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All operational matters are deliberated at the Operational
Committee, chaired by the Executive Director.
Various committees were formed to identify, evaluate, monitor
and manage the significant risks affecting the achievement of
business objectives. These committees are:
1. Medical Advisory Committee
Responsible for monitoring the ethical and good
medical practice of medical consultants.
2. Clinical Governance Committee
a. Responsible for the establishment of framework
for all the clinicians with the Group to:
i. Continuously improve service quality
ii. Ensure high standard of care
iii. Create an environment that promotes
excellence in clinical care
b. There are various sub-committees under the Clinical
Governance Committee; namely Clinical Governance
Policy Committee, Clinical Governance Action
Committee and Clinical Risk Management Committee.
3. Procurement/Tender Committee
a. Ensure that purchases of equipment and tender of
projects are made in accordance with the standard
operating procedures as well as leveraging on
bulk discounts.
b. Coordinates the standardization of equipment,
pharmaceutical items and medical supplies purchased.
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 monitors 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, 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 identified to prevent future recurrence and ensure
patient safety is given top priority.
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 9001:2008
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 certification ultimately.
For the year 2011, 11 of the hospitals in the Group have
been accredited by the MSQH Accreditation Certification
and two hospitals namely KPJ Ampang Puteri Specialist
Hospitals and KPJ Seremban Specialist Hospitals are
undergoing JCI Accreditation process.
As for the year 2012, four hospitals have been identified to
get the MSQH Accreditation certification.
Segregation of Duties
The delegation of responsibilities to the Board, the
Management and Operating Units are clearly defined 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 finance and
purchasing services.
KPJ Penang Specialist Hospital receiving the MSQH Accrediation certificate
ANNUAL REPORT 2011 66