Quality Management

NABH/JCI quality indicators, incidents, and CAPA tracking

Medication Error Rate

0.8/1000

Target: ≤1.0
↓ improved

Fall Rate

1.2/1000

Target: ≤1.5
→ stable

Hospital Readmission (30d)

4.2%

Target: ≤5%
↓ improved

Patient Satisfaction

4.4/5

Target: ≥4.0
↑ improved

Discharge Summary TAT

18.4 hrs

Target: ≤24 hrs
→ stable

Surgical Site Infection Rate

1.8%

Target: ≤2%
↓ improved

Patient Satisfaction Score (Monthly)

Open CAPA Items

Medication reconciliation SOP update

CAPA-041 · CNO · Due 30 Jun 2026

In Progress

Fall prevention bundle implementation

CAPA-039 · NM Ward 2 · Due 15 Jul 2026

Open

Discharge checklist compliance training

CAPA-037 · Med Director · Due 01 Jul 2026

In Progress