LIST OF HOSPITAL PERFORMANCE

INDICATORS FOR
ACCOUNTABILITY (HPIA)

HPIA Element Indicator

1 Internal Business Process 1 - 12
2 Customer Focus 13 - 17
3 Employee Satisfaction 18 - 20
4 Learning and Growth 21 - 23
5 Financial and Office Management 24 - 32
6 Environmental (Technical/ Community) Support 33 - 36

REPORTING
FREQUENCY Page
NO INDICATOR STANDARD
(Hospital to
JKN)
INTERNAL BUSINESS PROCESS
ST Elevation Myocardial Infarction (STEMI) [Without
1 ≤ 10% Monthly 6
Shock] Case Fatality Rate
Non ST Elevation Myocardial Infarction (STEMI) / Unstable
2 ≤ 10% Monthly 7
Angina (UA) Case Fatality Rate
Percentage of paediatric patients with unplanned
3 readmissions to the paediatric ward within 48 hours of ≤2% Monthly 8
discharge
Percentage of massive postpartum haemorrhage (PPH)
4 ≤ 1% Monthly
incidence in cases delivered in the hospital 9
Percentage of inappropriate triaging (UNDER-TRIAGING):
5 Category Green patients who should have been triaged as ≤ 0.5% Monthly 10
Category Red
Percentage of x-rays with turnaround time of ≤ 45 minutes
6 of Urgent Plain radiographic examination (X-ray) requested ≥ 80% Monthly 11
by the Emergency & Trauma Department (ED/ A&E)
Percentage of laboratory turnaround time (LTAT) for urgent
7 ≥ 90% 6 Monthly 12
Full blood count (FBC) within (≤) 45 minutes
Incidence of thrombophlebitis among inpatients with
8 ≤ 0.5% Monthly 13
intravenous (IV) cannulation
Percentage of Morbidity and/ or Mortality meetings being
conducted at the hospital level with documentation of the
9 cases discussed ≥ 80% 6 Monthly 14
State & Specialist Hospital: 12 times/ year
Other Hospital: 6 times/ year
10 Cross-match Transfusion (CT) ratio ≤ 2.5 6 Monthly 16
11 Rate of Healthcare Associated Infections (HCAI) < 5% 6 Monthly 16
 Percentage of Root Cause Analysis (of the Clinical
12 ≥ 80% 6 Monthly 17
Services) on Near Misses with corrective action taken
CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MOH
2