01/01/2023 KPI NORTH KELANTAN CLUSTER HOSPITAL TECHNICAL SPECIFICATIONS KEY PERFORMANCE INDICATORS NKCH : HRPZII, HTP, HPM AND HTA
1 | P a g e NO INDICATOR STANDARD MEDICAL 1 Percentage of Step Down cases from LH per total admissions medical NLH > 5% / year 2 Percentage of Step Up cases from NLH per total admissions medical NLH < 5% / year 3 Percentage of new patient per total patient in medical specialist clinic attendance in NLH > 5% / year 4 Percentage of new cases in medical ward NLH seen by specialist within 24 hours > 50% 5 Percentage of reduction of preventable death among medical patient in NLH < 10% from previous year EMERGENCY & TRAUMA 1 Percentage of critical patients with optimal resuscitation before transferred from emergency unit NLH to ETD LH > 90% 2 Average number of DID cases in NLH <2 DID/months 3 Percentage of STEMI patients receiving fibrinolytic therapy within 30 minutes of presentation at ED in NLH ≥70% 4 Percentage of Paramedic Completed standard Emergency Medical and Trauma Services Credentialing & Privileging in Cluster Hospitals ≥50% 5 Percentage of ambulance transfer fulfilment within 24 hours for step down care from LH to NLH ≥80% O&G 1 Increase number of patients see in Specialist Clinic NLH ≥5% from previous year REHABILITATATION 1 Increase number of patients admitted to Rehab Ward in NLH ≥5% from previous year 2 Increase in Bed Occupancy Rate (BOR) Rehab Ward in NLH ≥5% from previous year 3 Increase number of patients see in Rehab Clinic NLH ≥5% from previous year 4 Increase number of procedure performed in Rehab Clinic NLH ≥5% from previous year ORTHOPEDIC 1 Increase total number of Operations done in NLH 1 ≥5% from previous year 2 Increase in Specialist clinic attendance at NLH ≥5% from previous year SURGERY 1 Increase number of patients seen in Specialist Clinic in NLH ≥5% from previous year 2 Increase total number of Operations done in NLH ≥5% from previous year 3 Reduce Patients Waiting Time Of Surgery At Lead Hospital < 1 month NEFROLOGY 1 All New Cases will be seen in Clinic Nephrology HPM (NLH 2) within 1 month More than 70% new cases seen in less than 1 month and >5% increase from previous year 2 To achieve peritonitis rate less than 1:24 episode perpatient month in NLH 2 Less than 1:24 episodes per month PAEDIATRIC 1 Increase number of patients see in Specialist Clinic NLH 1 ≥5% from previous year 2 Increase in Bed Occupancy Rate of Paediatric ward in NLH 1 ≥5% from previous year 3 Increase number of patients see in Specialist Clinic NLH 2 ≥5% from previous year ORL 1 Percentage of elective tonsillectomy from HRPZII done at NLH 1 ≥5% from previous year
2 | P a g e KEY PERFOMANCE INDICATOR FOR NORTH KELANTAN CLUSTER HOSPITALS 2023 1. DEPARTMENT : MEDICAL Indicator 1 : Percentage of Step Down cases from LH per total admissions medical NLH Service : General Medicine Rationale/Objectives : Step down cases from LH is an important process to decongest LH. Besides, it will also increase and optimize the BOR of NLH. Def. of Terms : Step down cases : Only medical patient that step down from LH to NLH. Criteria : Inclusion: All medical cases including multi-disciplinary cases (medical primary team) step down from LH to NLH Exclusion: Non medical cases or multi-discipline cases (from ED/non medical ward) step down from LH to NLH Type of Indicator : Rate based process indicator Numerator : Number of step down cases from LH Denominator : Total number of medical admission in NLH Formula : Numerator x 100% Denominator Standard : > 5% / year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Six monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Percentage of Step Up cases from NLH per total admissions medical NLH Service : General Medicine Rationale/Objectives : Step up cases is an important process whereby LH can assist NLH in providing appropriate tertiary care for medical patient. Def. of Terms : Step Up cases : Only medical patient that step up from NLH to LH. Criteria : Inclusion: All medical cases including multi-disciplinary cases (medical as primary) step up from NLH to LH Exclusion: Non medical cases or multi-discipline cases (from ED/non medical bed/ ward) step up from NLH to LH Type of Indicator : Rate based process indicator Numerator : Number of step up cases from NLH Denominator : Total number of medical admission in NLH Formula : Numerator x 100% Denominator Standard : < 5% / year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator.
3 | P a g e Indicator 3 : Percentage of new patient per total patient in medical specialist clinic attendance in NLH Service : General Medicine Rationale/Objectives : New patient attendance in medical specialist clinic is important mechanisms to decongest patient in medical specialist clinic LH. Def. of Terms : New patient attendance in medical specialist clinic NLH Criteria : Inclusion: All new medical patient attended medical specialist clinic NLH Exclusion: All old medical patient including previously seen at medical specialist clinic NLH and was discharged. Type of Indicator : Rate based process indicator Numerator : Number of new patient attended medical specialist clinic NLH Denominator : Total number of patient in medical specialist clinic in NLH Formula : Numerator x 100% Denominator Standard : > 5% / year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Six monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 4 : Percentage of new cases in medical ward NLH seen by specialist within 24 hours Service : General Medicine Rationale/Objectives : All new medical cases admitted to medical ward/ bed in NLH must be seen within 24 hours of admission for appropriate specialist management. Def. of Terms : All new medical cases admitted in medical ward NLH Criteria : Inclusion: All new medical cases admitted in medical ward / bed in NLH and seen by specialist within 24 hours of admission. Exclusion: All new medical cases admitted in medical ward NLH but step up to LH prior to specialist review. Type of Indicator : Rate based process indicator Numerator : Number of new cases seen by specialist within 24hours Denominator : Total number of medical admission in NLH Formula : Numerator x 100% 3) How frequent : Six monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
4 | P a g e Denominator Standard : > 50% Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Six monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 5 : Percentage of reduction of preventable death among medical patient in NLH Service : General Medicine Rationale/Objectives : Preventable death among medical patient in NLH important to be identified and audited in order to identify problem leading to death and appropriate action taken. Def. of Terms : Preventable death : Causes of death that can be mainly avoided through effective public health and primary prevention/ intervention. ( Organisation For Economic Co-operation and Development (OECD)/ Eurostat Jan 2022) Criteria : Inclusion: All preventable death among medical patient in medical ward/ bed in NLH as reviewed by specialist in charge. Exclusion: Non- preventable death among medical patient in medical ward NLH Type of Indicator : Rate based outcome indicator Numerator : Number of preventable death among medical patient in NLH Denominator : Total number of medical admission in NLH Formula : Numerator x 100% Denominator Standard : < 10% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Yearly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
5 | P a g e 2. DEPARTMENT : EMERGENCY & TRAUMA Indicator 1 : Percentage of critical patients with optimal resuscitation before transferred from emergency unit NLH to ETD LH Service : Emergency & Trauma Rationale/Objectives : To improve competency of medical officer in NLH Def. of Terms : NIL Criteria : Inclusion: Nil Exclusion: Nil Type of Indicator : Rate based process indicator Numerator : Number of critical patients with optimal resuscitation Denominator : Total number of critical patient being transferred from NLH to LH Formula : Numerator x 100% Denominator Standard : > 90% Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Average number of DID cases in NLH Service : Emergency & Trauma Rationale/Objectives : To improve competency of medical officer in NLH Def. of Terms : Nil Criteria : - Type of Indicator : Rate based outcome indicator Numerator : Total number of DID Denominator : 6/12 month Formula : Numerator Denominator Standard : <2 DID/months Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : 6 Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
6 | P a g e Indicator 3 : Percentage of STEMI patients receiving fibrinolytic therapy within 30 minutes of presentation at ED in NLH Service : Emergency & Trauma Rationale/Objectives : To improve competency of medical officer in NLH Def. of Terms : NIL Criteria : - Type of Indicator : Rate based process indicator Numerator : Number of STEMI patients receiving fibrinolytic therapy within 30 minutes of presentation at ED in NLH Denominator : Total number of STEMI patients receiving fibrinolytic therapy at ED in NLH Formula : Numerator x 100% Denominator Standard : ≥70% Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent :Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 4 : Percentage of Paramedic Completed standard Emergency Medical and Trauma Services Credentialing & Privileging in Cluster Hospitals Service : Emergency & Trauma Rationale/Objectives : To improve competency of AMO & Staff Nurses in ED NLH. Def. of Terms : NIL Criteria : - Type of Indicator : Rate based process indicator Numerator : Number of Paramedic Completed standard Emergency Medical and Trauma Services Credentialing & Privileging in Cluster Hospitals Denominator : Total number of Paramedic Emergency Medical and Trauma Services in Cluster Hospitals Formula : Numerator x 100% Denominator Standard : ≥50% Data Collection : 6) Where : Data will be collected from respective wards in the NLH. 7) Who : Data will be collected by the NLH Coordinator. 8) How frequent : yearly data collection. 9) Who should verify : All performance data must be verified by HOD/ NLH Director. 10) How to collect : Data will be collected from the appointed in charge staff from NLH.
7 | P a g e 3. DEPARTMENT : O&G Indicator 5 : Percentage of ambulance transfer fulfilment within 24 hours for step down care from LH to NLH Service : Emergency & Trauma Rationale/Objectives : To strengthen the transport services for stepdown case from LH to NLH. Def. of Terms : NIL Criteria : - Type of Indicator : Rate based process indicator Numerator : Number of ambulance transfer fulfilment within 24 hours for step down care from LH to NLH Denominator : Total number of ambulance transfer for step down care from LH to NLH Formula : Numerator x 100% Denominator Standard : ≥80% Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 1 : Increase number of patients see in Specialist Clinic NLH Service : O&G Rationale/Objectives : To reduce congestion of cases in LH clinics Def. of Terms : NIL Criteria : Inclusion: All O&G patient attended O&G specialist clinic NLH Type of Indicator : Rate based output indicator Numerator : Number of patients see in Specialist Clinic NLH (current year) Denominator : Number of patients see in Specialist Clinic NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
8 | P a g e 4. DEPARTMENT : REHABILITATION Indicator 1 : Increase number of patients admitted to Rehab Ward in NLH Service : Rehabilitation Rationale/Objectives : To decongest Rehab ward in LH Def. of Terms : NIL Criteria : Inclusion: All Rehab patient admitted to NLH including step down and new admission Type of Indicator : Rate based output indicator Numerator : Number of patients admitted to Rehab Ward (current year) Denominator : Number of patients admitted to Rehab Ward (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Increase in Bed Occupancy Rate (BOR) Rehab Ward in NLH Service : Rehabilitation Rationale/Objectives : Increase utilization of Rehab ward in NLH Def. of Terms : NIL Criteria : - Type of Indicator : Rate based output indicator Numerator : Bed Occupancy Rate (BOR) Rehab Ward (current year) Denominator : Bed Occupancy Rate (BOR) Rehab Ward (previous year) Formula : Numerator -denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
9 | P a g e Indicator 4 : Increase number of procedure performed in Rehab Clinic NLH Service : Rehabilitation Rationale/Objectives : More procedures done at Rehab Clinic in NLH Def. of Terms : Criteria : Inclusion: All procedure performed in Rehab Clinic Exclusion: Type of Indicator : Rate based output indicator Numerator : Number of procedure performed in Rehab Clinic NLH (current year) Denominator : Number of procedure performed in Rehab Clinic NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 3 : Increase number of patients see in Rehab Clinic NLH Service : Rehabilitation Rationale/Objectives : To decongest rehabilitation clinic in LH Def. of Terms : NIL Criteria : - Type of Indicator : Rate based output indicator Numerator : Number of patients see in Rehab Clinic NLH (current year) Denominator : Number of patients see in Rehab Clinic NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
10 | P a g e 5. DEPARTMENT : ORTHOPEDIC Indicator 1 : Increase total number of Operations done in NLH 1 Service : Orthopaedic Rationale/Objectives : To decongest operation in Lead Hospital Def. of Terms : Nil Criteria : Inclusion: All orthopaedic operations performed in NLH 1 Type of Indicator : Rate based process indicator Numerator : Number of Operations done in NLH 1 (current year) Denominator : Number of Operations done in NLH 1 (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Increase in Specialist clinic attendance at NLH Service : Orthopaedic Rationale/Objectives : To decongest specialist clinic orthopaedic in LH Def. of Terms : NIL Criteria : Inclusion: All patient attended orthopaedic specialist clinic NLH Type of Indicator : Rate based output indicator Numerator : Number of Specialist clinic attendance at NLH (current year) Denominator : Number of Specialist clinic attendance at NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
11 | P a g e 6. DEPARTMENT : SURGERY Indicator 1 : Increase number of patients seen in Specialist Clinic in NLH Service : Surgery Rationale/Objectives : To decongest specialist clinic surgical in LH Def. of Terms : NIL Criteria : Inclusion: All patient attended specialist clinic Surgery in NLH Type of Indicator : Rate based output indicator Numerator : Number of patients seen in Specialist Clinic in NLH (current year) Denominator : Number of patients seen in Specialist Clinic in NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Increase total number of Operations done in NLH Service : Surgery Rationale/Objectives : To decongest elective operation in Lead Hospital Def. of Terms : NIL Criteria : Inclusion: All elective operation performed in NLH Exclusion: Type of Indicator : Rate based output indicator Numerator : Number of operation done in NLH (current year) Denominator : Number of operation done in NLH (previous year) Formula : Numerator -denominator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
12 | P a g e Indicator 3 : Reduce Patients Waiting Time Of Surgery At Lead Hospital Service : Surgery Rationale/Objectives : To improve care of Surgical patient Def. of Terms : NIL Criteria : Inclusion: All AVF surgery and laparoscopic hernia repair done in Lead Hospital Type of Indicator : Rate based output indicator Numerator : Waiting time for AVF surgery (Month) Waiting time for Laparoscopic Hernia repair (Month) Denominator : NIL Formula : NIL Standard : < 1 month Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
13 | P a g e 7. DEPARTMENT : NEFROLOGY Indicator 2 : To achieve peritonitis rate less than 1:24 episode perpatient month in NLH 2 Service : Nephrology Rationale/Objectives : To ensure quality of CAPD/APD performed in NLH Def. of Terms : Nil Criteria : Inclusion: All CAPD/APD Peritonitis in NLH2 Exclusion: Patient on IPD Type of Indicator : Rate based outcome indicator Numerator : Stage 1 : Total number of CAPD/APD patient days at risk Stage 2 : Number of patient months Denominator : Stage 1 : 30.4 days per month Stage 2 : Number of episodes of peritonitis Calculation Stage 1 Calculation Stage 2 : Total number of CAPD/APD patient days at risk = patient month expected 30.4 days per month Number of episodes of peritonitis = episode/patient month Number of patient months Standard : Less than 1:24 episodes per month Data Collection : 1) Where : Data will be collected from CAPD Clinic/ wards in the NLH. 2) Who : Data will be collected by the CAPD Nurse and SN incharge in ward NLH 3) How frequent : Monthly data calculation. 4) Who should verify : All data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from CAPD Clinic and Nephro Ward in NLH. Indicator 1 : All New Cases will be seen in Clinic Nephrology HPM (NLH 2) within 1 month Service : Nephrology Rationale/Objectives : To reduce waiting time of new cases be seen in Nephrology Clinic in NLH Def. of Terms : All new cases referred to Nephrology Clinic NLH in current year Criteria : - Type of Indicator : Rate based output indicator Numerator : Number of new cases seen in NLH in less than 1 month Denominator : Total of new cases seen in NLH in current year Formula : Numerator x 100% Denominator Standard : More than 70% new cases seen in less than 1 month and >5% increase from previous year Data Collection : 1) Where : Data will be collected Nephrology Clinic in NLH 2) Who : Data will be collected by the appointed in charge staff of Nephrology Clinic in NLH 3) How frequent : Monthly data collection 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from date registration book for new cases in Nephrology Clinic NLH
14 | P a g e 8. DEPARTMENT : PAEDIATRIC Indicator 1 : Increase number of patients see in Specialist Clinic NLH 1 Service : Paediatric Rationale/Objectives : To reduce congestion of cases in LH clinic Def. of Terms : NIL Criteria : Inclusion : All paediatric patient attended Paediatric specialist clinic in NLH 1 Type of Indicator : Rate based output indicator Numerator : Number of patients see in Specialist Clinic NLH 1 (current year) Denominator : Number of patients see in Specialist Clinic NLH 1 (previous year) Formula : Numerator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : yearly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 2 : Increase in Bed Occupancy Rate of Paediatric ward in NLH 1 Service : Paediatric Rationale/Objectives : To reduce congestion of cases in LH paediatric ward Def. of Terms : NIL Criteria : NIL Type of Indicator : Rate based output indicator Numerator : Number of inpatient day in a year Denominator : Total number of beds (paediatric) x 365 days Formula : Numerator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : yearly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.
15 | P a g e 9. DEPARTMENT : ORL Indicator 3 : Increase number of patients see in Specialist Clinic NLH 2 Service : Paediatric Rationale/Objectives : To reduce congestion of cases in LH clinic Def. of Terms : NIL Criteria : Inclusion : All paediatric patient attended Paediatric specialist clinic in NLH 2 Type of Indicator : Rate based output indicator Numerator : Number of patients see in Specialist Clinic NLH 2 (current year) Denominator : Number of patients see in Specialist Clinic NLH 2 (previous year) Formula : Numerator x 100% Denominator Standard : ≥5% from previous year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : yearly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH. Indicator 1 : Percentage of elective tonsillectomy from HRPZII done at NLH 1 Service : ORL Rationale/Objectives : To decongest elective operation (tonsillectomy) from HRPZ II to NLH Def. of Terms : Nil Criteria : Inclusion: All elective tonsillectomy done at NLH Type of Indicator : Rate based output indicator Numerator : Elective tonsillectomy from HRPZII done at NLH 1 Denominator : Total number of Elective tonsillectomy performed in LH and NLH Formula : Numerator x 100% Denominator Standard : 5% per year Data Collection : 1) Where : Data will be collected from respective wards in the NLH. 2) Who : Data will be collected by the NLH Coordinator. 3) How frequent : Monthly data collection. 4) Who should verify : All performance data must be verified by HOD/ NLH Director. 5) How to collect : Data will be collected from the appointed in charge staff from NLH.