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.