At the individual hospital level, the
Hospital MAC, under the chairmanship
of the respective Medical Director,
facilitates the implementation and
oversees compliance of clinical
governance through various clinical sub-
committees.
All our hospitals adhere to the six
International Patient Safety Goals set by
the World Health Organisation, namely:
• Identify patients correctly
• Improve effective communication
• Imp r ove t he sa f e t y o f us i ng
medication
• Ensure correct-site, correct-procedure
and correct-patient surgery
• Improve hand hygiene to prevent
health care associated infection
• Reduce the risk of patient harm
resulting from falls
Hospital Safety Standards
In recognition of our high medical
standards, KPJ holds a range of
certifications from prestigious medical
bodies including the Malaysian Society
for Quality in Healthcare (“MSQH”) and
Joint Commission International (“JCI”).
As at March 2016, 16 KPJ hospitals
have been accredited by MSQH and four
hold JCI accreditation. We also hold the
I n t eg r a t ed Managemen t Sy s t em
certification and 5S which covers proper
documentation and processes.
Clinical Policies
Ensuring patient safety and the adherence
to best clinical practices are an integral
part of KPJ’s corporate culture, and are
continuously safeguarded by our clinical
governance framework.
The Group Medical Advisory Committee
(“MAC”) develops and monitors clinical
governance activities and guidelines and
oversees a range of Clinical Governance
Committees, including the Clinical
Governance Policy Committee, the
Clinical Governance Action Committee,
the Clinical Risk Management Committee,
the Central Mortality Review Committee,
the Clinical Ethics Committee and the
Research and Development Committee.
As at 31 March 2016,
16 KPJ hospitals
have been accredited by MSQH and
four hold JCI accreditation
Annual Report
2015
KPJ Healthcare Berhad
149
5S programme
Hari Mekar 2015
