Clinical Indicator
-Calculation Methods-

Calculation Methods

No Chart Denominator / Divisor Numerator / Dividend
1 Patient Satisfaction (Outpatient) Total number of outpatient customers who participated in the patient satisfaction survey. Number of outpatient customers who answered the question “How would you rate your overall hospital experience?” with “Very Satisfied” or “Somewhat Satisfied”.
2 Patient Satisfaction (Inpatient) Total number of inpatient customers who participated in the patient satisfaction survey. Number of inpatient customers who answered the question “How would you rate your overall hospital experience?” with “Very Satisfied” or “Somewhat Satisfied”.
3 Discharge Due to Death Number of patients discharged. Number of patients discharged due to death.
4 Slips and Falls Among Inpatients Total number of inpatient cases. Number of slip and fall cases reported to the Medical Care Quality Control Office.
Injury Due to Slips and Falls Among Inpatients (Level 2 or Higher) Total number of inpatient cases. Number of slip and fall cases reported to the Medical Care Quality Control Office. (Our hospital incident report level 3a or higher)
Injury Due to Slips and Falls Among Inpatients (Level 4 or Higher) Total number of inpatient cases. Number of slip and fall cases reported to the Medical Care Quality Control Office. (Incident Report level 3b or higher)
5 Incidence of Pressure Ulcers Total number of inpatient cases.
Excluding: One-day inpatient treatment and inpatient customers who already had pressure ulcers at time of admission.
Rate of new pressure ulcer development of dermis or deeper during inpatient stay among surveyed patients.
6 Referral Rate Number of patients who came for their first visit by amublance other than on holidays and nights + number of emergency patients who came for their first visit on holidays and nights) First visit by referred patients
7 Outgoing Referral Rate Number of patients who came for their first visit by amublance other than on holidays and nights + number of emergency patients who who came for their first visit on holidays and nights) Number of patients with outgoing referral
8 Utilization rate of indwelling urinary catheter Total number of hospitalized patients The total number of hospitalized patients with indwelling urethral catheters inserted.
9 Symptomatic urinary tract infection incidence Total number of days indwelling urethral catheter is inserted in hospitalized patients Total numberthat matched with the catheter-related symptomatic urinary tract infection out of the denominator
10 Response rate of ambulance and hotline Ambulance acceptance request number Number of patients who came to our hospital by ambulance
11 Administration rate of prophylactic antibiotics less than one hour before the start of surgery using specific surgical techniques Number of surgeries with specific surgical techniques Number of surgery cases in which prophylactic antibiotics has been administered within one hour prior to the start of surgery
12 Stop rate of prophylactic antibiotics administration 24 hours (48 hours for cardiac surgery) after surgery using specific surgical techniques Number of surgeries with specific surgical techniques Number of surgery cases in which prophylactic antibiotics administration was started within 24 hours after surgery (within 48 hours in case of coronary artery bypass surgery or other cardiac surgery)
13 Selection rate of appropriate prophylactic antibiotics for specific surgical techniques Number of surgeries with specific surgical techniques Number of surgeries for which appropriate prophylactic antibiotics is selected for each surgical procedure
14 Blood Sugar Control in Diabetic Patients HbA1c (NGSP) < 7.0% All outpatient customers receiving medicine to treat diabetes. Number of outpatient customers with final HbA1c (NGSP) levels less than 7.0%
15 Emergency medical care hospitalization rate less than 6 weeks after discharge
(Number of patients with unplanned hospitalization other than emergency medical hospitalization or emergency medical hospitalization)
Number of patients discharged Emergency hospitalization less than 6 weeks after discharge
(Number of patients with unplanned hospitalization other than emergency medical hospitalization or emergency medical hospitalization)
Rate of Emergency Medical Re-Admission Within Six Weeks of Discharge Number of patients discharged. Number of patients re-admitted for emergency treatment within six weeks of discharge.
16 Early Administration of Aspirin to Acute Myocardial Infarction Patients (Within 48 Hours) Number cases hospitalized for acute myocardial infarction. Number of cases from the denominator group that were given aspirin within 48 hours of admission.
17 Administration of Aspirin to Acute Myocardial Infarction Patients at Time of Discharge Number cases hospitalized for acute myocardial infarction. Number of cases from the denominator group that were given aspirin at time of discharge.
18 Administration of β-blockers to Acute Myocardial Infarction Patients at Time of Discharge Number cases hospitalized for acute myocardial infarction. Number of cases from the denominator group that were given beta blockers at time of discharge.
19 Administration of Statins to Acute Myocardial Infarction Patients at Time of Discharge Number cases hospitalized for acute myocardial infarction. Number of cases from the denominator group that were given statins at time of discharge.
20 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients Number cases hospitalized for acute myocardial infarction. Number of cases from the denominator group that were given ACE inhibitors or angiotensin II receptor inhibitors at time of discharge.
21 Administration of ACE Inhibitors or Angiotensin II Receptor Inhibitors to Acute Myocardial Infarction Patients Number cases hospitalized for acute myocardial infarction.
Only No. 21 includes cases discharged due to death in denominator
Number of cases from the denominator group that were given ACE inhibitors or angiotensin II receptor inhibitors.
22 Initial PCI implementation rate within 90 minutes of the arrival of patients suffering from myocardial infarction to the hospital. Number of PCI patients aged 18 and above Of the denominator, number of cases who underwent surgery within 90 minutes of visiting the hospital
23 Administration of Antithrombotic Treatment to Stroke Patients By 2nd Day of Onset Total number of inpatient customers age 18 or older that were diagnosed with stroke or TIA. Number of cases from the denominator group that received antithrombotic treatment by the 2nd day of onset.
24 Prescription of Antiplatelet Drugs for Stroke Patients at Time of Discharge Total number of inpatient customers age 18 or older that were diagnosed with stroke or TIA. Number of cases from the denominator group that received antiplatelet drug treatment at time of discharge.
25 Percentage of stroke patients prescribed with statin during discharge Number of cases hospitalized with cerebral infarction Of the denominator, number of cases administered with statin during discharge from the hospital
26 Prescription of Anti-Clotting Drugs to Stroke Patients Diagnosed With Atrial Fibrillation at Time of Discharge Total number of inpatient customers age 18 or older that were diagnosed with stroke or TIA in addition to atrial fibrillation. Number of cases from the denominator group that received anti-clotting drugs at time of discharge.
27 Early Implementation of Rehabilitation for Cerebral Infarction Patients During Hospitalization Total number of cases hospitalized for cerebral infarction. Number of cases from the denominator group that received cerebrovascular rehabilitation therapy within 3 days of admission.
28 Prescription of Steroid Inhaler for Asthma Patients During Hospitalization Number of asthma patients age 5 or older that were hospitalized for asthma-related reasons. Number of patients from the denominator group that were prescribed a steroid inhaler during hospitalization.
29 Prescription of Oral or IV Steroids for Pediatric Asthma Patients During Hospitalization Number of cases of asthma patients age 2 to 15 that were hospitalized for asthma-related reasons. Number of cases from the denominator group that were prescribed systemic steroids during hospitalization.
30 Integrated indices [Surgery] Total of the denominators of No. 11, 12, and 13 Total of the numerators of No. 11, 12, and 13
31 Integrated indices [Ischemic heart disease] Total of the denominators of No. 16, 17, 18, 19, 20, and 22 Total of the numerators of No. 16, 17, 18, 19, 20, and 22
32 Integrated indices [Stroke] Total of the denominators of No. 23, 24, 25, 26, and 27 Total of the numerators of No. 23, 24, 25, 26, and 27

Page back