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Statement On Internal Control
(Pursuant to Paragraph 15.27(b) of the Bursa Malaysia Listing Requirements)
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The Executive Directors and the Chief Executive Officer (CEO) or
the General Managers are assisted by the Medical Directors in
relation to clinical issues in the hospitals. At the Corporate level, the
Group is assisted by the Medical Advisory Committee and Clinical
Governance Committee on matters pertaining to clinical matters.
ASSIGNMENT OF AUTHORITY AND RESPONSIBILITY
The Board assigns authority and responsibility mainly to the
Executive Committee (EXCO) to manage operation as well as
strategic issues pertaining to the delivery of services and future
direction of the Group. Major purchases are discussed and
deliberated by the EXCO before they are tabled at the respective
hospital’s Board meetings. The objective is to ensure Group synergy,
standardization and bulk discounts.
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 and medical
supplies purchased.
RISK ASSESSMENT FRAMEWORK AND PROCESS
Company-Wide Objectives
The Board has established an organizational structure with clearly
defined lines of accountability and responsibility to support control
environment. Audit Committee responsibility has been expanded to
include the assessment of internal control.
As a healthcare provider, the Board has entrusted the Clinical Risk
Management Committee to review and oversee the effectiveness
of the clinical risk management framework for patient safety.
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 objectives and report to their respective Board.
The Group focused its Risk Management activities on identifying
and assessing business risks, incident reporting, root cause
analysis, implementing 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, which
are updated regularly to ensure relevance and compliance with the
current and applicable laws and regulations. These policies and
procedures help to ensure management directives are carried out
and necessary actions are taken to address and minimize risks
and to ensure the continuity of business functions in the event of
crisis.
Regular fire drills at our hospitals and companies ranging from
basic fire safety to mass evacuation drills are conducted with the
assistance from the Fire Department. The objective is to ensure
all employees are well prepared and familiar with our emergency
response and crisis management plans.
SEGREGATION OF DUTIES
The delegation of responsibilities to the Board, the Management
and Operating Units are clearly defined and authority limits are
strictly enforced and reviewed regularly. Different authority limits
are set for different categories of managers for the procurement
of capital expenditure, awarding tenders, donations and approving
of general and operational expenses.. 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.
Annual Report
2012
KPJ Healthcare Berhad