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Medical Advisory Committee Report
1. Identify Patients Correctly
2. Improve Effective Communication
3. Improve the Safety of Using Medication
4. Ensure Correct-Site, Correct-Procedure,
Correct-Patient Surgery
5. Improved Hand Hygiene to Prevent Health Care-
Associated Infection
6. Reduce the Risk of Patient Harm Resulting
from Falls
iii. WHO World Alliance on Patient Safety Challenges
Clean Care is Safe Care (2005-2006)
The WHO guidelines on hand hygiene were reviewed
and adapted for KPJ Hospitals use in 2008. Continuous
training and monitoring of hand hygiene compliance is
part of the regular activities of the hospital Infection
Control Unit.
Safe Surgery Saves Lives (2007-2008)
The “Peri-operative Check List” for KPJ was
established at the end of 2009 based on the WHO
Check List and the Ministry of Health Check List
and the pilot project was successfully carried out. In
2010 all KPJ Hospitals started implementing this and
compliance is being monitored.
Tackling Antimicrobial Resistance (2009-2010)
The Infection Control Policy and Procedure are being
reviewed and the National Antibiotic Guidelines 2008
have been adopted for use for the Group. Antibiogram
and antibiotic resistance patterns are being monitored
at hospital as well as Group level.
iv. Infection Control Program (ICP)
ICP Manpower Status for the year 2011 showed that
there are 22 Infection Control Officers / Infection Control
Nurse (ICO / ICN) in the Group. All accredited and non
accredited hospitals with more than 110 beds comply
with the regulatory requirement of having dedicated
ICOs. ICOs are being supported by a total of 199
ICNs to facilitate and implement the Infection Control
Program (ICP).
Monitoring and Surveillance on Hospital Acquired
Infection (HAI)
6 parameters are monitored currently (Table 2) and
HAI monitoring results showed significant reduction
in Surgical Site Infection (SSI) and Catheter Related
Blood Stream Infection (CRBSI) when compared to the
same period last year. Currently this surveillance study
conducted in ICU/CICU only and will be extended to
other areas of the hospital next year.
v. Incident Reporting
The Group hospitals have been reporting since
2006 using a standardized format based on the
ICPS Classification for Patient Safety recommended
by the World Health Organization (WHO). List of
incidents reported include the following: (Refer to
Table 3 for details)
Clinical Governance is defined as “A framework through
which the organization is accountable for continually
improving the quality of their services and safeguarding
high standards of care by creating an environment in which
excellence in clinical care will flourish” and the Group
is committed to continuously strive to enhance clinical
governance as the main thrust for improving the quality of
care, ensuring patient safety and developing the capacity
to maintain high standards.
At the Group level, the Group Medical Advisory Committee
(MAC) develops and monitors clinical governance activities
and guidelines for the Group. Whereas at the individual
hospital level, the Hospital MAC under the chairmanship of
the hospital Medical Director facilitates the implementation
and oversees compliance to clinical governance through
various clinical sub-committees such as the Hospital
Credentialing & Privileging, Audit & Medical Education,
Infection Control, Medical Records, Mortality Review,
Pharmacy & Therapeutics and Surgical Medical Intervention
Committees and other hospital committees.
MAC governs and functions through a number of committees,
namely the Clinical Governance Policy Committee (CGPC),
Clinical Governance Action Committee (CGAC), Clinical
Risk Management Committee (CRM), Central Credentialing
& Privileging Committee (CCPC) and Central Mortality
Review Committee (CMRC); including two new committees
started in 2010; Clinical Ethics Committee and Research &
Development Committee. (Table 1)
In KPJ’s journey to always improve quality of care and to
ensure patient safety the Group has embarked on various
programs over the years. Starting with quality improvement
certifications (ISO, OSH certifications, etc.) to look at
proper documentation & processes, followed by MSQH
accreditation and 10 hospitals have been accredited thus far
i.e. KPJ Ampang, KPJ Johor, KPJ Damansara, KPJ Ipoh, KPJ
Selangor, KPJ Seremban, KPJ Perdana, KPJ Kajang, KPJ
Penang and Kedah Medical Centre.
Numerous quality and safety programs have been
implemented from the time when the Medical Advisory
Committee began in full swing in the year 2002. The report
on the Patient Safety programs for the year 2011 follows:
i. Quality Committees & Quality Officer
All hospitals have Quality Committees and Quality
Officers. The Quality Officer collects, complies,
analyzes, monitors the statistics and trends and
reports to the Quality Committee quarterly and
all reports are presented to the Hospital Board of
Director meeting.
ii. Patient Safety Day
In year 2011 all hospitals have commenced with the KPJ
Patient Safety Goals at their hospitals with participation
of patients, visitors, consultants and all staff. KPJ
hospitals have implemented and are monitoring the 6
international Patient Safety Goals identified by WHO:
77 ANNUAL REPORT 2011