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Annual Report 2013
KPJ HEALTHCARE BERHAD
91
To this end, the KPJ Group is committed to continuously enhancing
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 a Medical Director facilitates the
implementation and oversees compliance with clinical governance
through various clinical sub-committees as outlined in Figure 1:
Figure 1: Hospital Clinical Governance Committees 2013
Hospital Medical Advisory Committee
Credential Privileging; Peer Reviews, Ethics & Audit; Medical
Education
Infection Control
Medical Records
Morbidity & Mortality Review
Pharmacy & Therapeutics
Surgical & Medical Intervention
Blood Transfusion Committee
The Group MAC has oversight for several of the KPJ Group’s Clinical
Governance Committees. These include 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) as well as Research
and Development Committee (R&DC). The frequency at which these
committees meet over the course of a year is outlined in Figure 2:
Figure 2: Frequency of Clinical Committee Meeting in 2013
Committees
Frequency of
Meetings
GroupMedical Advisory Committee (GroupMAC)
Quarterly
Clinical Governance Policy Committee (CGPC)
Quarterly
Clinical Governance Action Committee (CGAC)
Quarterly
Clinical RiskManagement Committee (CRMC)
Quarterly
Research&Development Committee (R&D)
Biannual
Clinical Ethics Committee (CEC)
Quarterly
Medical Directors’ Meeting
Biannual
Medical Advisory
Committee Report
Clinical Governance is de ned as
“a framework through which the
organisation 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
ourish”.
Enhancing
Our
Clinical
Governance
Framework