Table 2

Indicator definitions, data collection methods and proposed targets

MeasureDomain coveredData collectionDefinitionTarget
Data source: Hospital administrative data
Morbidity and mortality conferenceSafe structureRetrospectiveMorbidity and mortality meeting conducted, documented as conductedMinimum of 9 per year
POMRSafe outcomeRetrospective from patient chartsTotal number of inhospital deaths of patients who underwent a surgical procedure during the same admission over the total number of surgical procedures performed in the same time period1%–2%
Readmission rate within 30 daysEffective outcomeRetrospective from patient chartsPercentage of patients who had a readmission to the study site within 30 days of their surgery<10%
Data source: OR logbook
ProceduredensityEffective processRetrospectiveNumber of surgical cases performed in the OR/population of catchment area 100 0005000 cases/100 000 population
Daily OR usageEfficient processRetrospectiveTotal usage/total available time across all OR. Usage was estimated from entry to exit of patient to the OR plus 30 min of turnover time. Availability was defined as time between start of the first case and end of the last case of the day, 7 days a week85%
Data source: Modified intraoperative checklist delivered by researcher
Safe surgery checklist useSafe processProspectiveProportion of surgical cases performed in the OR as per full WHO safe surgery checklist. Specific use of pulse oximetry, patient name band and intraoperative antibiotics100%
Use of consentPatient-centred processProspectiveProportion of cases performed in the OR with signed informed consent, paperwork or documentation that informed consent was obtained or unable to be obtained due to patient condition100%
Hours from ED arrival to non-elective abdominal surgeryTimely processProspectiveMean (time of incision − time of arrival in ED) for non-elective abdominal cases<24 hours
Fully qualified surgeon presentEffective structureProspectivePer cent of surgeries performed with an attending surgeon present100%
Data source: Patient discharge survey delivered by researcher
Patient hospital satisfaction questionnairePatient-centred outcomeProspectiveMean total score on HCAHPS survey‘Top box response rate’ 70% across all fields
Travel time to hospitalTimely structureProspectiveProportion of patients reporting having travelled <2 hours to reach the hospital80%
Follow-up planTimely outcomeProspectiveProportion of patients answering yes to ‘Have you received instructions on how you will receive continuing care?’100%
Mean income compared with mean catchment income (or GDP/capita)Equitable structureProspectiveMean income determined on patient exit interview/mean income of catchment population or GDP per capita≤1
Proportion of patients experiencing catastrophic expenditureEquitable outcomeProspectiveProportion of patients where sum of total self-reported expenditure/self-reported income is >40%0%
  • ED, emergency department; GDP, gross domestic product; HCAHPS, Hospital Consumer Assessment of Healthcare Providers and Systems; OR, operating room; POMR, perioperative mortality rate.