Data

S.N. source Indicator

1 HMIS Institutional stillbirths*1000

Institutional maternal
2 HMIS deaths*100

Early Institutional Neonatal

3 HMIS Death Rate*1000

4 HMIS Inpatient mortality rate*100

 Viral load suppression among
5 HMIS patients on ART
 Early viral load suppression
6 HMIS rate

7 HMIS TB cure rate * 100

 TB re-treatment rate *
8 HMIS 100
 Death rate among TB
9 HMIS cases * 100

Treatment outcome of
neonates admitted to NICU
10 HMIS (Mortality ) 100
 Treatment outcomes for
management of severe acute
malnutrition in children under
11 HMIS 5 year * 100
 Mortality rate in intensive care
12 HMIS unit (ICU) *100

Emergency
unit/Department
13 HMIS MortalityY *100

Proportion of pregnant
women tested for syphilis
14 HMIS during ANC *100
 Proportion of low birth weight
or premature newborns for
whom KMC was initiated after
15 HMIS delivery

Percentage of HIV-positive
pregnant women who
received ART for PMTCT
16 HMIS during L&D *100
 Percentage of infants born to
HIV-infected women who
were started on co-
trimoxazole prophylaxis within
17 HMIS two months of birth *100

Proportion of asphyxiated
neonates who were
resuscitated (with bag &
18 HMIS mask) and survived *

Percentage of women tested

positive with acetic acid (VIA)
and treated for cervical
19 HMIS lesions *
20 HMIS ANC dropout * 100

Immunization dropout rate

21 HMIS from penta 1 to penta 3 * 100
22 HMIS ART retention rate * 100

Leprosy treatment
23 HMIS completion rate * 100
 Lost to follow up rate
among new all forms of TB
24 HMIS cases

Proportion of pregnant and

lactating women (PLW)
screened for acute
25 HMIS malnutrition

Proportion of Sexually
Transmitted Infection (STI)
26 HMIS cases tested for HIV *
 TB case detection rate
27 HMIS *100

Drug Susceptibility Test

(DST) coverage for TB
28 HMIS patients
 HIV screening for TB
29 HMIS patients * 100

TB Screening for HIV positive

30 HMIS Clients * 100
 Proportion of women age 30-
49 screened for cervical
cancer with visual inspection
31 HMIS with acetic acid (VIA)
 AMBULANCE SERVICE
32 HMIS RESPONSE RATE *

33 HMIS REFERRAL RATE *

Percentage of occupied
beds during the period
under review(Bed
34 HMIS Occupacy rate)
35 HMIS C-section rate * 100

Immediate postpartum
contraceptive acceptance
36 HMIS rate (IPPCAR)
 KPI 17: Births by surgical,
instrumental or assisted
37 KPI vaginal delivery

KPI 6: Emergency room

attendances with length of
38 KPI stay > 24 hours

Waiting time for surgeryKPI 7:

Delay for elective surgical
39 KPI admission
 KPI 13: Mean duration of in-
hospital pre-elective operative
40 KPI stay(Number)

Surgical safety: KPI 15:

Anesthetic adverse
41 KPI outcome
 HOSPKPI15 - Number of
inpatients who develop a new
pressure ulcer during the
42 KPI reporting period (KPI)

ER timely action
HOSPKPI09 -KPI 5:
Emergency room patients
triaged within 5 minutes
43 KPI of arrival

KPI 3: Outpatient waiting

time to Consultation (in
44 KPI minutes)
45 KPI KPI 16: Proportion of women S
46 KPI KPI 11: Peri-operative Mortalit
 Patient satisfaction (KPI)
47 KPI (%)

KPI 18: Percentage of

Clients with 100%
48 KPI prescribed drugs filled

Number of women who

49 KPI have received TT2/TT4 *
 KPI 9: Surgical site infection
50 KPI rate (in %)

KPI 21: Blood unavailability

51 KPI ratio for surgical patients
52 KPI KPI 4: Outpatients not seen
53 KPI KPI 24: Staff satisfaction
 Frequenc
Dissagre y of
Numerator Denominator gation reporting
Total number of
births (still and live)
Number of stillbirths attended None Monthly

Number of maternal Total number of

deaths in the health deliveries in health
facility facility None Monthly
Total Number of
institutional Total number of live Time of
neonatal deaths in births attended by death: 0-
the first 7 days of skilled health 24hrs; 1-
life attendants 7 days Monthly

Age
group:
10-14
years;
15-19
years;
Number of inpatient Total number of >=20
deaths discharges years Monthly
 By
Age: .<1,
1-4, 5-9,
10-14,
15-19,
20-24,
25-49,
50+; By
Sex:
Male,
Female;
Number of adult By
and pediatric Pregnanc
patents on ART y status:
with undetectable Non-
viral load pregnant
(<1000copies/ml) in Estimated number and
the past 12 months of PLWHIV pregnant Monthly
 By
Age: .<1,
1-4, 5-9,
10-14,
15-19,
20-24,
25-49,
50+; By
Number of adults Sex:
and children who Male,
Number of adult initiated ART in the Female;
and pediatric 6 months prior to Pregnanc
patients with an the y status:
undetectable viral beginning of the Non-
load (<1,000 reporting period pregnant
copies/ml) at 6 with a viral load test and
months at 6-month pregnant Monthly

Number of cohort
of new
bacteriologically Total number of
confirmed new
Pulmonary TB bacteriologically
cases registered confirmed PTB
during specified cases registered
cohort period and in the same Quarterl
cured cohort period None y
 Sex ,
Treatme
nt after
Relapse,
treatme
nt after
Failure,
treatme
nt after
lost to
followup
Total number of cases,
new and other
retreatment TB previous
Total number of cases registered ly
retreatment TB during reporting treated Quarterl
cases period cases y
The number of
new all forms of
TB cases
registered in the
same period of The total number
the previous year of new all forms
that died during of TB cases
treatment, registered during
irrespective of the same cohort Quarterl
the cause period None y

The number of
admitted neonates
that were
recovered,
transferred, died or
with other treatment
outcomes from The total number of
NICU (Separately admitted neonates
by outcome discharged from
category) NICU None Monthly
 Treatmen
t
Outcome:
No. of children Recovere
under five that d, died,
recovered or died or defaulted,
defaulted or non- non-
responded or responde
medical transfer or nt,
transfer out or medical
unknown treatment transfer,
outcome from The total number of transfer
treatment center children exiting from out,
(Separately by treatment for acute Unknown
outcome category) malnutrition ) Monthly
 Death
With
Mechanic
al
ventilator
Death
Without
Total number of Mechanic
Number of deaths patients admitted to al
in ICU ICU ventilator Monthly

Sex:
Male/Fe
male
Age: <15
Total number of Total number of years,
deaths in emergency room 15+
emergency unit attendances years
Total number of
pregnant women
who attended first
Number of pregnant ANC
w X 100 visit Reactive aMonthly
Number of newborn Estimated number
weighing <2000gm of newborn
and premature weighing <2000gm
newborns for which and/or
KMC was initiated premature delivery* None Monthly

Number of HIV
positive pregnant
and lactating
women who
received ART at Newly
ANC, L&D and PNC started
for the first time and at: ANC,
those women who L&D,
get pregnant while Estimated HIV PNC
on ART & linked to positive pregnant Linked
ANC women in the year from ART Monthly
Number of infants
born to HIV infected
women started on
co-trimoxazole
prophylaxis within Estimated number
two months of birth of HIV- infected
during the reporting pregnant women
period who gave live birth None Monthly

Number of
neonates Total
resuscitated for Estimated number resuscitat
birth asphyxia & of neonates with ed ,
survived birth asphyxia survived Monthly

Normal
cervix,
Precance
rous
lesion
Number of women Total number of Suspiciou
age 30-49 screened women age 30-49 s for
with VIA for cervical within the cervical
cancer catchment area Cancer Monthly
ANC 4 - ANC 1 ANC 1 None Monthly

Penta 3- Penta 1 Penta 1 None Monthly

 Disaggre
gation
Age: 1-4,
5-9, 10-
14, 15-
19, 20-
24, 25-
Total number of 49, 50+
Number of adults adults and children Sex:
and children who who initiated ART in Male,
are still on the 12 months prior Female,
treatment at 12 to the beginning of pregnant,
months after the reporting period non-
initiating ART (net current cohort) pregnant Monthly

The number of
leprosy cases
who completed The total number
treatment of leprosy cases
successfully registered during
during specified the same
cohort period cohort period Type: PB,Quarterly
Number of all
forms of TB cases
registered in the
specific cohort
period that Total number of
interrupted new all forms of
treatment for TB cases
two or more registered during
consecutive the same cohort
months period None Quarterly

MUAC
Estimated number <23 and
The total number of of PLW > 23 Monthly

HIV test
result:
Positive,
Number of STI Negative
cases tested for Total number of STI Sex:
HIV in the reporting cases in the Male,
period reporting period Female Monthly
Number of all Estimated ry
forms of TB (New number of all negative
and Relapse) forms of TB cases TB, all
cases detected in the population Extra
during the during the same Pulmona Quarterl
reporting period period* ry TB) y

Age: < 5,
5-14,
15+,
Registrat
ion
group:
New,
previous
ly
Number of treated
pulmonary TB Total number of includin
(new and Pulmonary TB g
retreatment) (new and relapse,
cases and retreatment) unknow
contacts of DRTB cases and n
cases with contacts of treatme
documented DST DR-TB cases in nt Quarterl
results the same period* history y
 Sex:
male ,
The number of TB female,
patients enrolled HIV
in DOTS who The total number status:
have of TB patients HIV
documented HIV enrolled in DOTS positive,
result in the during the same HIV Quarterl
reporting period period Negative y

Number of patients Age: -

on ART whose TB Total number of <15, >15
status was patients on ART Sex:
assessed during the during the reporting Male,
reporting period period Female Monthly
 By
outcome:
Normal
cervix
Precance
rous
lesion
Number of women Total number of Suspiciou
age 30-49 screened women age 30-49 s for
with VIA for cervical within the cervical
cancer catchment area Cancer Monthly
 of
Ambulan
ce
dispatche
d (With
EMT,
Without
EMT)
• With
case
(labor
and
delivery ,
Number of Road
ambulance Total number of Traffic
requests for whom community requests Accident
ambulance made for and
was dispatched ambulance service other) Monthly
Emergen
Number of referred Total number of cy and
patients patients/clients non-
(emergency + non- seen in the health emergen
emergency) facility cy Monthly

(Number of beds
available) x
Total length of (Number of days
stay (in days) in period)
Number of women
having given birth
by caesarean Total number of
section expected deliveries None Monthly

By Age:
10-14, 15
- 19, 20–
24, 25–
29, 30-49
years
By
Number of women Methods:
who accepted a POP,
modern Implants,
contraceptive IUCD,
method immediately Tuba
after delivery (0- Total number of Ligation,
48hours) deliveries Others Monthly
Number of
Caesarean sections
(Q33) + Number of Total deliveries
abdominal surgical (Number of live
deliveries (Q34) + births attended in
Number of the hospital (Q36) +
instrumental or Number of stillbirths
assisted vaginal attended in the
deliveries (Q35) hospital) (Q37) None Monthly
Total number of
admissions who
remain in
emergency room for Total number of
more than 24 hrs emergency room
(Q11) admissions (Q12) None Monthly

Sum total of
number of days Number of patients
between date who were admitted
added to surgical for elective (non-
waiting list to date emergency) surgery
of admission for during the reporting
surgery (Q13) period (Q14) None Monthly
 Total number of
elective surgical
procedures during
the reporting period
Total sum of pre-oper(Q29) None Monthly

Number of
surgical cases
with anesthetic
adverse outcome
(high spinal
anesthesia, failed Total number of
intubation, major surgical
cardio-respiratory procedures
arrest) during performed in OR
reporting during reporting
period(Q30) period(Q25) x 100
 Number of patients
Number of discharged alive
inpatients who (including transfers
develop a new out) (Q16) +
pressure ulcer Number of deaths
during the reporting among admitted
period (Q15) inpatients (Q17) None Monthly

Number of
surveyed patients Number of
who undergo patients included
triage within 5 in emergency
minutes of arrival room during
in emergency triage time survey Quarterl
room (Q9) (Q10) None y

HOSPKPI06 -
HOSPKPI05 - Sum Number of
total of outpatient
outpatient "waiting time
waiting time (in cards" completed Quarterl
minutes) (KPI) None y
 women who gave
birth in the health
facility or referred in
or on arrival who
had any bleeding
with hypotension or
requiring blood
transfusion or died
(Q32) + Number of
Number of Women Women who gave
who gave birth in birth in the health
the health facility or facility or referred in
referred in who had who had any
any bleeding with bleeding with
hypotension or hypotension or
requiring blood requiring blood
transfusion and transfusion and
survived (Q31) survived (Q31) None Monthly
Total number of
deaths before
discharge within 24
hour after surgery
among patients who
underwent a major
surgical procedure
in an OR(Q23)+
Total number of
deaths before Total number of
discharge but more patients who
than 24 Hours post received major
op among patients surgery(both
who underwent a elective and non
major surgical electives) in the
procedure in an reporting
OR(Q24) period(Q25) None Monthly
 Total number of
Patient
Satisfaction
surveys
Total number of completed(Q59) x
“ Neutral” total number of
responses (Q57) + patient
Total number of satisfaction
“ satisfied” criteria’s
responses (Q58) evaluated (Q60) None Quarterly

Number of clients Total number of

who received clients who
100% of received
prescribed prescriptions(Q39 Quarterl
drugs(Q38) ) None y
 Number of operated
inpatients
discharged alive
Number of operated (including transfers
inpatient with new out) (Q19) +
surgical site Number of operated
infection arising inpatients
before discharge discharged dead
(Record at during the reporting
discharge) (Q18) period (Q20) None Monthly

Total number of
major
surgical/obstetric
procedures
cancelled or Total number of
referred because of surgical patients for
lack of blood for whom cross - match
transfusion(Q45) was done (Q46) None Monthly
Number of Total number of
outpatients not Number of new
staff Satisfaction
seen
Total on same of
number day and repeat
surveys
as registration in outpatient
“ Neutral” completed( Q53)
OPD
responses (Q51)+ attendances
during the x total number at of
reporting period
Total number of “ public facility
staff satisfaction
(Q7)
satisfied” (Q8)
criteria’s None Quarterly
Bi-
responses (Q52) evaluated (Q54) None annaul
Quality Quality
dimensio dimensio
ns ns

Quality Better
impact health

Quality Better
impact health

Quality Better
impact health

Quality Better
impact health
Quality Better
impact health
Quality Better
impact health

Quality Better
impact health
Quality Better
impact health
Quality Better
impact health

Quality Better
impact health
Quality Better
impact health
Quality Better
impact health

Quality Better
impact health
Compete
nt
care/asse
Process ofssment
 Compete
nt
care/Appr
opriate
Process oftreatment

Compete
nt
care/Appr
opriate
Process oftreatment
 Compete
nt
care/Appr
opriate
Process oftreatment

Compete
nt
care/Appr
opriate
Process oftreatment

Compete
nt
care/Appr
opriate
Process oftreatment
 Compete
nt
Systems/
Continuity
or
Process ofretention
Compete
nt
Systems/
Continuity
or
Process ofretention
 Compete
nt
Systems/
Continuity
or
Process ofretention

Compet
ent
Systems
/Continu
ity or
retentio
Process on
 Compet
ent
Systems
/Continu
ity or
retentio
Process on

Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration
 Compet
ent
Systems
/Integrat
Process oion

Compet
ent
Systems
/Integrat
Process oion
 Compet
ent
Systems
/Integrat
Process oion

Compete
nt
Systems/I
Process ofntegration
 Compete
nt
Systems/I
Process ofntegration
 Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration
 Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration
 Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration
 Compete
nt
Systems/I
Process ofntegration

Compet
ent
Systems
/Integrat
Process oion
 Compete
nt
Systems/I
Process ofntegration

Compet
ent
Systems
/Integrat
Process oion

Positive
user
experien
Process oce
Quality Better
impact health
Quality Better
impact health
Quality
impact Confidence in system

Compet
ent
care/Ap
propriat
e
treatme
Process ont

Compet
ent
care/Ap
propriat
e
treatme
Process ont
 Compete
nt
Systems/I
Process ofntegration

Compete
nt
Systems/I
Process ofntegration
Process of care
Process of care
S.N. Data source Indicator

1 HMIS Institutional stillbirths*1000

2 HMIS Early Institutional Neonatal Death Rate*1000

3 HMIS Emergency unit/Department MortalityY *100

Immediate postpartum contraceptive acceptance

36 HMIS rate (IPPCAR)
KPI 6: Emergency room attendances with
38 KPI length of stay > 24 hours

50 KPI KPI 9: Surgical site infection rate (in %)

7 HMIS TB cure rate * 100

30 HMIS TB Screening for HIV positive Clients * 100

KPI 3: Outpatient waiting time to Consultation
44 KPI (in minutes)

47 KPI Patient satisfaction (KPI) (%)

1 KPI Average HSTQ Score

Numerator Denominator

Number of stillbirths Total number of births (still and live) attended

Total Number of institutional neonatal deaths in the first Total number of live births attended by skilled health
7 days of life attendants

Total number of deaths in emergency unit Total number of emergency room attendances
Number of women who accepted a modern
contraceptive method immediately after delivery (0-
48hours) Total number of deliveries
Total number of admissions who remain in emergency
room for more than 24 hrs (Q11) Total number of emergency room admissions (Q12)
Number of operated inpatients discharged alive
Number of operated inpatient with new surgical site (including transfers out) (Q19) + Number of operated
infection arising before discharge (Record at discharge) inpatients discharged dead during the reporting period
(Q18) (Q20)
Number of cohort of new bacteriologically confirmed
Pulmonary TB cases registered during specified cohort Total number of new bacteriologically confirmed PTB
period and cured cases registered in the same cohort period
Number of patients on ART whose TB status was Total number of patients on ART during the reporting
assessed during the reporting period period
HOSPKPI05 - Sum total of outpatient waiting time (in HOSPKPI06 - Number of outpatient "waiting time
minutes) cards" completed (KPI)

Total number of Patient Satisfaction surveys

Total number of “ Neutral” responses (Q57) + Total completed(Q59) x total number of patient satisfaction
number of “ satisfied” responses (Q58) criteria’s evaluated (Q60)

Number of Hospitals conducted clinical audit in the

Average HSTQ score Quarter
Dissagregation Frequency of reporting

None Monthly
Time of death: 0-24hrs;
1-7 days Monthly
By
Sex:Age: 10-14, 15 - 19,
Male/Female
20–24,
Age: 25–29,
<15 years,30-49
15+
years Monthly
By Methods: POP,
Implants, IUCD, Tuba
Ligation, Others Monthly

None Monthly

None Monthly

None Quarterly
Age: - <15, >15
Sex: Male, Female Monthly

None Quarterly

None Quarterly

None Quarterly