Patient Safety indicators

DOH KPI title
QI005

Rate of Perioperative Pulmonary Embolism (PE) or Deep Vein Thrombosis (DVT) 

KPI meaning 
Tracking Risk of Blood Clots After Surgery

What it means
This tracks how often patients develop dangerous blood clots after surgery.

Mair 001

Current Performance

99.89% of surgical patients stayed free of blood clots after their operation, showing our continued commitment to safe surgical care

DOH KPI title
QI029

30 day all cause unplanned readmission rate 

KPI meaning 
Unplanned Return to Hospital Within 30 Days of discharge

What it means
Shows how many patients return to the hospital for same or different complaints within 30 days of discharge

Mair 003

Current Performance

96.1% of patients did not need to return to the hospital within 30 days of discharge. A strong indicator of continued appropriate care

Hospital acquired infections

DOH KPI title
QI006

Rate of Healthcare-Associated Multidrug-Resistant Organism (MDRO) Bloodstream Infection 

KPI meaning 
Monitoring Drug-Resistant Blood Infections

What it means
Measures serious hospital infections caused by germs in blood that don't respond to common antibiotics

Mair 005

Current Performance

Our strong hygiene and infection prevention practices are protecting patients from acquiring drug-resistant infections during their hospital stay. No Cases were reported for whole year 2025

DOH KPI title
QI031

Rate of healthcare associated infection (HAI) Clostridium Difficile Infection (CDI) in all adult inpatients 

KPI meaning 
Tracking Gut Infections caused by antibiotic overuse in Hospital

What it means
Tracks gut infections usually caused by antibiotics, which can be serious

Mair 007

Current Performance

Our careful antibiotic use and hygiene measures are top notched. CDI cases are virtually eliminated. Zero cases reported over the last 2 years

Access & Timeliness of Care KPIs

DOH KPI title
WT004

Consultant or Specialist Hospital Appointment (Excluding Cancer) 

KPI meaning 
Time taken to get a Specialist Appointment

What it means
How many people get timely specialist appointments

Mair 009

Current Performance

90.1% of patients got appointments with a specialist/consultant at a time that suited them, within the approved timeline

DOH KPI title
WT003

Hospital Wait at Point of Arrival 

KPI meaning 
Time taken to Start Care After Arrival at clinic

What it means
Measures how quickly patients are attended to after arrival.

Mair 011

Current Performance

94.2% of patients visiting the Outpatient Department were seen by a doctor promptly, within regulatory approved waiting times.

DOH KPI title
WT008

Door to Doctor in ER/ UC 

KPI meaning 
Time taken to See a Doctor in Emergency/Urgent Care

What it means
Shows how fast a doctor sees you after you arrive at the Emergency Room.

Mair 013

Current Performance

89.1% of patients visiting the Emergency Department were seen by a doctor promptly, within approved waiting times

DOH KPI title
WT010

24hrs - Re attendance Rate to Emergency Department 

KPI meaning 
Return Visits to ER Within 24 Hours

What it means
Tracks how many patients return to the ER within a day, which can indicate unresolved issues.

Mair 015

Current Performance

96.2% of patients treated in our Emergency Department did not need to come back for the same problem within 72 hours

DOH KPI title
WT011

Left without being seen (LWBS) by an Emergency departments doctor 

KPI meaning 
Patients Leaving ER Before Being Seen

What it means
How many patients left the ER without being treated by a doctor.

Mair 017

Current Performance

99.98% of patients visiting our Emergency Department were seen by a doctor. Very few ever leave without care

disclaimers

(a)- All annual performance data is verified by the Department of Health.
(b)- Some data points have been standardized to ensure consistency and facilitate clear interpretation