NABH Quality Indicators: The Complete 6th Edition KPI List (32 + 18)

Where quality indicators sit in the 6th Edition

Quality indicators belong to Chapter 6, Patient Safety and Quality Improvement (PSQ). Standard PSQ.3 says the organisation identifies key indicators to monitor structures, processes and outcomes, and uses them for continual improvement. Its objective elements are:

Under 6th Edition scoring, every Core element must score at least 4 out of 5. A hospital that collects infection or safety data but cannot show it to assessors is therefore at real risk. The edition also changed the interpretation of PSQ.3.a to put more weight on clinical quality indicators. Our summary of what changed in the 6th Edition covers the rest.

The KPI annexure itself starts on page 202 of the standards. NABH's stated intent is that the indicators cover the whole scope of services you apply for, each with a standard definition, numerator and denominator.

The 32 hospital-wide indicators

All are collated monthly. "PSQ" is the objective element NABH links each indicator to.

*The annexure lists the surgical site infection rate against PSQ 3a; like the device infections, it is defined by the latest CDC/NHSN criteria.

How NABH wants the tricky ones measured

The annexure's definitions and remarks settle many arguments that come up during implementation:

• Initial assessment time (1): starts when the patient arrives at the ward bed and ends when a doctor has completed and documented the initial assessment: chief complaint, history, examination findings and provisional or final diagnosis. Day-care patients are excluded, and later edits must not change the time stamp.
• Reporting errors (2): errors found after a report has been signed and released, including transcription errors, in both laboratory and radiology. NABH suggests analysing them separately by department and imaging modality.
• Safety precautions in diagnostics (3): a monthly audit done by someone from outside the department. Breaking any one safety requirement counts as non-adherence.
• Medication errors (4): NABH uses the NCC MERP definition, covering any preventable event that may cause or lead to inappropriate medication use or patient harm. Capture follows NABH's own document on medication errors, for admitted patients.
• Unplanned return to OT (6): any secondary procedure for a complication of the index operation during the same admission, such as post-operative bleeding, debridement, secondary suturing or evaluation under anaesthesia. Data is captured with a 30-day delay so complications have time to appear.
• Wrong site, patient or surgery (7): audited against the WHO safe surgery checklist. NABH prefers the auditor's identity to be hidden from the operating team, and the sample spread across days and surgeons.
• Transfusion reactions (8): the denominator is units transfused, not units issued from the blood bank, and includes whole blood and components.
• ICU mortality (9): actual deaths divided by predicted deaths, with prediction from a model such as APACHE, SOFA, SAPS or MPM.
• Return to ICU (10): covers all ICUs and excludes HDUs.
• Device infections and SSI (13–16): use the latest CDC/NHSN definitions. SSI figures stay provisional until each patient's surveillance window closes, so last month's rate is updated as data matures.
• Hand hygiene (17): measured by direct observation. NABH points to the WHO hand hygiene monitoring tool and wants every relevant staff category observed at least once a quarter.
• Prophylactic antibiotics (18): right drug and dose within the right time. A patient who correctly received none (for example, a clean surgery where it is not indicated) counts as appropriate. One given an antibiotic that was not indicated counts as inappropriate.
• Rescheduled surgeries (19): every case on the OT list counts, including tentative bookings. Delays are measured from the first booked time.
• Nurse–patient ratio (21): calculated separately for ICUs and wards and for each shift, excluding the in-charge. NABH prefers separate ICU ratios for ventilated and non-ventilated patients.
• OPD and diagnostic waiting times (22–23): for appointment patients the clock starts at the appointment time. OPD waiting ends when the consultant (not a junior doctor) starts the assessment. Early starts count as zero.
• Discharge time (24): the clock stops when discharge formalities are complete. Time a patient asks for themselves is not added, and day-care patients are excluded.
• Consent (25): "incomplete" means an essential element is missing. "Improper" means invalid, such as consent given by or taken from the wrong person.
• Emergency medicine stock-outs (26): count instances, not drugs. Two drugs out of stock on the 7th and one on the 24th give a value of two.
• Mock drills (27): NABH suggests a checklist for capturing variations and includes tabletop exercises.
• Falls (28): every fall counts, whether physiological (fainting) or environmental, and assisted falls are included.
• Needlestick injuries (30): per 1,000, using average occupied beds as the denominator, reported cumulatively through the year.
• Handovers (31): captured separately for doctors and nurses on an all-or-none basis. With an SBAR template, every component must be filled in.
• Safe and rational prescriptions (32): measured by prescription audit, using NABH's methodology and a stratified random sample.

The 18 department-specific indicators

NABH says these are captured from in-patients unless an indicator states that all patients are included.

A few definitions worth knowing:

• Bronchiolitis (13): steroids, bronchodilators and antimicrobials are not recommended, so using them counts as inappropriate treatment. NABH cites the American Academy of Pediatrics and notes this applies mostly to children under 24 months.
• Contrast extravasation (16): includes every patient given intravenous contrast during CT or MRI.
• Triage (17): runs from the patient's arrival in the emergency department to the completion of triage.

Sampling and data capture

NABH expects indicators to come from the hospital information system (HIS/EMR) wherever possible. Where the system cannot collate a numerator or denominator, it should at least allow manual entry so the value is still calculated automatically. For audit-based indicators such as hand hygiene, medication errors, safety precautions, surgical safety and prescriptions, the annexure recommends stratified random sampling and specifies minimum sample sizes. Rates that rely on complete counts, such as falls, transfusion reactions and infection rates, are not sampled.

Making the indicators count at assessment

Collecting 50 numbers is the easy part. Assessors look for the full loop that PSQ.3.e–g describes:

1. Defined ownership. Each indicator has an owner, a data source and a collection method that matches NABH's definition.
2. Verification. The quality team cross-checks figures against registers and records before they are reported.
3. Analysis. Monthly trends, comparisons with targets or benchmarks, and an explanation for every spike.
4. Action. Corrective and preventive actions, a root cause analysis where needed, and evidence that the indicator moved afterwards.

The commonest gaps we see are indicators measured with home-made definitions (especially initial assessment time and OPD waiting time), infection rates calculated per patient instead of per 1,000 device days, and committees that review numbers without recording any action. Our NABH documentation checklist lists the registers that feed these indicators, and the hospital accreditation page explains how we set up the quality programme with your team.