KPJ defines clinical governance as: “A framework through
which organisations are 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 flourish.” This definition is intended to
embody three key attributes: recognisably high standards of
care; transparent responsibility and accountability for those
standards, and a constant dynamic of improvement.
There are seven (7) areas of activity that are used to make
sure we deliver the highest quality health care to our service
users as shown below.
Figure 1: The 7 Pillars of Clinical Governance
Clinical Governance is about the quality and
safety of patient care. Patient safety, health
and satisfaction underlines everything we do
as an organisation, to maintain high
standards of clinical care. This includes the
management of resources, clinical and
self-governance.
Enhancing Our Clinical
Governance Framework
At KPJ hospitals’, overall responsibility for clinical governance
lies with the Medical Director. However, clinical governance is
the responsibility of every member of the staff, including
doctors, nurses, physiotherapists, radiographers, laboratory
staff, cleaners, porters and administrative staff. Everyone
works together to ensure that patients receive the best
possible care.
At Group level, the Group Medical Advisory Committee (MAC)
develops and monitors clinical governance activities and
guidelines for the Group (Figure 2). 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;
Surgical Medical Intervention Committee and other hospital
Committees.
AWARENESS TEAMWORK COMMUNICATION OWNERSHIP LEADERSHIP
PATIENT – PROFESSIONAL PARTNERSHIP
Patient & carer
experience and public
involvement;
Risk management;
Clinical audit;
Staffing and staff
management;
Education, training
and continuing
professional development;
Clinical evidence based
care and effectiveness;
and
Clinical information or
communication
effectiveness
178
KPJ Healthcare Berhad annual report
2014
Medical Advisory Committee
(MAC) Report
