The Group adopts the COSO Internal Control Framework to
ensure an appropriate and sound system of internal controls
are in place, which encompasses five inter-related
components, namely the Control Environment, Risk
Assessment Framework, Control Activities, Information and
Communication and Continuous Monitoring process.
CONTROL ENVIRONMENT
Integrity and Ethical Values
The Management is committed to promote ethical behaviour
culture in employees and medical consultants. At the annual
staff assembly called
“Pedoman” (Perhimpunan, Dialog dan
Anugerah Tahunan Anggota Pekerja)
, all employees and medical
consultants were reminded of the five (5) Core Values adopted
by the Group, which are Safety, Courtesy, Integrity,
Professionalism and Continuous Improvement. Employees are
expected to be transparent in their conduct to promote high
ethical values and reaffirm their commitment to the Group
through the Staff Integrity Pledge ceremony.
In addition, the Group also encouraged employees to report
directly to the Managing Director of any misconduct or
unethical behaviour committed by any staff of the Group
through the annual
Borang Peradaban
declaration.
To complement this expectation, the Group also has in place a
comprehensive Whistle-Blowing Policy that outlines the
Group’s commitment to promote the highest standards of
governance, ethics and integrity in all aspects of business
dealings. The Policy covers, inter-alia, three (3) tiers of
whistle-blowing reporting line, comprising of the Managing
Director, the Chairman of the Audit Committee or the
Chairman of the Board, to facilitate whistle-blowing activities
according to different possible circumstances. In order to
encourage a conducive environment for effective whistle-
blowing, the Policy also provides assurances on the
preservation of identity, confidentiality of information and
protection of whistle-blowers from possible retaliation.
The Group is also a signatory to the “Malaysian Corporate
Integrity Pledge” since 2011, introduced by the Malaysian
Institute of Integrity (MII) in support of the Government efforts
to combat corruption and unethical practices.
In July 2014, the Group implemented the “No Gifts and
Entertainment” policy, outlining to staff the principles and
guidelines in relation to gifts and entertainment, to uphold
ethical and responsible behaviour by all its employees. The
purpose of this policy is to avoid any conflict of interests or
the appearance of conflict of interests in ongoing or potential
business dealings in the Group.
Organisation Structure
The President/Managing Director is assisted by five (5) Vice
Presidents for the following functions:
• Business Operations and Clinical Services;
• Corporate and Finance Services;
• Project Management and Biomedical Services;
• Business Development; and
• Talent Management.
All the hospitals within the Group have been clustered into five
(5) zones, whereby one hospital at each cluster will act as the
control hub of the other hospitals within the cluster. Each
cluster is headed by an Executive Director who oversees and
controls all these hospitals’ operations.
At the hospital level, the Executive Directors and the Chief
Executive Officers (CEO) or the General Managers are assisted
by the Medical Directors who oversee all clinical governance 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.
Control
Environment
Risk Assessment
Framework
Control
Activities
Information &
Communication
Continuous
Monitoring Process
5 Interrelated components of COSO
Internal Control Framework
169
KPJ Healthcare Berhad annual report
2014
