TOR of Medical Advisory Committee
Clinical Governance is a framework through which KPJ is accountable for continuously
improving the quality of the service and safeguarding high standards of care by
creating an environment in which excellence in clinical care will flourish.
Two levels of Clinical Governance Committee are formed to discuss various clinical
issues and to initiate clinical governance activities. One is at the Group level while the
other is at the Hospital’s level. At the Group level, the Group Medical Advisory
Committee lead the other governance committees to develop and monitor clinical
governance activities for all KPJ hospitals
2. POLICY STATEMENT
Committees are to be established to develop and monitor clinical governance activities
of the KPJ Group of Hospitals. These committees will be under the purview of the
Group Medical Advisory Committee (Group MAC).
- To improve and strengthen professional self-regulation and building on principle
of performance review.
- To strengthen existing systems for quality control, based on clinical standards,
evidence based practice and lesson learnt from poor performance.
CLINICAL GOVERNANCE COMMITTEES AT GROUP LEVEL
3.1. Group Medical Advisory Committee (Group MAC)
The MAC was formed in 2002, to initiate as well as to oversee clinical governance
activities undertaken by the Group. The Chairman of MAC is an Independent NonExecutive
Director. The new Chairman, Dato’ Dr. Zaki Morad Mohamad, a Consultant
Nephrologist was appointed on 1 July 2017, replacing Dr. Yoong Fook Ngian has retired,
the Chairman since 2011.
The Management of Clinical Governance as below:
TERMS OF REFERENCE OF THE SUB COMMITTEES
3.2 Clinical Governance Policy Committee (CGPC)
The following terms of reference for CGPC:
1. Establishing policies related to good clinical practice and governance;
2. Maintaining and strengthening a framework/structure & procedures;
3. Regular reports on Clinical Governance policies to the Medical Advisory Committee
and KPJ Board;
4. KPJ Clinical Governance Policies arises from:
4.1. Quality Improvement Activities - clinical audit, quality assurance, national
confidential enquiries i.e. mortality review (peri/post-operative, maternal,
4.2. Established evidence based & best practices and assessment of new innovation
and emerging technology;
4.3. Regulatory and National/International Professional Bodies and Academies;
4.4. Analytic Reports from Incident Reports, Indicators, Complaints, etc;
4.5. Requests from the MDs, Consultants, hospital management, other staff, etc.
5. Meetings will be held quarterly i.e. every three (3) months.
3.3 Clinical Action Committee (CGAC)
The following terms of reference for CGAC:
- Monitoring progress of implementation of policies recommended by the
Medical Advisory Committee and Clinical Governance Policy Committee
(CGPC) and to identify the problems that are hindering implementation of the
- Training and development of clinical staff to support the clinical governance
- Overseeing the implementation of the Clinical Audit, Mortality review, Clinical
performance Indicators and others;
- To analyse, evaluate and monitor activities, policies and procedures that need
to be carried out with regards to ensuring quality in clinical care;
- To mobilize existing hospital committees and encourage clinician’s
participation to add more value and quality to the hospital;
- For each committee to describe the job description, function, policies and
procedures to follow with room for flexibilities in order to suit each hospital
- To work closely with Managing Director and Medical Directors to ensure
clinical committee members function and cooperate better;
- To assist Medical Directors in looking into the performance of doctors and
- Meetings will be held quarterly i.e. every three (3) months.
3.4 Clinical Risk Management Committee (CRM)
The overall objective of CRM strategy is to:
- To improve the quality of care received by our patients,
- To ensure the maintenance of a safer environment for our
patients, Healthcare providers and visitors
- To reduce the clinical risks to a minimum, and
- To enable achievement of clinical operational and strategic
- Meetings will be held quarterly i.e. every three (3) months.
3.5 Research and Development (R&D)
The overall objective of R&D strategy is to:
- To facilitate research within the KPJ Hospitals for the Clinicians or the KPJ staff
who would like to conduct research involving clinical and/or healthcare related
matters in the KPJ Hospitals.
- To facilitate research involving patient safety
- To promote integration of research and development (R&D) projects with service
- To promote the establishment of a quality assurance and improvement
programme for R&D
- To oversee the process of research governance
- Meetings will be held 2 times a year or whenever there is a need to review research proposals
3.6 Clinical Ethics Committee (CEC)
- Introduction: The concept of medical ethics has been present since the beginning of the practice of medicine. The principles of beneficence, nonmaleficience, justice and autonomy have been ingrained in every practitioner. Clinical Ethics is a development from the traditional medical ethics. They refer in general to the activity or the discipline of identifying, analyzing and resolving ethical issues arising from the patient care. To facilitate research involving patient safety
- Objective: The goals of clinical ethics service are to assist the doctor, the patient and family and the hospital management to resolve ethical issues. The outcome should lead to the best interests of the patient. To promote the establishment of a quality assurance and improvement programme for R&D
- Roles : Its role is advisory in nature and concerns ethics in clinical care. The CEC does not make decisions on behalf of the clinician nor does it act on behalf of the management to regulate clinicians. The CEC members shall undergo training in order to be able to solve of problems in a structured way
- Meetings will be held at least 3 times
3.7 Research Ethics Review Committee (RERC)
The overall objective of RERC is to:
- To review all proposals that are submitted to R&D to conduct research involving
human subjects in the KPJ Group of hospitals or the KPJ Healthcare University
College. The committee will review both scientific merit and the ethical
acceptability of the research proposal.
- All research involving human subjects should be carried out in accordance with the fundamental ethical principles of respect for persons (respect for autonomy and protection of persons with impaired or diminished autonomy), beneficence (Ethical obligation to maximize benefit and o minimize harm) and justice (to treat each person in accordance with what is morally right and proper and to give each person what is due to him or her). It should abide by the guidelines of the Malaysian ICH-GCP or any other internationally accepted guidelines such as the WHO GCP guidelines.
- Meetings will be held when review is required
All research involving human subjects should be carried out in accordance with
the fundamental ethical principles of respect for persons (respect for autonomy
and protection of persons with impaired or diminished autonomy), beneficence
(Ethical obligation to maximize benefit and o minimize harm) and justice (to treat
each person in accordance with what is morally right and proper and to give each
person what is due to him or her). It should abide by the guidelines of the
Malaysian ICH-GCP or any other internationally accepted guidelines such as the
WHO GCP guidelines.
More details about MAC can be found at CG Report pages 51 to 59 at