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Annual Report 2013
KPJ HEALTHCARE BERHAD
92
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 respective hospitals’ Quality Committee or Quality
Of cer are discussed during the various hospital meetings
and presented at the Hospital Board of Directors Meetings.
The statistics and trends are reported to the Group MAC
which meets every quarter.
Since 2002, the MAC has endorsed several quality and
safety programmes for the Group’s hospitals. The following
is the report on the various patient safety programmes
implemented for the year 2013:
i.
Patient Safety
To strengthen patient safety standards, all the KPJ
Group of Hospitals continuously monitor the six
International Patient Safety Goals (IPSG) that were
identi ed 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; and
6.
Reduce the risk of patient harm resulting from
falls.
Various safety strategic measures have been
undertaken to ensure compliance to the six IPSGs.
Clinical Survey and Compliance Of cers have been
appointed to constantly monitor the patient safety
compliance levels at their respective hospitals. The
status of compliance is reported to the Group MAC at
various clinical governance platforms and success
stories are shared amongst the Group.
Following the launch of the 13 National Patient
Safety Goals by Datuk Dr. Noor Hisham Abdullah, the
Director General of the Ministry of Health Malaysia,
the KPJ Group of Hospitals has initiated data
collection for an additional seven goals (on top of the
six IPSGs) for online submission under an initiative
titled “e-goals patient safety”.
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
which include the following certi cations: Integrated Management System
(IMS) certi cation which also includes Occupational Safety and Health (OSH)
and Environmental Management System certification; 5S which covers proper
documentation and processes; Malaysian Society for Quality in Healthcare (MSQH)
accreditation; and more recently, Joint Commission International (JCI) accreditation.
The hospitals that have received MSQH and JCI accreditation are spelt out in Figure 3:
Figure 3:
Hospitals in the KPJ Group with MSQH and JCI Accreditation
No.
Name of hospital
MSQH Accreditation
Cycle - 2013
JCI Accreditation
1.
KPJ Ampang Puteri
Specialist Hospital
Completed 5th cycle
JCI Accredited
in 2012
2.
KPJ Johor
Specialist Hospital
Completed 3rd Cycle
JCI Accredited
in 2014
3.
KPJ Ipoh
Specialist Hospital
Completed 4th cycle
-
4.
KPJ Damansara
Specialist Hospital
Completed 4th cycle
-
5.
KPJ Selangor
Specialist Hospital
Completed 3rd cycle
-
6.
KPJ Seremban
Specialist Hospital
Completed 2nd cycle
JCI Accredited
in 2012
7.
KPJ Kajang
Specialist Hospital
Completed 2nd cycle
-
8.
Kedah Medical Centre Completed 2nd cycle
-
9.
KPJ Perdana
Specialist Hospital
Completed 2nd cycle
-
10.
KPJ Penang
Specialist Hospital
Completed 2nd cycle
JCI Accredited
in 2013
11.
KPJ Tawakkal
Specialist Hospital
Completed 1st cycle
-
12 KPJ Puteri
Specialist Hospital
Completed 1st cycle
-
13 KPJ Kuantan
Specialist Hospital
Completed 1st cycle in 2014 -
14 Sentosa Medical Centre Completed 1st cycle in 2014 -
Two hospitals in the Group, namely KPJ Johor and KPJ Penang, commenced
preparations to undergo JCI accreditation in 2012. The initiative proved successful
when KPJ Penang was awarded the full three (3) years JCI accreditation in 2013 and
KPJ Johor was awarded the full three (3) years JCI accreditation in 2014.
Two Klinik Wakaf An-Nur from KPJ Ampang and KPJ Selangor were awarded MSQH
certi cation for medical clinics in 2013, while three Klinik Wakaf An-Nur, two from
KPJ Damansara and one fromKPJ Johor have been identi ed to undergo the process
for MSQH Medical Clinic certi cation in 2014.