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Medical Advisory
Committee Report
Clinical Governance is defined as “A framework through which the
organization is accountable for continually improving the quality of
their services and safe guarding 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 (Figure 1). Whereas at the individual hospital level,
the Hospital MAC under the chairmanship of the 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.
Hospital Committees
Hospital Medical Advisory Committee
Credential Privileging; Peer Reviews, Ethics &
Audit; Med Education
Infection Control
Medical Records
Morbidity & Mortality Review
Pharmacy & Therapeutics
Surgical & Medical Intervention
Blood Transfusion Committee
Figure 1: Hospital Clinical Governance Committees 2012
The Group MAC governs the following KPJ Clinical Governance
meetings for the Group, namely the Clinical Governance Policy
Committee (CGPC), Clinical Governance Action Committee (CGAC),
Clinical Risk Management Committee (CRM), Central Mortality
Review Committee (CRMC), Clinical Ethics Committee (CEC) and
Research and Development Committee (R&DC). (Figure 2)
Committees
Date of Meetings
Group Medical Advisory
Quarterly
Committee (Group MAC)
Clinical Governance Policy
Quarterly
Committee (CGPC)
Clinical Governance Action
Quarterly
Committee (CGAC)
Clinical Risk Management
Quarterly
Committee (CRMC)
Research & Development
Bi-annual
Committee (R&D)
Clinical Ethics Committee (CEC)
Quarterly
Medical Directors’ Meeting
Bi-annual
Figure 2: Frequency of Clinical Committee Meeting 2012.
Annual Report
2012
KPJ Healthcare Berhad