5.2% 0.2% 2.3%
4 10
SATISFACTION Admin staff 1.3% 5.2% 5.1% 5.8%
Target<1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1% 1%

Follow up events 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Naraa emch
11
Target>95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95% 95%
5 RISK Number of medication events (near misses, 4 0 1 1 4 2.00
adverse drug reactions) Naraa emch
12
Target=0 0 0 0 0 0 0 0 0 0 0 0 0

Closed medical record completeness and 99.0% 96.0% 97.0% 96.0% 99.0% 99.0% 97.7%
quality Urtaa Demberel 2 gargana
13 Naraa emch negtgedeg
Target>90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
Open medical record completeness and 86.0% 79.0% 92.0% 69.0% 83.0% 83.0% 82.0%
14 quality Болор
Target> 90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
6 MEDICAL
RECORD Outpatient medical record completeness 73.0% 72.0% 77.5% 75.5% 79.4% 86.0% 77.2%
15 and quality Ulirald neg udaa
Target>90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
ER form completeness and quality 99.5% 99.5% 98.5% 99.2% March data missing, Mungunsarnai emch avah
16
Target>90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90% 90%
Copy and paste function improper use 36.30% 30.30% 33.3% Раднаа, Нямхорол
17
Target<20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20% 20%
 Number of cases of drug stock out 1 1 0 0 0 0.4 Цэрмаа
Number of cases of consumable stock out 2 0 3 2 4 2.2
7 18 SUPPLY CHAIN Number of cases of reagent stock out 0 1 0 0 1 0.4
Target<4 4 4 4 4 4 4 4 4 4 4 4 4 4

Number of occurrences regarding incorrect 2 2 1 2 2 0 0 2 11

ID (IPSG 1) Event reportoos
19
Target=0 0 0 0 0 0 0 0 0 0 0 0 0

Critical value report within TAT (30 min) rate 93.1% 96.4% 99.6% 98.5% 100.0% 98.8% 99.1% 98.3% 98.0%
- Lab (IPSG 2) Сумъяа
Critical value report within TAT (30 min) rate 100.0% 100.0% 100.0% 100% 100.0% 100.0% 100.0% 100.0% 100.0%
20 - Rad (IPSG 2) Өлзийсайхан
Critical value report within TAT (30 min) rate 96.5% 98.2% 99.8% 99.0% 100.0% 99.4% 99.6% 99.2% #DIV/0! #DIV/0! #DIV/0! #DIV/0! 99.0%
(IPSG 2) LAB, RAD iin dundaj
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Time out (IPSG 2) 90.0% 89.0% 85.0% 98.8%
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Safety storage and use of LASA medicaton 0 0 0 0 0 0 0 2 0.3

21 in patient care areas (IPSG 3) Ариунаа, Тодруулах!!
Target=0 0 0 0 0 0 0 0 0 0 0 0 0
8 PSI Surgical site marking (IPSG 4) 100.0% 100.0% 100.0% 100.0% Батсайхан, Гэндэнсүрэн
22
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Time out (IPSG 2) 90.0% 89.0% 85.0% 98.8%
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Ventilator associated pneumonia (IPSG 5) 0.0 0.0 0.0 0.0 0.0 0.0
23 rates per 1000 MV days Мядагмаа (nehej avah)
Target<13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1 13.1
Urinary tract infection rate per 1000 0.0 0.0 0.0 0.0 0.0 0.0
24 catheter days Мядагмаа (nehej avah)
Target<5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07 5.07
Central line-associated blood stream 0.0 0.0 0.0 0.0 0.0 0.0
25 infection per 1000 CL days Мядагмаа (nehej avah)
Target<4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11 4.11
Surgical site infection (IPSG 5) 0.0% 0.0% 0.0% 0.0% 2.0% 0.4% Мядагмаа (nehej avah)
26
Target<5% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0% 5.0%
Fall rate Inpatient (falls per 1,000 occupied 0.5 0.7 1.6 0.5 0.5 0.7 0.7
27 bed days IPSG 6) Bed days - Чукагаас MSO
Target=0 3.56 3.56 3.56 3.56 3.56 3.56 3.56 3.56 3.56 3.56 3.56 3.56
GW 31 (2)
Ped 1 ped ped
Ped (1)
Fall rate Outpatient 1
SB clinic 1

Acute pain management 100% 100% 100% NA NA 100.0% Mungusarnai

28
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

9 CLINICAL
INDICATORS
 Acute coronary syndrome guideline 100% 100% 75% 100% 100% 95.0%
29 compliance Bolormaa cardiologist
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Community acquired pneumonia guideline #DIV/0!
30 CLINICAL compliance
9 Mungunsarnai, Enkhmandal
INDICATORS
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Sepsis and septic shock immediate 80% na 75% 68% 80% 75.8%
31 management guideline completeness Цолмон, улиралд нэг удаа
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Hypertensive emergency guideline 100.0% na 75.0% 93.0% 100.0% 92.0%
32 compliance Mungunsarnai
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Elective Delivery (Patients with elective vaginal
deliveries or elective cesarean sections at >= 37 0.0% 0.0% 0.0% 0.0% 0.0%
33 and < 39 weeks of gestation completed) Ulsin dundaj 28
Түмэнцогт
WHO recommendation 30
Target<10% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% 10.0% aas doosh bolgoh

Library of Cesarean Section (Nulliparous women with a

10 Measure term, singleton baby in a vertex position 0.0% 0.0% 0.0% 0.0% 0.0%
34
(Perinatal Care) delivered by cesarean section ) Түмэнцогт
Target<20% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0% 20.0%

Exclusive Breast Feeding (Exclusive breast milk

feeding during the newborn's entire hospitalization) 95.8% 98.3% 93.7% 97.6% 96.4%
35
Түмэнцогт
Target>90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
 биелэлт, АB checklist жигд бус байгаа

Тухайн сарын AB авсан IP тоо

International benchmark 50%, sanal 50% bolgoh

Prevention surgery AB hasaj tootsoh sanaltai bn

Хүүхдийн тасгийн дунджаар авна.

Ulirald neg hiigddeg, Tumen-Od data tsugluuldag

Nehej avah

nehej avah

nehej avah

ngunsarnai emch avah

Цаашид кесарово хагалгаа хийгдэх заалт байсан эхсэхийг өвчний түүхэнд аудит хийж шалгах
 Culture testing rate prior to antibiotic use, inpatient
100.0%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0% 26.7%
17.4% 20.2%
20.0% 16.3% 17.9% 18.8%

10.0%
0.0% 0.0% 0.0% 0.0% 0.0%
0.0%
1 2 3 4 5 6 7 8 9 10 11

Percentage of culture testing rate Target

ntibiotic use, inpatient Antibiotic prescription policy co
100.0%

90.0% 93.3% 92.7%

80.0% 82.5%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%

1 2 3 4 5 6 7
7 8 9 10 11 12
Percentage of AB policy compliance
esting rate Target

Procalcitonin policy compliance

100%

90%

80%

70%

60%

50%

40%

30%
60%

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10 11 12

Procalcitonin policy compliance Target >95%

otic prescription policy compliance

4 5 6 7 8 9 10 11 12

ercentage of AB policy compliance Target

0 11 12
 Staff Hand Hygiene
100.0%
99.0%
98.0%
98.0%
97.0% 97.0%
96.5%
96.0%
96.0%

94.0%

92.0%

90.0%

88.0%

86.0%

84.0%
1 2 3 4 5 6 7 8 9 10 11
Percentage of hand hygiene rate Target
 Staff N
ne
10.0%

9.0% 9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0%

2.0%

1.0%
0.5% 0.5%
0.0% 0.0% 0.2%
8 9 10 11 12 1 2 3 4 5

ate Target
 Staff Needle Stick

9.0%

0.5%
0.2% 0.0%
3 4 5 6 7 8 9 10 11 12

Needle stick rate

100%

95%

90%

88.2%

85%
85% 85.2%
84.

80%

75%
1 2 3 4
 Patient satisfaction (IP/OP)
0%

5%

0%

89.0%
88.2% 88.3%

5%
85% 85.2%
84.4%

0%

5%
1 2 3 4 5 6 7 8 9 10 11 12

Patient satisfaction rate Target

 Turnover rate of IH employees
10.0%

9.0%

8.0%

7.0%

6.0%

5.0%

4.0%

3.0% 2.9% 3.0%

2.0%
1.7% 1.8%

1.0%

0.0%
1 2 3 4 5 6 7 8 9

Turnover rate Target

te of IH employees

6 7 8 9 10 11 12

over rate Target

100.0%
Event Follow-up
100.0% 100.0% 100.0% 100.0% 100.0% 10
99.0% 9
8
98.0%
7
6
97.0%
5
96.0% 4 4
3
95.0% 2
1
94.0%
0 0
1 2
93.0%

92.0%
1 2 3 4 5 6 7 8 9 10 11 12

Follow up events Target>95%

 Medication events
10
9
8
7
6
5
4 4 4
3
2
1 1 1
0 0
1 2 3 4 5 6 7 8 9 10 11 12

Number of medication events Target

 Closed medical record completeness an
quality
100.0%
99.0% 99.0% 99.0%
98.0%
97.0%
96.0% 96.0% 96.0%
94.0%
92.0%
90.0%
88.0%
86.0%
84.0%
1 2 3 4 5 6 7 8 9 10

Closed medical record completeness and quality

Target>90%

Outpatient medical record complete

100.0%
90.0%
80.0% 86.0%
70.0% 77.5% 75.5% 79.4%
73.0% 72.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1 2 3 4 5 6 7

Outpatient medical record complete

Target>90%

Copy an
40.00%36.30%
35.00%
30.00%
25.00%
20.00%
15.00%
 Copy an
40.00%36.30%
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
1 2 3

Copy an
al record completeness and
quality Open medical record completeness and qual-
ity
99.0% 99.0% 100.0%
90.0% 92.0%
86.0% 83.0% 83.0%
.0% 80.0% 79.0%
70.0% 69.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
5 6 7 8 9 10 11 12 0.0%
1 2 3 4 5 6 7 8 9 10 11
dical record completeness and quality
% Open medical record completeness and quality
Target> 90%

ER form com
medical record completeness and quality
102.0%
100.0% 99.5%
99.5%
98.0% 98.5%
86.0%
96.0%
.5% 75.5% 79.4%
94.0%
92.0%
90.0%
88.0%
86.0%
84.0%
1 2 3 4 5 6
3 4 5 6 7 8 9 10 11 12
ER form completeness and
atient medical record completeness and quality
et>90%

Copy and Paste function improper use

40.00%36.30%
35.00%
30.30%
30.00%
25.00%
20.00%
15.00%
 Copy and Paste function improper use
40.00%36.30%
35.00%
30.30%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
1 2 3 4 5 6 7 8 9 10 11 12

Copy and paste function improper use Target<20%

d completeness and qual-
ity

83.0% 83.0%

6 7 8 9 10 11 12

ecord completeness and quality

ER form completenss

9.5%
99.5%
98.5%

2 3 4 5 6 7 8 9 10 11 12

ER form completeness and quality Target>90%

 Stock out
4.5

3.5

2.5

1.5

0.5

0
1 2 3 4 5 6 7 8

Number of cases of drug stock out Number of cases of consumable stock out

Target<4
 Stock out

6 7 8 9 10 11 12

r of cases of consumable stock out Number of cases of reagent stock out

 IPSG 1: Inco

2.5

2 2 2 2 2

1.5

1 1

0.5

0 0
1 2 3 4 5 6
Number of occurences regar
 IPSG 1: Incorrect ID

2 2 2

0 0
4 5 6 7 8 9 10 11 12
Number of occurences regarding incorrect ID Target
 Critical value report within time frame, Lab &
Rad
102.0%

100.0%

98.0%

96.0%

94.0%

92.0%

90.0% Critical value report within TAT (30 min) rate - Lab (IPSG 2)
Critical value report within TAT (30 min) rate - Rad (IPSG 2)
88.0%
1 Critical
2 3value report
4 within
5 TAT
6 (307min) rate
8 (IPSG
9 2) 10 11 12
Target>100%
 LASA medica
2.5

1.5

0.5

0 0 0 0 0 0
0
1 2 3 4 5 6

Number of cases improper use of

 LASA medication use

0 0 0 0
4 5 6 7 8 9 10 11 12

Number of cases improper use of LASA medication Target

 IPSG 4: Surgical site marking
100.0% 100.0% 100.0% 100.0%

90.0%

80.0%

70.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
1 2 3 4 5 6 7 8 9

Surgical site marking (IPSG 4) Target>100%

ical site marking
0%

6 7 8 9 10 11 12

ng (IPSG 4) Target>100%
 Ventilator associated pneumon
14.0 13.1 13.1 13.1 13.1 13.1 MV
13.1days
13.1 1
12.0

10.0

8.0

6.0

4.0

2.0

0.0
0.0
1 0.0
2 0.0
3 0.0
4 0.0
5 6 7

Ventilator associated pneumonia (IPSG 5)

Target<13.1

Central line associat

per
4.5
4.0
3.5
3.0
2.5
2.0
1.5
1.0
0.5
0.0 0.0 0.0 0.0 0.0 0
1 2 3 4 5

Central line-associated
Target<4.11
tilator associated pneumonia rates per 1000
.1 13.1 13.1 13.1 MV
13.1days
13.1 13.1 13.1 13.1 13.1 13.1 UTI rate per 1000 catheter days
14.0
12.0
10.0
8.0
6.0
4.0
2.0
0.0 0.0 0.0 0.0 0.0
20 0.0
3 0.0
4 0.0
5 6 7 8 9 10 11 12 0.0
1 2 3 4 5 6 7 8 9

ntilator associated pneumonia (IPSG 5) rates per 1000 MV days Ventilator associated pneumonia (IPSG 5) rates per 100
rget<13.1 Target<13.1

Surgica
6.0%
Central line associated blood stream infection rate
per 1000 CL days 5.0%

4.0%

3.0%
2
2.0%

1.0%
0.0% 0.0% 0.0% 0.0%
0.0%
1 2 3 4
0.0 0.0 0.0 0.0 0.0
1 2 3 4 5 6 7 8 9 10 11 12
Surgical site i
Central line-associated blood stream infection per 1000 CL days
Target<4.11
e per 1000 catheter days

0.0
5 6 7 8 9 10 11 12

ated pneumonia (IPSG 5) rates per 1000 MV days

Surgical site infection rate

.0%

.0%

.0%

.0%
2.0%
.0%

.0%
0.0% 0.0% 0.0% 0.0%
.0%
1 2 3 4 5 6 7 8 9 10 11 12

Surgical site infection (IPSG 5) Target<5%

 Jan Feb Mar Apr May Jun Jul
Fall rate per 1000
0 0 2.67 0.93 0 0 0.6
bed days
Average falls per
3.56 3.56 3.56 3.56 3.56 3.56 3.56
1000 bed days

1: 90%
Falls in 2: 80%
hospitals (IPSG 3: 70%
2 1 2 1 1 0 1
6) >3: 0%

Target=0 0 0 0 0 0 0 0

3.5

2.5

1.5 1.6

1
0.7
0.5 0.5

0
1 2 3 4

Fall rate Inp

Target=0
 Aug Sep Oct Nov Dec

1.088 0 1 2 0.4

3.56 3.56 3.56 3.56 3.56

1 0 0 0

0 0 0 0

Falls rate
4

3.5

2.5

1.5 1.6

1
0.7 0.7 0.7
0.5 0.5 0.5 0.5

0
1 2 3 4 5 6 7 8 9 10 11 12

Fall rate Inpatient (falls per 1,000 occupied bed days IPSG 6)
Target=0
 Elective Delivery (Patients with elective vaginal
deliveries or elective cesarean
100.0% sections
100.0% at >= 37 and < 39 weeks of
100.0% 93.0% gestation completed)
90.0%
80.0% 75.0%

70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0%
1 2 3 4 5 6 7 8 9 10 11 12

Exclusive Breast Feeding (Exclusive breast milk feeding during

the newborn's entire hospitalization)
100.0%
98.3%
97.6%
98.0%
95.8%
96.0%
93.7%
94.0%

92.0%

90.0%

88.0%

86.0%

84.0%
1 2 3 4 5 6 7 8 9 10 11 12

Exclusive Breast Feeding (Exclusive breast milk feeding during the newbor...
90.0%

88.0%

86.0%

84.0%
1 2 3 4 5 6 7 8 9 10 11 12

Exclusive Breast Feeding (Exclusive breast milk feeding during the newbor...
 lective vaginal
arean Cesarean Section (Nulliparous women with a term, single
weeks of ton baby in a vertex position delivered by cesarean section
100.0%
d) 90.0%
80.0%
70.0%
60.0%
50.0%
40.0%
30.0%
20.0%
10.0%
0.0% 0.0% 0.0% 0.0%
0.0%
1 2 3 4 5 6 7 8 9 10 11
10 11 12

st milk feeding during

alization)

10 11 12

g the newbor...
10 11 12

g the newbor...
women with a term, single-
vered by cesarean section)

8 9 10 11 12
 Acute Pain Management CPG compliance
100% 100% 100% 100%

90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10 11 12

Acute pain management Target>80%

Sepsis and septic shock management CPG compliance

100%

90%

80%
80% 80%
70% 75%
68%
60%

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10 11 12

Sepsis and septic shock immediate management guideline completeness

Target>80%
10%

0%
1 2 3 4 5 6 7 8 9 10 11 12

Sepsis and septic shock immediate management guideline completeness

Target>80%

100%
Community acquired pneumonia CPG compliance
90%

80%

70%

60%

50%

40%

30%

20%

10%

0%
1 2 3 4 5 6 7 8 9 10 11 12

Community acquired pneumonia guideline compliance Target>80%

 Acute Coronary Syndrome CPG compliance
100% 100% 100% 100% 100%

90%

80%
75%
70%

60%

50%

40%

30%

20%

10%

10 11 12 0%
1 2 3 4 5 6 7 8 9 10 11 12
Acute coronary syndrome guideline compliance
Target>80%

ance 100.0%
Hypertensive emergency CPG compliance
100.0% 100.0%
90.0% 93.0%

80.0%

70.0% 75.0%

60.0%

50.0%

40.0%

30.0%

20.0%

10.0%

0.0%
0 11 12 1 2 3 4 5 6 7 8 9 10 11 12

mpleteness Hypertensive emergency guideline compliance Target>80%

 10.0%

0.0%
0 11 12 1 2 3 4 5 6 7 8 9 10 11 12

mpleteness Hypertensive emergency guideline compliance Target>80%

ance

10 11 12

Target>80%
ompliance

8 9 10 11 12
e compliance

mpliance

9 10 11 12

Target>80%
9 10 11 12

Target>80%
 Priority CPGs
1
 Clinical guidelines SEP_2018 DEC_2018

Stroke guideline compliance 100.00% 100.00%

Acute coronary syndrome guideline compliance 87.50% 87.50%
Clinical guidelines
Community acquired pneumonia guideline compliance 86.60% 83.10%
Fever in pediatrics and adults guideline compliance 100.00% 98.50%
Hypertensive emergency guideline compliance 76.00% 74.00%
Target>80% 80.0% 80.0%

Chart Title
120.00%

100.00%

80.00%

60.00%

40.00%

20.00%

0.00%
SEP_2018 DEC_2018 MAR_2019 JUN_2019

Stroke guideline compliance

Acute coronary syndrome guideline compliance
Community acquired pneumonia guideline compliance
Fever in pediatrics and adults guideline compliance
Hypertensive emergency guideline compliance

March June
Stroke guideline compliance 100% 100%
Acute coronary syndrome guideline compliance 87.50% 87.50%

Community acquired pneumonia guideline compliance 61% 78%

Fever in pediatrics and adults guideline compliance 100% 100%

Hypertensive emergency guideline compliance 80.0% 56.0%
Target>80% 80.0% 80.0%
 MAR_201 JUN_2019
9 Average
100% 100%
87.50% 87.50%
61% 78%
100% 100%
80.0% 56.0%
80.0% 80.0%

Clinical Guidelines
120.00%

100.00%

80.00%

60.00%

JUN_2019 40.00%

20.00%

0.00%
SEP_2018 DEC_2018 MAR_2019 JUN_2019

Stroke guideline compliance Acute coronary syndrome guideline compliance

Community acquired pneumonia guideline compliance Fever in pediatrics and adults guideline compliance
Hypertensive emergency guideline compliance Target>80%

120%
100%
SeptemberDecember 80%
100% 88% 60%
40%
87.50% 87.50% 20%
0%
46.60% 48%
92% 97%
89.0% 75.8%
80.0%

March June September December

March June September December
R_2019 JUN_2019

onary syndrome guideline compliance

ediatrics and adults guideline compliance
%

er
er
 IH -
HOSPITALWID
E QUALITY
INDICATOR
Q1
2022 Q2

Inpatient‘s pathogen detection rate prior to

1 antibiotic treatment
28.4% 27.3%
Target>80%
Antibiotic prescription policy compliance 88.1% 92.7%
2 rate (IM & Ped)
Target>95%
ANTIBIOTIC Procalcitonin policy compliance
1 3 STEWARDSHIP
PROGRAM Target >95% 95%
IV to oral antibiotic conversion rate (Policy
4 compliance)
Target >
Inpatient cumulative antibiogram
5
Target >
Inpatient Antibiotic DDD/100 bed days
6
Target <285
Staff hand hygiene compliance rate 96.7% 96.7%
7
Target>90%
2 Infection control
Needle sticks to employees 0.2% 0.1%
8
Target<1%

PATIENT AND Patient satisfaction IPD/OPD 79.3% 85.3%

3 9 FAMILY
SATISFACTION Target>85%

STAFF Turnover rate 1.1% 1.5%

4 10 SATISFACTION Target<1%
Follow up events 100.0% 100.0%
11
Target>95%
5 RISK Number of medication events (near misses, 6 8
adverse drug reactions)
12
Target=0
 Closed medical record completeness and 95.7% 95.7%
quality
13
Target>90%
Open medical record completeness and 90.8%
14 quality
Target>90%
Outpatient medical record completeness 76.1% 87.7%
MEDICAL and quality
6 15 RECORD
Target>90%

ER form completeness and quality 99.3% 96.2%

16
Target>90%

Copy and paste function improper use

17
Target<
Number of cases of drug stock out 1
Number of cases of consumable stock out 1
7 18 SUPPLY CHAIN Number of cases of reagent stock out 3
Target<4
Number of occurrences regarding incorrect 9 9
ID (IPSG 1)
19
Target=0

Critical value report within TAT (30 min) rate 99.9% 100.0%
- Lab (IPSG 2)

Critical value report within TAT (30 min) rate 93.9% 100.0%
20 - Rad (IPSG 2)
Critical value report within TAT (30 min) rate 96.9% 100.0%
(IPSG 2)
Target>100%
Safety storage and use of LASA medicaton 0.0% 0.0%
21 in patient care areas (IPSG 3)
Target=0

5 зөвийн дүрэм алдагдсан (Буруу тун,

буруу цагт, буруу замаар, буруу
8 IPSG үйлчлүүлэгчид өгөх)

Target=0
8 IPSG

Surgical site marking (IPSG 4) 98.2% 84.4%

22
Target>100%
Ventilator associated pneumonia (IPSG 5) 0.0%
23 rates per 1000 MV days
Target<13.1
Urinary tract infection rate per 1000 3.7 3.7
24 catheter days
Target<5.07
Central line-associated blood stream 0.0
25 infection per 1000 CL days
Target<4.11
Surgical site infection (IPSG 5) 0.0% 0.0%
26
Target<3.5%
Falls in hospitals (IPSG 6) 3
27
Target=0

Acute pain management 84% 86.7%

28
Target>80%
Acute coronary syndrome guideline 87% 92.0%
29 compliance
Target>80%
Community acquired pneumonia guideline
30 CLINICAL compliance
9
INDICATORS Target>80%
Sepsis and septic shock immediate 92% 93.0%
31 management guideline completeness
Target>80%
Hypertensive emergency guideline 86% 91.0%
32 compliance
Target>80%

Elective Delivery (Patients with elective vaginal

deliveries or elective cesarean sections at >= 37 0.0% 0.0%
33 and < 39 weeks of gestation completed)

Target<30%

Cesarean Section (Nulliparous women with a

Library of term,
0.0% 0.0%
10 34 Measure singleton baby in a vertex position
(Perinatal Care) delivered by cesarean section )
 Library of
10 34 Measure
(Perinatal Care)

Target<30%

Exclusive Breast Feeding (Exclusive breast milk

feeding during the newborn's entire hospitalization) 92% 94.6%
35

Target>80%
 2017 2018 2019
11.60%
Elective Delivery (Patients with elective vaginal deliveries or C-section at >=37-39 weeks 14.40%
of gestation completed 24.60%
Target <30% 30% 30% 30%

Elective Delivery
deliveries or C-se
ta
35.00%
30.00%
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
2017

Target <30%
Elective Delivery (Patients with el
gestation completed
 Elective Delivery (Patients with elective vaginal
deliveries or C-section at >=37-39 weeks of ges-
tation completed
.00%
.00%
.00%
.00%
.00%
.00%
.00%
.00%
2017 2018 2019

Target <30%
Elective Delivery (Patients with elective vaginal deliveries or C-section at >=37-39 weeks of
gestation completed
 First births by ce
baby, vertex posi
35%

30%
2016 2017 2018 Q2_2019 25%
28% vertex11.60%
First births by cesarean section (singleton baby, position) 27.20% 22.80% 20%
Target <30% 30% 30% 30% 30%
15%

10%

5%

0%
2016 2017

First births by cesarea

Target <30%
 First births by cesarean section (singleton
baby, vertex position), 4 year comparison
35%

30%

25%

20%

15%

10%

5%

0%
2016 2017 2018 Q2_2019

First births by cesarean section (singleton baby, vertex position)

Target <30%
 Exclusive breast milk feed
ison
120.00%

100.00%
2018 Q2_2019
80.00%
Exclusive breast milk feeding, 2 year
97.30%
comparison
94.10%
Target >80% 80% 80% 60.00%

40.00%

20.00%

0.00%
2018

Exclusive breast milk fee

Target >80%
Exclusive breast milk feeding, 2 year compar-
ison

2018 Q2_2019

Exclusive breast milk feeding, 2 year comparison

Target >80%
 ANTIBIOTIC
STEWARDSHIP
PROGRAM

Infection control

PATIENT AND
FAMILY
SATISFACTION
STAFF
SATISFACTION

RISK

MEDICAL
RECORD
 MEDICAL
RECORD

SUPPLY CHAIN

IPSG
 CLINICAL
INDICATORS

Library of
Measure
(Perinatal Care)
 IH - HOSPITALWIDE QU
Jan Feb Mar Apr May
51 56 69 54 67
Inpatient‘s pathogen detection rate prior to 229 246 252 234 223
antibiotic treatment
22.3% 22.8% 27.4% 23.1% 30.1%
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%

Antibiotic prescription policy compliance 95.5% 95.4% 95.9% 91.6% 93.9%

rate (IM & Ped)
Target>95% 95% 95% 95% 95% 95%
Procalcitonin policy compliance
Target >95% 95%
IV to oral antibiotic conversion rate (Policy
compliance)
Target >
Inpatient cumulative antibiogram
Target >
Inpatient Antibiotic DDD/100 bed days
Target <285 285 285
Staff hand hygiene opportunity rate 97.5% 98.0% 96.5% 95.5% 92.0%
Target>90% 90.0% 90.0% 90.0% 90.0% 90.0%
Needle sticks to employees 0.0% 0.2% 0.2% 0.0% 0.4%
Target<1% 1% 1% 1% 1% 1%
Patient satisfaction IPD/OPD 88% 91.0% 91.0% 85.0% 87.0%
Target>85% 85% 85% 85% 85% 85%
Turnover rate 0.7% 1.8% 0.2% 1.3% 1.9%
Target<1% 1% 1% 1% 1% 1%
Follow up events 99.0% 100.0% 100.0% 100.0% 100.0%
Target>95% 95% 95% 95% 95% 95%
Number of medication events (near misses, 2 2 1 2 3
adverse drug reactions)
Target=0 0 0 0 0 0

Closed medical record completeness and 95.0% 92.0% 90.0% 89.0% 90.0%
quality

Target>90% 90% 90% 90% 90% 90%

Open medical record completeness and 90.0% 85.0% 90.0% 89.0%
quality
Target>90% 90.0% 90.0% 90.0% 90.0% 90.0%
Outpatient medical record completeness 70.0% 90.0% 90.0% 90.0%
and quality
Target>90% 90% 90% 90% 90% 90%
Integrated care plan (ICP) completeness 100% - Eliminat
Target>95% 95% 95% 95% 95% 95%
ER form completeness and quality 87.0% 80.0% 79.0% 93.5% 79.0%
Target>90% 90% 90% 90% 90% 90%
Copy and paste function improper use
Target<
Number of cases of drug stock out 2 2 2 3 2
Number of cases of consumable stock out 1 1 1 3 1
Number of cases of reagent stock out 1 2 3 6 6
Target<4 4 4 4 4 4
Number of occurrences regarding incorrect 2 1 0 1 0
ID (IPSG 1)
Target=0 0 0 0 0 0
Critical value report within TAT (30 min) rate 100.0% 100.0% 100.0% 100.0% 100.0%
- Lab (IPSG 2)
Critical value report within TAT (30 min) rate 100.0% 90.0% 100.0% 100.0% 100.0%
- Rad (IPSG 2)
Critical value report within TAT (30 min) rate 100.0% 95.0% 100.0% 100.0% 100.0%
(IPSG 2)
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0%
Safety storage and use of LASA medicaton 0 0 0 0 0
in patient care areas (IPSG 3)
Target=0 0 0 0 0 0
Surgical site marking (IPSG 4) 96.0% 100.0% 96.5% 94.0% 93.0%
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0%
Ventilator associated pneumonia (IPSG 5) 0.0 0.0 0.0 0.0 0.0
rates per 1000 MV days
Target<13.1 13.1 13.1 13.1 13.1 13.1
Urinary tract infection rate per 1000 0.0 0.0 0.0 0.0 0.0
catheter days
Target<5.07 5.07 5.07 5.07 5.07 5.07
Central line-associated blood stream 0.0 0.0 0.0 0.0 0.0
infection per 1000 CL days
Target<4.11 4.11 4.11 4.11 4.11 4.11
Surgical site infection (IPSG 5) 0.0% 0.0% 0.0% 0.0% 1.0%
Target<3.5% 3.5% 3.5% 3.5% 3.5% 3.5%
Falls in hospitals (IPSG 6) 1 2 1 2 1
Target=0 0 0 0 0 0
Acute pain management N/A N/A N/A
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%
 Acute coronary syndrome guideline n/A N/A N/A
compliance
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%
Epileptic status guideline compliance No case - Elimina
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%

Community acquired pneumonia guideline 100% N/A 100% 100% 100%

compliance
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%

Sepsis and septic shock immediate 75% 73%

management guideline completeness

Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%

Hypertensive emergency guideline 90.0% 90.0% 94.0% n/a 92.0%
compliance
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%
Elective Delivery (Patients with elective vaginal
deliveries or elective cesarean sections at >= 37 0.0% 0.0% 3.5% 0.0% 0.0%
and < 39 weeks of gestation completed)
Target<30% 30.0% 30.0% 30.0% 30.0% 30.0%

Cesarean Section (Nulliparous women with a

term,
0.0% 0.0% 1.1% 0.0% 0.0%
singleton baby in a vertex position
delivered by cesarean section )

Target<30% 30.0% 30.0% 30.0% 30.0% 30.0%

Exclusive Breast Feeding (Exclusive breast milk

feeding during the newborn's entire hospitalization) 94.0% 95.0% 98.0% 92.0% 98.0%

Target>80% 80.0% 80.0% 80.0% 80.0% 80.0%

HOSPITALWIDE QUALITY INDICATOR 2021
June Jul Aug Sep Oct Nov Dec
55 63 71 75 69 87 91 Мөнхтуяа

245 234 279 256 268 286 286

Ариунаа
22.4% 26.9% 25.4% 29.2% 26% 30% 32% 26.5%
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

Дотор Хүүхдийн
98.8% 94.6% 94.0% 93.2% 86.5% 89.0% 89.9% 93.2% тасгийн
дунджаар авна.
95% 95% 95% 95% 95% 95% 95%

95%

355.4 355.4
285 285 285
94.5% 97.5% 97.0% 97.0% 96.0% 96.5% 96.5% 96.2% Мядагмаа
90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.6% 0.12% Мядагмаа
1% 1% 1% 1% 1% 1% 1%
88.0% 88.5% 87.5% 81.0% 86.0% 85.0% 86.5% 87.0% Ундрал
85% 85% 85% 85% 85% 85% 85%
0.4% 2.8% 2.1% 1.1% 2.1% 2.1% 1.3% 1.48% Бүжин/Batzaya
email
1% 1% 1% 1% 1% 1% 1%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.9% Байгаль
95% 95% 95% 95% 95% 95% 95%

2 0 0 1 0 1 0 1.17
Байгаль
0 0 0 0 0 0 0

91.0% 98.0% 98.0% 97.4% 98.6% 98.8% 97.5% 94.6%

Байгаль /Mirzak
Nomio
90% 90% 90% 90% 90% 90% 90%

89.0% n/a 94.0% 89.6%

Болор
90.0% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
90.0% 62.5% 67.5% 78.3%
Болор
90% 90% 90% 90% 90% 90% 90%
100% - Eliminated #DIV/0! Болор
95% 95% 95% 95% 95% 95% 95%
77.0% 69.0% 96.9% 100.0% 100.0% 100.0% 100.0% 88.5% ER aas haraad
bichih
90% 90% 90% 90% 90% 90% 90%
Раднаа

2 1 0 0 0 2 2 1.5 Туяа, Цэрмаа

1 0 0 1 2 2 4 1.4
7 5 4 2 1 4 1 3.5
4 4 4 4 4 4 4 6.4

1 0 0 3 2 2 1 13
Байгаль
0 0 0 0 0 0 0

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Сумъяа

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.2%

Өлзийсайхан

100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6%

Байгаль
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 99.6%

0 0 0 0 0 0 0 0.0
Ариунаа
0 0 0 0 0 0 0
93.5% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 97.8% Батсайхан
100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Мядагмаа
13.1 13.1 13.1 13.1 13.1 13.1 13.1

0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0

Мядагмаа
5.07 5.07 5.07 5.07 5.07 5.07 5.07
0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0% Мядагмаа
4.11 4.11 4.11 4.11 4.11 4.11 4.11
0.0% 2.0% 0.0% 1.0% 0.0% 0.0% 1.0% 0.4% Мядагмаа
3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5%
1 0 1 1 0 0 0 10 Байгаль
0 0 0 0 0 0 0
#DIV/0! Байгаль
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
 #DIV/0!
Цолмон
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
No case - Eliminated Цолмон
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

100% 100% 100% 67% 81% 100% 63% 91.9%

Байгаль
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

73% 68% 83% 74.4%

Цолмон
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

89.0% 94.0% 75.0% 75.0% n/a n/a n/a 87.4%

Mungunsarnai
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.3%

Түмэнцогт
30.0% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.0% 0.1%

Түмэнцогт
30.0% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

97.0% 95.6% 94.0% 96.0% 96.9% 96.7% 94.4% 95.6%

Түмэнцогт
80.0% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
35 6 indicators
indicators not 29 indicators
planned reported reported
 биелэлт %
total 28 100
yes 16 57.1
no 13 46.4 2017
improve no 2018

1 2019

constant no 2020
2 2021 Q3

percenta
number ge
Improving 6 20.7
Worsening 7 24.1
constant 16 55.2
29 100
worsen no

constant yes
3
constant yes
4
worsen yes

5
worsen no
6
constant yes

7
improve no

constant yes

9
constant no
 asuuh+ Ariunjargal emch
worsen no

improve no
10

11
improve no 12
13
worsen no

14

Radiology Zaya emch

15
deed 2-iin dundaj
constant yes 16
17
constant yes
18
improve no

19
constant yes

20
constant yes
21
constant yes
22
constant yes
23
constant no
!!! 24
 !!!

CPG guideline compliance in

Children +ER data Sarnai
emch
worsen yes

25

!!!
improve no

!!!!
worsen yes

constant yes

26

constant yes

27

constant yes
 28

yes=16
no=13
 Not
Achieved 2017
achieved
43 57 Achieved Not achieved
55 45

53.3 46.7

51.6 48.4 Achieved

57.1 42.9 43%
Not achieved
57%

2019
Achieved Not achieved

Not
achieved Achieved
47% 53%

2021
Achieved Not achieved

Not achieved
43%
 Achieved Not achieved

Not achieved
43%

Achieved
57%
 2018
eved Achieved Not achieved

Achieved
43% Not achieved
45%
Achieved
55%

2020
hieved Achieved Not achieved

Not
hieved achieved Achieved
53% 48% 52%

achieved
achieved

Achieved
57%
 Closed medical record completeness and quality
Year % Target
2016 77 98 Chart Titl
2017 88.6 98 120

2018 83.3 98 100

2019 77.3 98
2020 96.1 98 80

2021 93.4 98
60

40

20

0
1 2 3

% Targe

Closed medical record com

120

100

80

60

40

20

0
2016 2017 2018

% Linea

Open medical record completeness and quality

Year percenta target
ge

Percentage Target
2019 67 90
2020 84.8 90
2021 Q1-Q2 85 90

ER form completeness
ER form completen
Year Percentage Target
2020 80.4 90 92

2021 Q1-Q3 84.6 90 90

88
86
84
82
80
78
76
74 Percentage Linear ( Percent
2020

Patient satisfaction (IP and OP)

Patient satisfaction (IP and OP) 95

Year Percentage Target 90

2016 75.9 85
2017 83.8 85 85
2018 84.6 85
80
2019 88.1 85
2020 89.1 85 75
2021 Q1-Q3 87.4 85
70

65
2016 2017 2018 2019

Percentage Line
Target

Staff turnover rate (2016-2021Q3) Staff turnover rate (2016

2.5

2
 Staff turnover rate (2016
Year Percentage Target 2.5
2016 1.7 1
2017 1.6 1 2
2018 1.2 1
2019 1.5 1
1.5
2020 1.05 1
2021 Q1-Q3 2 1
1

0.5

0
2016 2017 2018 20

Number of cases of drug,

consumables and reagent stock
out, 2016-2021Q1-Q3 Number of cases of drug,
reagent stock out, 201
Year Number Target 12

10
2016 6 4
2017 6.1 4 8
2018 4.8 4
2019 6.4 4 6
2020 10.5 4
2021 Q1-Q3 6.6 4 4

0
2016 2017 2018

Number of occurrence regarding to incorrect ID,

2016-2021
Number of occurrence regardin
Year Number Target 2016-2021
2016 0.6 0 1.6
2017 0.9 0
1.4
2018 0.9 0
2019 1.25 0 1.2
2020 1.42 0 1
2021Q1-Q3 0.8 0
0.8

0.6

0.4

0.2

0
2016 2017 2018 2019
 0.4

0.2

0
2016 2017 2018 2019

Safety storage and use of LASA medication inpatient care

areas, 2018-2020 Safety storage and use of LASA m
care areas, 2018-2
Year Number Target
2018 0 0 1
0.9
2019 0 0 0.8
2020 0 0 0.7
2021Q1-Q3 0 0 0.6
0.5
0.4
0.3
0.2
0.1
0
2018 2019 2

Surgical site marking 2016-2021Q1-Q3

Year Number Target Surgical site marking 2016
2016 88.5 100 102
2017 95.7 100 100
2018 100 100 98
2019 100 100 96
2020 100 100 94
2021Q1-Q3 97 100 92
90
88
86
84
82
2016 2017 2018 201

Number T

Ventilator associated pneumonia rates

per 1000 MV days, 2016-2021Q1-Q3 Ventilator associated pneum
1000 MV days, 2016-2
Year Number Target
14
2016 11 13.1
2018 0 13.1 12 11
2019 3.5 13.1 10
2020 2.2 13.1 8
2021Q1-Q3 0 13.1 6
4 3.5

2
0
0
2016 2018 2019
Central line-associated blood stream infection per Central line-associated bloo
1000 CL days, 2016-2021Q1-Q3
fection per 1000 CL days, 20
Year Number Target Q3
2016 0.1 4.11 4.5
2018 0 4.11 4
3.5
2019 0 4.11
3
2020 0 4.11
2.5
2021Q1-Q3 0 4.11
2
1.5
1
0.5 0.1 0 0
0
2016 2018 2019

UTI rate per 1000 urinary catheter days,

2016-2021Q1-Q3

Year Number Target UTI rate per 1000 urinary catheter d

2017 0.6 5 6
2018 0 5
2019 2.4 5 5
2020 0 5
2021Q1-Q3 0 5 4

3
2.4

1
0.6

0
0
2017 2018 2019

Surgical site infection, 2016- Surgical site infection, 201

2021Q1-Q3
4
Year Number Target
2016 0.1 3.5 3.5
2017 0 3.5
3
2018 0.2 3.5
2019 0 3.5 2.5

2020 0.2 3.5 2

2021Q1-Q3 0.4 3.5
1.5

0.5

0
2016 2017 2018 20
 1.5

0.5

0
2016 2017 2018 20

Falls in the hospital, 201

Falls in the hospital, 2016-2021Q1-Q3
1.8
Year Number Target
1.6
2016 0.6 0
2017 0.4 0 1.4

2018 0.5 0 1.2

2019 1.33 0 1

2020 1.33 0 0.8

0.6
2021Q1-Q3 1.7 0 0.6 0.5
0.4
0.4
0.2
0
2016 2017 2018

Ratio of women with elective vaginal del

sarean sections at >= 37 and < 39 weeks of
Ratio of women with elective vaginal deliveries or 35
elective cesarean sections at >= 37 and < 39 weeks of
gestation completed
30
Year Number Target
25
2017 11.6 30
2018 14.4 30 20 17.8
2019 17.8 30 14.4
15
2020 5.3 30 11.6
2021Q1-Q3 0.4 30 10

0
2017 2018 2019

Ratio of nulliparous women with

in a vertex position delivered
Ratio of nulliparous women with a term, singleton
baby in a vertex position delivered by cesarean section 35

Year Percentage Target 30 28 27.2

2016 28 30
25
2017 11.6 30
2018 27.2 30 20
2019 15.9 30
15
2020 1.6 30 11.6
2021Q1-Q3 0.1 30 10

0
2016 2017 2018
 15
11.6
10

0
2016 2017 2018

Ratio of exclusive breast milk feeding

during the newborn's entire hospitalization
without indication Ratio of exclusive breast milk fee
newborn's entire hospitalization w
Year Percentage Target
120
2016 80 80
2017 100 80 100
100 99
95.3
2018 99 80
2019 95.3 80 80
80
2020 93.4 80
2021Q1-Q3 95.5 80 60

40

20

0
2016 2017 2018 2019
mpleteness and quality

Chart Title
120

100

80

60

40

20

0
1 2 3 4 5 6

% Target

Closed medical record completeness and quality

120 120

100 100

80 80

60 60

40 40

20 20

0 0
2016 2017 2018 2019 2020 2021

% Linear (%) Target

completeness and quality

Open medical record completeness and quality

90 100
80 90
70 80
70
60
60
50
50
40
40
30
30
 90 100
80 90
70 80
70
60
60
50
50
40
40
30
30
20 20
10 10
0 0
2019 2020 2021 Q1-Q2

Percentage Linear (Percentage)

Target

ER form completeness
92
90
88
86
84
82
80
78
76
74 Percentage Linear ( Percentage ) Target
2020 2021 Q1-Q3

Patient satisfaction (IP and OP) 2016-2021Q3

95

90

85

80

75

70

65
2016 2017 2018 2019 2020 2021 Q1-Q3

Percentage Linear ( Percentage )

Target

Staff turnover rate (2016-2021Q1-Q3)

2.5

2
 Staff turnover rate (2016-2021Q1-Q3)
2.5

1.5

0.5

0
2016 2017 2018 2019 2020 2021 Q1-Q3

Number of cases of drug, consumables and

reagent stock out, 2016-2021Q1-Q3
12

10

0
2016 2017 2018 2019 2020 2021 Q1-Q3

Number of occurrence regarding to incorrect ID,

2016-2021
1.6

1.4

1.2

0.8

0.6

0.4

0.2

0
2016 2017 2018 2019 2020 2021Q1-Q3
0.4

0.2

0
2016 2017 2018 2019 2020 2021Q1-Q3

Safety storage and use of LASA medication inpatient

care areas, 2018-2020
1
0.9
0.8
0.7
0.6
0.5
0.4
0.3
0.2
0.1
0
2018 2019 2020 2021Q1-Q3

Surgical site marking 2016-2021Q1-Q3

102
100
98
96
94
92
90
88
86
84
82
2016 2017 2018 2019 2020 2021Q1-Q3

Number Target

Ventilator associated pneumonia rates per

1000 MV days, 2016-2021Q1-Q3
14
12 11
10
8
6
4 3.5
2.2
2
0 0
0
2016 2018 2019 2020 2021Q1-Q3
 Central line-associated blood stream in-
fection per 1000 CL days, 2016-2021Q1-
Q3
4.5
4
3.5
3
2.5
2
1.5
1
0.5 0.1 0 0 0 0
0
2016 2018 2019 2020 2021Q1-Q3

UTI rate per 1000 urinary catheter days, 2016-2021Q1-Q3

6

3
2.4

1
0.6

0 0 0
0
2017 2018 2019 2020 2021Q1-Q3

Surgical site infection, 2016-2021Q1-Q3

4

3.5

2.5

1.5

0.5

0
2016 2017 2018 2019 2020 2021Q1-Q3
 1.5

0.5

0
2016 2017 2018 2019 2020 2021Q1-Q3

Falls in the hospital, 2016-2021Q1-Q3

1.8 1.7
1.6
1.4 1.33 1.33
1.2
1
0.8
0.6
0.6 0.5
0.4
0.4
0.2
0
2016 2017 2018 2019 2020 2021Q1-Q3

Ratio of women with elective vaginal deliveries or elective ce-

sarean sections at >= 37 and < 39 weeks of gestation completed
35

30

25

20 17.8

15 14.4
11.6
10
5.3
5
0.4
0
2017 2018 2019 2020 2021Q1-Q3

Ratio of nulliparous women with a term, singleton baby

in a vertex position delivered by cesarean section
35

30 28 27.2
25

20
15.9
15
11.6
10

5
1.6
0.1
0
2016 2017 2018 2019 2020 2021Q1-Q3
 15
11.6
10

5
1.6
0.1
0
2016 2017 2018 2019 2020 2021Q1-Q3

Ratio of exclusive breast milk feeding during the

newborn's entire hospitalization without indication
120

100 99
100 95.3 93.4 95.5

80
80

60

40

20

0
2016 2017 2018 2019 2020 2021Q1-Q3
 2015 2016 2017 2018
Improved 48% 39.50% 35% 13%
Consisten 33% 50% 58% 52%
Declined 19% 12% 7.70% 35%

2015 2016 2017 2018

Reached t 40% 38% 50% 65%
Not reach 60% 62% 50% 35%
 Dynamics

7.70%
Declined

58%
Consistent

35%
Improved

0% 10% 20% 30% 40% 50% 60% 70%

2018 2017 2016 2015

Target status
120%

100%

80% 35%
50%
60% 62%
60%

40%
65%
50%
20% 40% 38%

0%
2015 2016 2017 2018

Reached target Not reached target

 IH - HOSPITALWIDE QUALIT
Jan Feb Mar Apr May June

80 70 108 77 95 87
Inpatient‘s pathogen detection rate prior to
286 264 353 304 321 323
1 antibiotic treatment
28.0% 26.5% 30.6% 25.3% 29.6% 26.9%

ANTIBIOTIC Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

1 STEWARDSHIP Antibiotic prescription policy compliance
PROGRAM 78.6% 97.2% 88.6% 97.8% 89% 91.3%
2 rate (IM & Ped)
Target>95% 95% 95% 95% 95% 95% 95%
Procalcitonin policy compliance 81%
3
Target >95% 95%
Staff hand hygiene compliance rate 95.5% 96.5% 98.0% 96.5% 96.0% 97.5%
4
INFECTION Target>90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
2 CONTROL
Needle sticks rate of employees 0.0% 0.4% 0.2% 0.0% 0.4% 0.0%
5
Target<1% 1% 1% 1% 1% 1% 1%

PATIENT AND Patient satisfaction IPD/OPD 79% 73.0% 86.0% 86.0% 84.0% 86.0%
3 6 FAMILY
SATISFACTION Target>85% 85% 85% 85% 85% 85% 85%

STAFF Turnover rate 0.4% 1.5% 1.3% 1.8% 1.3% 1.4%

4 7 SATISFACTION Target<1% 1% 1% 1% 1% 1% 1%

Follow up events 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

8
Target>95% 95% 95% 95% 95% 95% 95%
5 RISK Number of medication events (near misses, 2 3 1 1 4 3
adverse drug reactions)
9
5 RISK
9
Target=0 0 0 0 0 0 0

Closed medical record completeness and 95.0% 95.0% 97.0% 96.0% 95.0% 96.0%
quality
10
Target>90% 90% 90% 90% 90% 90% 90%
Open medical record completeness and 88.3% 93.3% 96.0% 82.0% 82.0% 89.0%
11 quality
Target> 90% 90.0% 90.0% 90.0% 90.0% 90.0% 90.0%
Outpatient medical record completeness 72.7% 78.2% 77.5% 87.7% 86.3% 89.1%
MEDICAL and quality
6 12 RECORD
Target>90% 90% 90% 90% 90% 90% 90%

ER form completeness and quality 100.0% 100.0% 98.0% 93.6% 95.1% 100.0%
13
Target>90% 90% 90% 90% 90% 90% 90%

Copy and paste function improper use

14 36.60% 26.60%
Target<20% 20% 20% 20% 20% 20% 20%
15 Number of cases of drug stock out 1 1 1 2 0 0
16 Number of cases of consumable stock out 0 2 1 4 1 1
7 17 SUPPLY CHAIN Number of cases of reagent stock out 1 2 6 5 1 2
18 Target<4 4 4 4 4 4 4
Number of occurrences regarding incorrect 0 7 2 2 3 4
ID (IPSG 1)
19
Target=0 0 0 0 0 0 0

Critical value report within TAT (30 min) rate

20 100.0% 100.0% 99.6% 100.0% 100.0% 100.0%
- Lab (IPSG 2)

Critical value report within TAT (30 min) rate

21 100.0% 100.0% 81.8% 100% 100.0% 100.0%
- Rad (IPSG 2)
 Critical value report within TAT (30 min) rate 100.0% 100.0% 90.7% 100.0% 100.0% 100.0%
(IPSG 2)
22
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Safety storage and use of LASA medicaton 0 0 0 0 0 0

23 in patient care areas (IPSG 3)
Target=0 0 0 0 0 0 0
8 IPSG Surgical site marking (IPSG 4) 100.0% 96.7% 98.0% 74.2% 85.0% 94.0%
24
Target>100% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%
Ventilator associated pneumonia (IPSG 5) 0.0 0.0 0.0 0.0 0.0 37.0
25 rates per 1000 MV days
Target<13.1 13.1 13.1 13.1 13.1 13.1 13.1
Urinary tract infection rate per 1000 0.0 0.0 23.3 166.7 0.0 0.0
26 catheter days
Target<5.07 5.07 5.07 5.07 5.07 5.07 5.07
Central line-associated blood stream 0.0 0.0 0.0 0.0 0.0 0.0
27 infection per 1000 CL days
Target<4.11 4.11 4.11 4.11 4.11 4.11 4.11
Surgical site infection (IPSG 5) 0.0% 3.0% 3.0% 0.0% 0.0% 0.0%
28
Target<3.5% 3.5% 3.5% 3.5% 3.5% 3.5% 3.5%
Fall rate in hospitals (falls per 1,000 occupied 0 1.2 0.89 0 1.5 0
29 bed days IPSG 6)
Target=0 0 0 0 0 0 0
Acute pain management 81% 84% 87% 81% 88% 91%
30
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Acute coronary syndrome guideline 81% 87% 92% 95% 91% 90%
31 compliance
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Community acquired pneumonia guideline 97% 100%
32 CLINICAL compliance
9 INDICATORS
 32 CLINICAL
9 INDICATORS Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Sepsis and septic shock immediate 90% 91% 96% 95% 91% na
33 management guideline completeness
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%
Hypertensive emergency guideline 82.0% 83.0% 92.0% 90.0% 90.0% 93.0%
34 compliance
Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

Elective Delivery (Patients with elective vaginal

deliveries or elective cesarean sections at >= 37 0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
35 and < 39 weeks of gestation completed)

Target<30% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

Cesarean Section (Nulliparous women with a

Library of term,
0.0% 0.0% 0.0% 0.0% 0.0% 0.0%
10 36 Measure singleton baby in a vertex position
(Perinatal Care) delivered by cesarean section )

Target<30% 30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

Exclusive Breast Feeding (Exclusive breast milk

feeding during the newborn's entire hospitalization) 91.8% 90.2% 93.3% 95.8% 95.1% 92.9%
37

Target>80% 80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

ALWIDE QUALITY INDICATOR 2022
Jul Aug Sep Oct Nov Dec Average

64 60 50
247 278 327
25.9% 21.6% 15.3% 25.5%
80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

91.7% 83.5% 95.7% 90.4%

95% 95% 95% 95% 95% 95% 95.0%

95%
97.5% 97.5% 96.5% 96.8%

90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

0.4% 0.0% 1.0% 0.27%

1% 1% 1% 1% 1% 1%

86.5% 87.5% 88.0% 84.0%

85% 85% 85% 85% 85% 85%

0.5% 1.3% 2.0% 1.28%

1% 1% 1% 1% 1% 1%

100.0% 100.0% 100.0% 100.0%

95% 95% 95% 95% 95% 95%

2 0 1 1.89
 0 0 0 0 0 0

96.0% 94.0% 95.5% 95.5%

90% 90% 90% 90% 90% 90%

89.0% 89.0% 96.0% 96.0% 93.0% 90.3%

90.0% 90.0% 90.0% 90.0% 90.0% 90.0%

77.0% 82.0% 82.0% 81.4%

90% 90% 90% 90% 90% 90%

95.1% 93.3% 98.0% 97.0%

90% 90% 90% 90% 90% 90%

33.3%
36.60%

20% 20% 20% 20% 20% 20%

2 1 2 1.1
0 3 1 1.4
0 1 1 2.1
4 4 4 4 4 4 6.4

0 1 2 21

0 0 0 0 0

100.0% 100.0% 100.0% 100.0%

85.0% 100.0% 100.0% 96.3%

92.5% 100.0% 100.0% 98.1%

100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

2 0 0 0.2

0 0 0 0 0 0
91.0% 93.0% 98.0% 92.2%
100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

0.0 0.0 50.0 9.7

13.1 13.1 13.1 13.1 13.1 13.1

0.0 0.0 0.0 21.1

5.07 5.07 5.07 5.07 5.07 5.07

0.0 0.0 0.0 0.0%

4.11 4.11 4.11 4.11 4.11 4.11

3.0% 0.0% 3.0% 1.3%
3.5% 3.5% 3.5% 3.5% 3.5% 3.5%

1.3 1.8 0 6.69

0 0 0 0 0 0
81% 89% 91% 85.9%

80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

89% 91% 81% 88.6%

80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

94% 97.0%
80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

91% 92% 92% 92.3%

80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

91.0% 90.0% 88.0% 88.8%

80.0% 80.0% 80.0% 80.0% 80.0% 80.0%

0.0% 0.0% 0.0% 0.0%

30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

0.0% 0.0% 0.0% 0.0%

30.0% 30.0% 30.0% 30.0% 30.0% 30.0%

98.6% 97.6% 95.8% 94.6%

80.0% 80.0% 80.0% 80.0% 80.0% 80.0%