1. INTRODUCTION

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).

Objective

1. To improve and strengthen professional self-regulation and building on principle of performance review.
2. To strengthen existing systems for quality control, based on clinical standards, evidence based practice and lesson learnt from poor performance.

3. PROCESS

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, neonatal), etc.;
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:

1. 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 agreed policies/programs;
2. Training and development of clinical staff to support the clinical governance activities;
3. Overseeing the implementation of the Clinical Audit, Mortality review, Clinical performance Indicators and others;
4. To analyse, evaluate and monitor activities, policies and procedures that need to be carried out with regards to ensuring quality in clinical care;
5. To mobilize existing hospital committees and encourage clinician’s participation to add more value and quality to the hospital;
6. For each committee to describe the job description, function, policies and procedures to follow with room for flexibilities in order to suit each hospital
7. To work closely with Managing Director and Medical Directors to ensure clinical committee members function and cooperate better;
8. To assist Medical Directors in looking into the performance of doctors and nurses;
9. 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:

1. To improve the quality of care received by our patients,
2. To ensure the maintenance of a safer environment for our patients, Healthcare providers and visitors
3. To reduce the clinical risks to a minimum, and
4. To enable achievement of clinical operational and strategic objectives.
5. 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:

1. 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.
2. To facilitate research involving patient safety
3. To promote integration of research and development (R&D) projects with service commitment
4. To promote the establishment of a quality assurance and improvement programme for R&D
5. To oversee the process of research governance
6. Meetings will be held 2 times a year or whenever there is a need to review research proposals

3.6 Clinical Ethics Committee (CEC)

1. 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
2. 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
3. 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
4. Meetings will be held at least 3 times

3.7 Research Ethics Review Committee (RERC)

The overall objective of RERC is to:

1. 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.
2. 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.
3. 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 http://kpj.listedcompany.com/cg_report.html