2556 2556 61

1.1 ()1.2 1.3 1.4 2500 1.5 1.6 1.7 VAP1.8 CAUTI1.9 SSI1.10 28

1 (PCR) 18 1 ()1.11 1.12 ROP1.13 STEMISK 30 1.14 ER Re-visit48 .1.15 (Response time) EMS

1.1 5%

79 IPD 3,518

1

2.18

2.19

2.73

2.61

2.44

2.15

2.45

2.36

1.98

2.71

2.39

1.93

2.24

Sheet1

25552.18

Oct-552.19

Nov-552.73

Dec-552.61

Jan-562.44

Feb-562.15

Mar-562.45

Apr-562.36

May-561.98

Jun-562.71

Jul-562.39

Aug-561.93

Sep-562.24

5 25561. Bacteria Pneumonia 6 2. UTI3 3. Gastroenteritis and colitis 3 4. UGIB 3 5. Septic shock2

5 25561. 8 2. 2 3. 2 4. 1 13

1.2 < 9 : 1000 1 1.DFIU . . 301

1

6.52

6.31

3.58

10.49

0

7.78

16.33

0

7.63

14.81

3.74

7.07

3.32

Sheet1

25556.52

Oct-556.31

Nov-553.58

Dec-5510.49

Jan-560

Feb-567.78

Mar-5616.33

Apr-560

May-567.63

Jun-5614.81

Jul-563.74

Aug-567.07

Sep-563.32

1.3 30:1,000 BA 7 2 5 301

1

11.66

3.15

21.51

3.5

10.42

7.78

0

7.72

7.63

11.11

3.74

3.53

6.64

Sheet1

255511.66

Oct-553.15

Nov-5521.51

Dec-553.5

Jan-5610.42

Feb-567.78

Mar-560

Apr-567.72

May-567.63

Jun-5611.11

Jul-563.74

Aug-563.53

Sep-566.64

1.4 2,500ANC

1.5 < 18:100,000 0 301

1

29.27

0

0

0

0

0

0

3.86

0

0

0

0

0

Sheet1

255529.27

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-563.86

May-560

Jun-560

Jul-560

Aug-560

Sep-560

1.6 < 0.13% 0 27

1

0

0

0

0

0

0

0

0

0

0.7

0.4

0

0

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

..560.70

Jul-560.40

Aug-560

Sep-560

1.7 VAP < 10 : 1,000

1

10.12

12.38

13.55

11.79

10.76

9.42

16.76

7.51

10.54

9.85

7.34

7.53

7.99

Sheet1

255510.12

Oct-5512.38

Nov-5513.55

Dec-5511.79

Jan-5610.76

Feb-569.42

Mar-5616.76

Apr-567.51

May-5610.54

Jun-569.85

Jul-567.34

Aug-567.53

Sep-567.99

VAP 2556

VAP

< 5 : 1,0001.8 CAUTI (Catheter associated urinary tract infection)

1

0.91

1.49

0

1.87

2.01

1.56

0.03

0.51

0

0.61

0.52

0.48

0.47

1 ICU 1 A.Baum

Sheet1

25550.91

Oct-551.49

Nov-550

Dec-551.87

Jan-562.01

Feb-561.56

Mar-560.03

Apr-560.51

May-560

Jun-560.61

Jul-560.52

Aug-560.48

Sep-560.47

1.9 SSI (01,02) Sit Specific Infection (,) < 4.5 %

1

0.2

0.7

0.43

0

0

0.36

0.12

0.17

0

0

0.73

0.15

0.18

1 1 case Herniorrhaphy Ps.Aeruginosa

Sheet1

25550.20

Oct-550.70

Nov-550.43

Dec-550.00

Jan-560.00

Feb-560.36

Mar-560.12

Apr-560.17

May-560.00

Jun-560.00

Jul-560.73

Aug-560.15

Sep-560.18

1.7 Tube < 10 : 1,000

1

2555

..-55

12.77

13.31

5.18

9.78

29.72

20.68

21.74

16.07

9.62

9.63

11.2

Sheet1

2555

Oct-55

Nov-5512.77

Dec-5513.31

Jan-565.18

Feb-569.78

Mar-5629.72

Apr-5620.68

May-5621.74

Jun-5616.07

Jul-569.62

Aug-569.63

Sep-5611.20

Tube 2556

1.10 28 < 2.5 %Re-Admitted 23 Admitted 3,884

1

0.36

0.42

0.43

0.36

0.42

0.75

0.46

0.36

0.64

0.64

1.08

0.24

0.59

Sheet1

25550.36

Oct-550.42

Nov-550.43

Dec-550.36

Jan-560.42

Feb-560.75

Mar-560.46

Apr-560.36

May-560.64

Jun-560.64

Jul-561.08

Aug-560.24

Sep-560.59

28

wardPCT- 15

PCT- 4

PCT- 1 1 EENT 2 - 15 (1.CKD 5 2.UTI 3 3.Thalassaemias1 4.SLE 1 5. Unstable angina 1 6.CA ovary 1 7.Cerebral infarction 1 8.Cirrhosis 1 9.Inflammatory liver diseases 1 ) - 4 (1.Febrile convulsions 2 2.Bacterial pneumonia 1 3.Broncitis 1 )- 1 IIH Acute psychosisHypertrophy of tonsils , Acute tonsillitis

1.11 0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-560

Sep-560

1.12 ROP(Retinopathy of prematurity) 0% ROP 2 18

1

0.64

0

0

0

0

0

0

0

0

0

0

7.69

11.11

Sheet1

25550.64

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-567.69

Sep-5611.11

1.13 STEMI SK 30 >40%

1.14 Re-Visit ER 48 . 0%

1

0.002

0

0

0

0

0

0

0

0

0

0

0

0

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-560

Sep-560

1.15 (Response time) EMS 80%

1

96.26

98.36

89.13

91.04

94

96.92

97.96

98.39

91.23

93.75

98.46

100

95.45

10 63 66

Sheet1

255596.26

Oct-5598.36

Nov-5589.13

Dec-5591.04

Jan-5694.00

Feb-5696.92

Mar-5697.96

Apr-5698.39

May-5691.23

Jun-5693.75

Jul-5698.46

Aug-56100

Sep-5695.45

1.16 Elective Case24. 0%

1

0

0

0

0

0

0

0

0

0

0

0

0

0

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-560

Sep-560

1.17 0%

545 2 case ACDFICU case Sigmoidectomy with colostomy

1

0.45

0.7

0.22

0.2

0.17

0.18

0

0

0

0

0

0

0.37

Sheet1

25550.45

Oct-550.70

Nov-550.22

Dec-550.20

Jan-560.17

Feb-560.18

Mar-560.00

Apr-560.00

May-560.00

Jun-560.00

Jul-560.00

Aug-560.00

Sep-560.37

1.18 seroma 0%

1

4.17

33.33

66.67

0

0

0

0

20

16.67

seroma 1 6

Sheet1

25554.17

Oct-5533.33

Nov-5566.67

Dec-550

Jan-560

Feb-560

.560

Apr-5620.00

May-5616.67

2

2.1 2.2 2.3 2.4 ( 15 )

2.1 >85%

1

80.91

Sheet1

255580.91

2.2 >85%

1

86.65

Sheet1

255586.65

2.3 >85%

1

86.06

91.67

85.66

91.5

86.14

Sheet1

255586.06

Mar-5691.67

May-5685.66

Jun-5691.50

Sep-5686.14

2.4 ( 15 ) 100%

1

100

0

100

100

..-56

100

..-56

..-56

..-56

..-56

..-56

..-56

..-56

NA

NA

NA

NA

NA

NA

NA

Sheet1

2555100

Oct-550

Nov-55100

Dec-55100

Jan-56

Feb-56100

Mar-56

Apr-56

May-56

Jun-56

Jul-56

Aug-56

Sep-56

3

3.1 (Quick Ratio) 3.2 (Current Ratio) 3.3 (Cash Ratio)

3.1 (Quick Ratio) 1% .. 56Quick Ratio 1.56

1

1.61.6400

1.71.65....

1.521.65....

1.691.65....

1.531.46....

1.71.26....

1.591.31..

1.511.37....

1.731.18....

1.541.56....

1.32......

1.32......

2555

2556

Sheet1

.......................

25551.601.701.521.691.531.701.591.511.731.541.321.32

25561.641.651.651.651.461.261.311.371.181.56

3.2 (Current Ratio) 1.5% ..56Current Ratio 1.70

1

1.811.8100

1.931.95....

1.731.95....

1.951.95....

1.811.61....

1.921.4....

1.821.44..

1.721.56....

1.961.32....

1.81.7....

1.57......

1.57......

2555

2556

Sheet1

.......................

25551.811.931.731.951.811.921.821.721.961.801.571.57

25561.811.951.951.951.611.401.441.561.321.70

3.3 ( Cash Ratio) 0.8% ..56Cash Ratio 1.41

1

1.211.2100

1.351.22....

1.231....

1.331....

1.121.24....

1.311....

1.170.86..

1.060.81....

1.390.72....

1.391.41....

1......

1......

2555

2556

Sheet1

.......................

25551.211.351.231.331.121.311.171.061.391.391.001.00

25561.211.221.001.001.241.000.860.810.721.41

4.1 / R2R /mini research4.2 4.3 4.4 Turn Over Rate 4.5 /

Part 4 4

4.1 / R2R /mini research >5 /

1

0

Sheet1

25550

4.2 >10 /

1

74

0

0

30

0

33

0

0

0

47

0

..-56

..-56

Sheet1

255574

Oct-550

Nov-550

Dec-5530

Jan-560

Feb-5633

Mar-560

Apr-560

May-560

Jun-5647

Jul-560

Aug-56

Sep-56

4.3 >85%

1

81.9

..-55

Sheet1

255581.90

Oct-55

4.4 Turn Over Rate

4.5 /

5.1 E RCA 5.2 GHI5.3 G H I RCA 5.4 G H I 5.5 Patient safety goal 5.6 5.7 ( )5.8 (Infusion Pump ,monitor)

55.9 5.10 5.10.1 (Prescribing error) 5.10.2 (Dispensing error)5.11 5.11.1 (Prescribing error) 5.11.2 (Dispensing error) 5.11.3 5.12 5.13 - BOD - BOD - - (Suspended Solids;SS) - 5 ()

5.1 E RCA >80%NA

1

67.04

..-55

60

..-55

50

..-56

66.67

66.67

100

50

75

..-56

..-56

NA

NA

Sheet1

255567.04

Oct-55

Nov-5560.00

Dec-55

Jan-5650.00

Feb-56

Mar-5666.67

Apr-5666.67

May-56100.00

Jun-5650.00

Jul-5675.00

Aug-56

Sep-56

5.2 GHI 0

1

11

1

0

0

0

0

0

0

2

1

1

..-56

..-56

Sheet1

255511

Oct-551

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-562

Jun-561

Jul-561

Aug-56

Sep-56

5.3 GHI RCA 100%NANANANA

1

100

..-55

..-55

..-55

..-56

..-56

..-56

..-56

100

100

100

..-56

..-56

NA

NA

NA

Sheet1

2555100

Oct-55

Nov-55

Dec-55

Jan-56

Feb-56

Mar-56

Apr-56

May-56100

Jun-56100

Jul-56100

Aug-56

Sep-56

5.4 G H I 0%

1

0

0

0

0

0

0

0

0

0

0

0

0

..-56

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-560

Sep-56

5.5 Patient safety goal 100%

1

90.91

81.82

100

81.82

81.82

81.82

81.82

90.91

81.82

90.91

100

..-56

..-56

Sheet1

255590.91

Oct-5581.82

Nov-55100

Dec-5581.82

Jan-5681.82

Feb-5681.82

Mar-5681.82

Apr-5690.91

May-5681.82

Jun-5690.91

Jul-56100

Aug-56

Sep-56

5.6 80%

1

82.54

82.02

74.56

72.02

71.19

73.18

71.59

72.48

74.11

83.76

89.38

86.78

81.67

Sheet1

255582.54

Oct-5582.02

Nov-5574.56

Dec-5572.02

Jan-5671.19

Feb-5673.18

Mar-5671.59

Apr-5672.48

May-5674.11

Jun-5683.76

Jul-5689.38

Aug-5686.78

Sep-5681.67

5.7 () 100%

1

100

Sheet1

2555100

5.8 (Infusion Pump ,monitor) >70%

1

64.4

95

Sheet1

255564.4

Sep-5695.00

5.9

5.10.1 (Prescribing error)

5.10.2 (Dispensing error) < 2 /1000 OPD 16,532 46

1

1.42

1.15

1.23

0.54

1.8

1.26

1.15

1.78

2.04

0.48

2.74

2.78

Sheet1

25541.42

Oct-551.15

Nov-551.23

Dec-550.54

Jan-561.80

Feb-561.26

Mar-561.15

Apr-561.78

May-562.04

Jun-560.48

Jul-562.74

Aug-562.78

5.11.1 (Prescribing error) < 35 /1000 14,527 319

1

19.94

29.35

29.35

24.26

18.29

29.28

21.28

16.08

31.6

20.49

20.92

21.96

Sheet1

255419.94

Oct-5529.35

Nov-5529.35

Dec-5524.26

.5618.29

Feb-5629.28

Mar-5621.28

Apr-5616.08

May-5631.60

Jun-5620.49

Jul-5620.92

Aug-5621.96

5.11.2 (Dispensing error) < 3 /1000 14,527 14

1

2.35

1.68

2.98

1.91

1.93

1.81

0.75

2.21

1.77

2.14

1.74

0.96

Sheet1

25542.35

Oct-551.68

Nov-552.98

Dec-551.91

Jan-561.93

Feb-561.81

Mar-560.75

Apr-562.21

May-561.77

Jun-562.14

Jul-561.74

Aug-560.96

5.11.3 < 1 : 1000 14,527 9

1

1.16

1.38

1.57

1.03

1.68

0.9

0.5

1.96

1.53

1.4

0.67

0.62

Sheet1

25541.16

Oct-551.38

Nov-551.57

Dec-551.03

Jan-561.68

Feb-560.90

Mar-560.50

Apr-561.96

May-561.53

Jun-561.40

Jul-560.67

Aug-560.62

5.12 >80%

1

80.73

82.77

Sheet1

255580.73

..55-..5582.77

5.13 - PH. 5-9

1

6.7

7.9

7.5

7.5

7.6

7

7.1

7.2

7.3

..-56

..-56

Sheet1

25556.7

Oct-557.9

Nov-557.5

Dec-557.5

Jan-567.6

Feb-567.0

Mar-567.1

Apr-567.2

May-567.3

Jun-56

Jul-56

5.13 - (Suspended Solids ; SS)

5.13 - < 0.5 :

1

7.5

7

8

15

4

4

6

6

18

..-56

..-56

Sheet1

25557.5

Oct-557

Nov-558

Dec-5515

Jan-564

Feb-564

Mar-566

Apr-566

May-5618

Jun-56

Jul-56

6.1 6.2 6.3 6.4 Part 4 6 (LDR)

6.1

2555 2556( ..55)

6.2 NANANANANANA

1

15

..-55

3

..-55

..-56

1

..-56

..-56

..-56

..-56

..-56

..-56

..-56

NA

NA

NA

Sheet1

255515

Oct-55

Nov-553

Dec-55

Jan-56

Feb-561

Mar-56

Apr-56

May-56

Jun-56

Jul-56

Aug-56

Sep-56

6.3 >80%

1

95

100

Sheet1

255495

2555100

6.4

1

84

100

>80%

Sheet1

255484

2555100

7.1 7.2 Fasting blood sugar(70-130%mg/dl)7.3 ( TB) 7.4 6 (-)7.5 35 7.6 (-)7.7 7 (HPR)

7.1

1

87.48

90.7

>80%

Sheet1

255587.48

May-5690.70

7.2 Fasting blood sugar (70-130%mg/dl) 60%

1

81.12

45.06

34.5

53.58

37.2

90.63

50.42

44.44

39.11

61.09

53.86

51.77

..-56

Sheet1

255581.12

Oct-5545.06

Nov-5534.50

Dec-5553.58

Jan-5637.20

Feb-5690.63

Mar-5650.42

Apr-5644.44

May-5639.11

Jun-5661.09

Jul-5653.86

Aug-5651.77

Sep-56

7.3 (TB) 0

1

0

0

0

0

0

0

0

0

0

0

0

0

0

Sheet1

25550

Oct-550

Nov-550

Dec-550

Jan-560

Feb-560

Mar-560

Apr-560

May-560

Jun-560

Jul-560

Aug-560

Sep-560

7.4 6 (-) >30%

1

81.83

56.17

55.05

56.56

50.6

52.99

49.1

58.29

52.44

54.03

55.02

56.18

59.36

Sheet1

255581.83

Oct-5556.17

Nov-5555.05

Dec-5556.56

Jan-5650.60

Feb-5652.99

Mar-5649.10

Apr-5658.29

May-5652.44

Jun-5654.03

Jul-5655.02

Aug-5656.18

Sep-5659.36

7.5 35 >80%

1

81.12

92.64

93.32

93.32

Sheet1

255581.12

Mar-5692.64

Apr-5693.32

Sep-5693.32

7.6 (-) >80%

1

81.83

89.59

88.5

95.99

95.72

95.98

97.12

Sheet1

255581.83

Mar-5689.59

May-5688.50

Jun-5695.99

Jul-5695.72

Aug-5695.98

Sep-5697.12

7.7 ( 1//)

2555 25563 31 29