Quality Improvement (QI) Framework for Bangladesh – Key Indicators & Assessment Criteria ( Donabedian-Based)
This section operationalizes the QI framework by defining measurable indicators and assessment criteria for each category (Structure, Process, and Outcome). The justification for each component is as follows:
- Structure (Inputs & Readiness) Justification
- The availability and quality of inputs (e.g., infrastructure, workforce, equipment, policies) directly impact service delivery and patient outcomes.
- For example:
- Workforce Availability (≥85% positions filled) is justified because healthcare personnel shortages lead to service delays and poor quality of care.
- Health Information Systems (HIS) & Digital Records are essential for data-driven decision-making and continuity of care.
- Process (Service Delivery & Quality) Justification
- This section ensures that care is delivered in a way that is safe, timely, effective, and patient-centered.
- For example:
- Patient Safety (IPC, medication safety, surgical safety) ensures adherence to WHO’s standards to prevent medical errors and infections.
- Waiting Time & Service Efficiency (OPD waiting time <30 mins, emergency response <15 mins) ensures patients receive timely care, reducing complications.
- Outcome (Impact & Performance) Justification
- This section ensures that quality interventions lead to measurable improvements in patient health and system performance.
- For example:
- Maternal & Neonatal Mortality Rate (MMR, NMR, U5MR) is a critical indicator of maternal and child health service effectiveness.
- Financial Protection (Catastrophic Health Expenditure Rate <5%) ensures that healthcare is affordable and reduces financial hardship.
By linking each indicator to clear assessment criteria, this section ensures that healthcare facilities can track, measure, and improve their performance. It aligns with international standards (WHO, Donabedian, 5S-CQI-TQM) while being adaptable to Bangladesh’s context
Donabedian-Based Quality Improvement (QI) Framework for Bangladesh
Structure (Inputs & Readiness)
| Indicator | Measurement | Data Source |
|---|---|---|
| Hospital Infrastructure & Essential Utilities (Water, Sanitation, Electricity, Waste Disposal, Internet) | Compliance with infrastructure standards | Environmental health reports |
| Structural Integrity, Safety Compliance | Inspection reports, engineering assessment | Facility audits, government records |
| Total Number of Beds, Bed Occupancy Rate | Patient admission/discharge records | Hospital management system, reports |
| Availability of Emergency Rooms, ICU Beds, Equipment | Time taken for emergency patient admission, ICU occupancy | Hospital logs, ICU records |
| Equipment Availability, Functionality, Maintenance | Equipment audits, downtime analysis | Maintenance logs, procurement data |
| Essential Medicines & Consumables Availability | No stockouts, temperature control | Pharmacy records, supply chain data |
| Policy & Governance (SOPs, Guidelines, Compliance) | Full implementation of quality protocols | Policy documents, audit reports |
| Health Information System (HIS) & Digital Records | System uptime, data accessibility | IT department records |
| Facility Safety & Security (Fire Safety, Disaster Preparedness, Hospital Security) | Compliance certificates, safety drills | Security logs, government audits |
| Workforce Availability (Doctors, Nurses, Technicians, Support Staff) | ≥85% positions filled | HR records |
| Workforce Availability (Doctors, Nurses, Technicians, Support Staff) | % of positions filled with trained personnel (≥85%) | HR records |
| Doctor-Patient Ratio | Number of doctors per 1,000 patients seen daily | OPD logs |
| Nurse-Patient Ratio | Number of nurses per admitted patients per shift | HR records |
| Training & Competency Development | % of staff completing CPD training | HR training records |
| Workload Indicator of Staffing Need (WISN) Score | WHO tool-based calculation of workforce adequacy | WISN assessment |
Process Indicators (Service Delivery & Quality)
| Indicator | Measurement | Data Source |
|---|---|---|
| Bed Occupancy Rate (BOR) | % of hospital beds occupied (Optimal: 75–85%) | Hospital admin records |
| Average Length of Stay (ALOS) | Mean duration of inpatient stay (Target: 3–5 days for general cases) | EHR, patient records |
| OPD & Emergency Waiting Time | Average time from arrival to consultation (Target: <30 mins for OPD, <15 mins for emergency) | Time-motion study, ER logs |
| Referral & Emergency Transport System | % of emergency cases referred within 30 minutes | Referral logs, transport records |
| Clinical Effectiveness (Guideline Adherence) | >90% compliance with treatment protocols | Medical chart reviews |
| Patient-Centered Care | >90% patient satisfaction, informed consent compliance | Patient satisfaction survey |
| Incident Reporting & Learning System | % of incidents reported and analyzed within 72 hours | Incident reporting system |
| Emergency & Disaster Preparedness | % of staff trained in emergency protocols (Target: >80%) | Emergency preparedness audits |
| Training & Competency Development | % of staff completing required training (Target: >85%) | HR training records |
| Hand Hygiene Compliance Rate | % of staff following hygiene protocols (Target: >90%) | Compliance audits |
| Safe Surgery Checklist Adherence | % of surgeries following WHO checklist (Target: >95%) | Surgery observation logs |
| 30-Day Readmission Rate | <5% readmission within 30 days of discharge | EHR, readmission logs |
| Hospital-Acquired Infection Rate | <7 per 1,000 patient-days | Infection control records |
| Surgical Site Infection Rate | <2% of all surgical procedures | Infection control reports |
| Adverse Drug Reaction Rate | <2% of all prescribed medications | Pharmacy reports |
| Patient Mortality Rate | <2% of total admissions (adjusted for case severity) | Mortality records |
| Waiting Time in OPD & Emergency | OPD: <30 mins; Emergency: <15 mins | Patient logs, time-motion studies |
| Timeliness of Care | % of patients receiving care within national guidelines (Target: >90%) | EHR, patient records |
| Communication Quality | % of patients reporting clear communication with doctors and nurses (Target: >85%) | Patient surveys |
| Respect & Dignity | % of patients reporting being treated with dignity (Target: >90%) | Patient experience survey |
| Ease of Access to Service | % of patients who find services easily accessible (Target: >85%) | Facility accessibility audit |
| Electronic Health Record (EHR) Utilization Rate | % of patient encounters recorded digitally (Target: >95%) | EHR logs |
| Interoperability Score | % of health data successfully shared across facilities (Target: >80%) | IT system logs |
| Telemedicine Adoption Rate | % of consultations conducted via telemedicine (Target: >20%) | Telehealth records |
| System Usability Score (SUS) | Average usability rating by hospital staff (Target: >75 on a 100-point scale) | SUS survey |
| IT Downtime Rate | % of operational hours affected by system failure (Target: <2%) | IT logs |
| Digital Prescription Rate | % of prescriptions issued electronically (Target: >85%) | EHR, pharmacy logs |
5S-Based Indicators (Workplace Organization & Efficiency)
Assessment Tools: 5S Checklist Audits, Direct Observation, Staff Surveys
| Indicator | Definition/Measurement | Data Source |
|---|---|---|
| Workplace Organization Score (5S Compliance Rate) | % of departments meeting 5S implementation standards | 5S audit checklist |
| Availability of Essential Supplies | % of workstations stocked with necessary medical supplies | Direct observation |
| Response Time for Emergency Equipment Access | Time taken to access emergency medical tools (oxygen, defibrillator, etc.) | Time-motion study |
| Staff Adherence to Clean & Safe Workplace Standards | % of staff following proper organization & cleanliness | Observation & staff feedback |
| Reduction in Equipment & Supply Retrieval Time | Time saved in accessing tools due to 5S implementation | Pre & post-5S audit comparison |
CQI-Based Indicators (Continuous Quality Improvement)
Assessment Tools: PDSA (Plan-Do-Study-Act) Cycle Analysis, Quality Improvement Reports, Process Audits
| Indicator | Definition/Measurement | Data Source |
|---|---|---|
| Number of QI Projects Implemented | Total number of active quality improvement projects | QI reports |
| Process Cycle Time Reduction | % improvement in workflow efficiency (e.g., OPD registration time, discharge process) | Time-motion study |
| Adherence to PDSA Cycles | % of departments actively applying PDSA cycles for improvements | Quality audit reports |
| Reduction in Medication Errors | % decrease in reported prescription & dispensing errors | Incident reporting system |
| Improvement in Compliance with Clinical Protocols | % increase in adherence to updated treatment guidelines | Medical chart reviews |
TQM-Based Indicators (Total Quality Management)
Assessment Tools: Patient Satisfaction Surveys, Staff Engagement Surveys, Hospital Performance Dashboard
| Indicator | Definition/Measurement | Data Source |
|---|---|---|
| Leadership Commitment to Quality Score | % of management actively engaged in quality initiatives | Leadership survey |
| Patient-Centered Care Implementation Rate | % of care processes designed with patient feedback integration | Policy & process review |
| Employee Engagement in Quality Improvement | % of staff participating in hospital QI initiatives | Staff QI survey |
| Rate of Staff Suggestion Implementation | % of employee suggestions for service improvement adopted | Suggestion box records |
| Cross-Departmental Collaboration in Quality Initiatives | % of departments engaged in joint QI projects | QI committee reports |
Summary of Additional Indicators (5S, CQI, TQM)
Summary of Additional Indicators
| Category | Key Indicators |
| 5S – Workplace Organization | Workplace Organization Score, Emergency Equipment Response Time, Staff Adherence to 5S |
| CQI – Continuous Improvement | QI Projects Implemented, Process Cycle Time Reduction, Reduction in Medication Errors |
| TQM – Total Quality Management | Leadership Commitment, Employee Engagement, Cross-Departmental Collaboration |
Outcome (Impact & Performance)
| Indicator | Measurement | Data Source |
|---|---|---|
| Maternal & Neonatal Mortality Rate (MMR, NMR, U5MR) | MMR <50 per 100,000 live births, NMR <5 per 1,000 | Birth & mortality records |
| Post-Surgical Complication Rate | <2% complications post-surgery | Surgical outcome records |
| Hospital Readmission Rate | <5% within 30 days | Readmission records |
| Hospital-Acquired Infection (HAI) Rate | % of infections per patient admissions | Infection control records |
| 30-Day Readmission Rate | % of readmissions within 30 days | EHR, readmission logs |
| Adverse Drug Event (ADE) Rate | % of medication errors causing harm | Pharmacy reports |
| Financial Protection (Catastrophic Health Expenditure Rate) | <5% households spending >10% on healthcare | Health financing records |
| Equity in Service Utilization | ≥90% marginalized populations accessing care | Patient demographic reports |
| Overall Patient Satisfaction Score | % of patients rating care as ‘satisfactory’ | Patient satisfaction survey |
| Complaint Resolution Rate | % of patient complaints addressed within standard time | Patient grievance records |
| Digital Health & IT System Integration (EHR, Telemedicine, Interoperability) | % of patient encounters recorded digitally, % consultations via telemedicine | EHR logs, telehealth records |
| Number of Quality Improvement (QI) Projects Implemented | Total QI initiatives active | QI reports |
| Process Cycle Time Reduction | % improvement in workflow efficiency | Time-motion study |
| Leadership Commitment to Quality Score | % of management engaged in QI | Leadership surveys |
| Cross-Departmental Collaboration in QI | % of departments engaged in joint QI | QI committee reports |
Justification for This QI Framework
- Aligns with Donabedian’s Model (Structure, Process, Outcome) to ensure systematic quality assessment.
- Incorporates WHO Quality Standards (safety, efficiency, patient-centeredness, equity).
- Uses 5S-CQI-TQM principles for continuous improvement, facility organization, and process efficiency.
- Includes Facility Assessment Tools to measure performance objectively.