National Quality Indicators

Analysis

Performance showed an improving trend. At the beginning of the year it was still below the standard, then continued to improve and reached the required standard by the end of March 2026. This indicates that the continuous PDSA improvement efforts carried out by IPCN produced results.

Recommendation

Maintain staff compliance in hand hygiene implementation through consistent monitoring and evaluation by IPCN and active support from all unit coordinators.

Analysis

Performance improved during the first quarter, although it had not yet reached the established standard. Staff were still found removing PPE in ways that did not comply with the SOP.

Recommendation

Continue monitoring staff compliance in the use of PPE.

Analysis

Patient identification compliance for this quarter met the target that had been set.

Recommendation

Maintain indicator compliance and continue monitoring.

Analysis

The outpatient waiting time indicator for this quarter met the target that had been determined.

Recommendation

Maintain indicator compliance and continue monitoring.

Analysis

The elective surgery delay performance for this quarter remained above the established standard value (standard less than or equal to 5%) and showed an upward trend, indicating that improvement efforts still need to be strengthened.

Recommendation

Carry out improvement efforts by coordinating surgery scheduling with the related units.

Analysis

Performance showed an increasing trend, rising by 3%, and was already above the minimum standard set by the Ministry of Health.

Recommendation

Maintain the achievement and strive for continued improvement in the following months, or at minimum remain in line with the 80% minimum standard.

Analysis

The reporting time for critical laboratory results in the first quarter was in line with the established standard. In March 2026 there were no critical-value results, so assessment for that month was not applicable.

Recommendation

Maintain indicator performance and continue monitoring.

Analysis

National formulary compliance in the first quarter of 2026 met the target that had been determined.

Recommendation

Maintain indicator performance and continue monitoring.

Analysis

Compliance with fall-risk prevention efforts in the first quarter met the established standard.

Recommendation

Maintain the achievement and continue monitoring staff compliance in carrying out fall-risk prevention.

Analysis

The first-quarter performance trend improved, with response time exceeding the established minimum standard.

Recommendation

Maintain the achievement and continue monitoring.

Analysis

The patient satisfaction index achieved or exceeded the established minimum standard.

Recommendation

Maintain the achievement.