All hospitals have complied with the Hospital Clinical
Committee meetings as stipulated in the KPJ Medical
Professional By-Laws. The reports collected and compiled by
the hospital were discussed during the various hospital
meetings and finally presented to the Hospital Board of
Directors. Eventually, the statistics and trends were reported
to the Group MAC meeting quarterly.
In 2014, two (2) Medical Directors’ Meetings were held in April
and November. It represented an avenue for all the Medical
Directors of the hospitals in the Group to meet and discuss
issues raised by the respective clinicians in the hospitals. It
allowed the Medical Directors to share best practices for
others to emulate.
The MAC endorsed several new quality and safety programmes
for the Group. Following is the report on the various patient
safety programmes for the year 2014:
1. PREVENTION AND CONTROL OF INFECTION (PCI)
Preparedness & response towards emergence of
infectious diseases: Ebola Virus Disease (EVD)
Ebola, one of the notifiable disease listed within the
Prevention & Control of Infectious Disease (PCID) Act
1988 (Act 342) was very predominant in the news this
year with more than 8,000 deaths in the African countries
of Sierra Leone, Liberia and Guinea.
With the ease of world travel now, it was very important
to ensure that all our hospitals were prepared to identify
and manage any suspected case. It was vital that
healthcare workers apply standard precautions
consistently with all patients regardless of their diagnosis,
in all work practices.
Hospital Infection Control teams at the respective
hospitals were actively and consistently involved in
training all healthcare workers in preparedness for Ebola
by conducting campaigns for public awareness, training
on personal protective equipment (PPE), conducting Ebola
drills, and more (Figure 3).
Figure 2: Structure of Clinical Governance
KPJHB BOARD
Hospital Board
GROUP MEDICAL ADVISORY COMMITTEE
1. Clinical Governance Policy Committee (CGPC)
2. Clinical Governance Action Committee (CGAC)
3. Clinical Risk Management Committee (CRM)
4. Research & Development (R&D)
5. Clinical Ethics Committee (CEC)
Medical
Directors’
Committee
HOSPITAL MAC
(Hospital Clinical Governance
Committee)
HOSPITAL CLINICAL COMMITTEES
HOSPITAL COMMITTEES
Credentialing, Medical Audit, Ethics,
Peer Review and Medical Education
Committee
Mortality Review
Risk & OSH Management
Infection Control
Pharmacy & Therapeutics
Patient Complaints & Resolution
Medical Records
Surgical & Medical Intervention
Consultants’ Meeting
179
KPJ Healthcare Berhad annual report
2014
