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Medical Advisory Committee Report
In the journey towards continuously improving the quality of care and ensuring patient safety, the Group has embarked on various quality
improvement programmes. This includes the following certifications; Integrated Management Systems (IMS) which also include Occupational
Safety and Health (OSH) and Environmental Management System certification, 5S to look at proper documentation and processes, followed by
Malaysian Society for Quality in Healthcare (MSQH) accreditation and recently the Joint Commission International (JCI) standards. (Figure 3):
No. Name of hospital
MSQH Accreditation Cycle
1.
KPJ Ampang Puteri Specialist Hospital
Completed 5th Cycle (Awarded JCI Accreditation in 2012)
2.
KPJ Johor Specialist Hospital
Completed 3rd Cycle
3.
KPJ Ipoh Specialist Hospital
Going for 4th cycle in 2013
4.
KPJ Damansara Specialist Hospital
Going for 5th cycle in 2013
5.
KPJ Selangor Specialist Hospital
Going for 3rd cycle in 2013
6.
KPJ Seremban Specialist Hospital
Going for 3rd cycle in 2013 (Awarded JCI Accreditation in 2012)
7.
KPJ Kajang Specialist Hospital
Going for 2nd cycle in 2013
8.
Kedah Medical Centre
Going for 2nd cycle in 2013
9.
KPJ Perdana Specialist Hospital
Going for 2nd cycle in 2013
10. KPJ Penang Specialist Hospital
Going for 2nd cycle in 2013
11. KPJ Puteri Specialist Hospital
1st cycle
Figure 3: Hospitals in the KPJ Group with MSQH Accreditation.
In 2011, KPJ Healthcare Berhad had identified KPJ Ampang Puteri and KPJ Seremban to be accredited for the JCI Accreditation and both
the hospitals were successfully awarded the full three (3) years JCI accreditation in 2012. Two other hospitals, KPJ Johor and KPJ Penang
have been identified to be surveyed for JCI Accreditation in the year 2013.
All hospitals have complied with the Hospital Medical Advisory Committee meetings as stipulated in the KPJ Medical Staff By-Laws. The
reports collected and compiled by the hospital’s Quality Committee or Quality Officer are discussed during the various hospital meetings
and presented to the Hospital Board of Directors Meetings. Eventually the statistics and trends are reported to the Group MAC meeting
quarterly.
The MAC has endorsed several quality and safety programmes for the hospitals in the Group since 2002. The following are the reports on
the various patient safety programmes for the year 2012:
i. Patient Safety
To strengthen the patients’ safety, all the KPJ Group of Hospitals continuously monitor the 6 International Patient Safety Goals (IPSG)
that were identified by WHO in 2004:
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. Improve Hand Hygiene to prevent Health Care Associated Infection.
6. Reduce the risk of Patient Harm Resulting from Falls.
Various safety strategic measures have been taken to ensure compliance to the IPSGs. Clinical Survey & Compliance Officers have been
appointed to constantly monitor the patient safety compliance level in their hospital. The status of compliance is reported to Group MAC
at various Clinical Governance platforms and the success stories of others are shared among the Group.
Annual Report
2012
KPJ Healthcare Berhad