Page 84 - ar2010

82 KPJ Healthcare Berhad

(Company No. 247079 M)

Annual Report 2010

RISK ASSESSMENT FRAMEWORK AND PROCESS

Company-Wide Objectives

Enterprise-Wide Risk Management has been implemented across the Group through Risk Coordinators, appointed at each hospital to co-ordinate and monitor the implementation of risk management activities. All hospitals and companies are encouraged to identify and mitigate relevant risks that may affect the achievement of the Group’s Key Performance Indicators and report to their respective Board.

The Group focused its Risk Management activities on incident reporting, root cause analysis, developing and adopting the Seven Patient Safety Goals of the World Health Organization and monitoring activities that depart from best practices. This is to ensure that every incident is investigated and root cause identifed to prevent future recurrence and ensure patient safety is given top priority.

The Seven Patient Safety Goals fully implemented in the year 2010:- 1. Identify Patient Correctly

2. Improve the Effectiveness of Communication among Caregivers

3. Improve the Safety of Using Medication

4. Accurately and Completely Reconcile Medication across the Continuum of Care

5. Ensure Correct-Site, Correct-Procedure, Correct Patient Surgery

6. Improve Hand Hygiene to Prevent Health Care-Associated Infection

7. Reduce the Risk of Patient Harm Resulting from Falls

The Management is going to conduct audit for the above to ensure compliance.

CONTROL ACTIVITIES

Policies and Procedures

Policies and procedures are documented comprehensively in the Malaysian Society for Quality in Healthcare (MSQH) accreditation standards as well as the MS ISO 9001:2000 standard operating procedure manuals, which are updated from time to time. These policies and procedures help to ensure management directives are carried out and necessary actions are taken to address and minimize risks. All hospitals in the Group are targeted to obtain the MSQH Accreditation certifcation.

KPJ Seremban Specialist Hospital obtained the 1st cycle of three (3) years MSQH Accreditation Certifcation in 2009 whereas KPJ Perdana Specialist Hospital, KPJ Kajang Specialist Hospital and Kedah Medical Centre obtained their certifcation in 2010. KPJ Penang Specialist Hospital has been surveyed for the 1st cycle in October 2010 and the result was obtained in January 2011 that they have been awarded for the 3 years MSQH Accreditation Certifcation.

KPJ Selangor Specialist Hospital has been surveyed for the 2nd cycle in 2010. KPJ Johor Specialist Hospital has obtained the 2nd cycle of MSQH Accreditation Certifcation in 2009.

KPJ Damansara Specialist Hospital and KPJ Ipoh Specialist Hospital has been accorded the 3rd cycle of MSQH Accreditation Certifcation in 2010 whereas KPJ Ampang Puteri Specialist Hospital has been awarded the 4th cycle in 2009.

The other hospitals are certified with the MS ISO 9001:2000 certifcation and the integrated ISO certifcation.

SEGREGATION OF DUTIES

The delegation of responsibilities to the Board, the Management and Operating Units are clearly defned and authority limits are strictly enforced. Different authority limits are set for different categories of executives for the procurement of capital expenditure. Similarly, cheque signatories and authority limits are clearly defined and enforced. As a measure to curb and reduce the incident of fraud and error, duties and tasks are segregated between different members of staff especially those in fnance and purchasing services.

INFORMATION AND COMMUNICATION PROCESS

KPJ has successfully implemented the KPJ Clinical Information System (KCIS) in KPJ Penang Specialist Hospital, KPJ Johor Specialist Hospital, Puteri Specialist Hospital, KPJ Tawakkal Specialist Hospital, KPJ Ampang Puteri Specialist Hospital and KPJ Damansara Specialist Hospital. New modules introduced include the Medical Care Solution for patient management, Nursing Care Solution catering for nursing care plan and management, Pharmacy with interface to a drug database decision support system and also Picture Archiving and Communications System for the imaging department and medical records. We achieved basic operation requirements as bare minimal at the initial stage of implementation and rollout in year 2010.

In 2011, efforts are being made to further implement the KCIS targeting existing and new KPJ hospitals including KPJ Ipoh Specialist Hospital, KPJ Seremban Specialist Hospital, KPJ Klang Specialist Hospital, KPJ Kajang Specialist Hospital, KPJ Selangor Specialist Hospital and Kuantan Specialist Hospital. Ultimately all KPJ hospitals within the Group would be connected to the same system. By implementing and utilizing this system, all patient activities from the point of registration until discharge will be recorded electronically. The system also captures follow-up information and future requests for services and facilities in the hospitals.

STATEMENT ON

INTERNAL CONTROL

(Pursuant to Paragraph 15.27(b) of the Bursa Malaysia Listing Requirements)