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
s t anda r ds o f ca r e ; t r anspa r en t
responsibility and accountability for
those standards; and a constant dynamic
of improvement.
At KPJ hospitals, overall responsibility for
clinical governance lies with the hospital’s
Medical Director. However, clinical
governance is the responsibility of every
member including doctors, nurses,
phys i o t he r ap i s t s , r ad i og r aphe r s ,
laboratory staff, cleaners, porters and
administrative staff. Everyone works
together to ensure that patients receive
the best possible care.
At the Group level, the Group Medical
Advisory Committee (MAC) develops and
monitors clinical governance activities and
guidelines for the Group (Figure 1).
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;
Infection Control; Medical Records;
Mo r t a l i t y Re v i ew ; Ph a rma c y &
Therapeutics; Surgical and Medical
Intervention Committee and other hospital
Committees.
All hospitals have complied with the
Hospital Clinical Committee meetings as
stipulated in the KPJ Medical Professional
By-Laws. The reports from the Hospital
Clinical Committee meetings are
collected and compiled and discussed
during the various hospital meetings and
finally presented to the Hospital Board
of Directors. Eventually the statistics
and trends are reported to the Group
MAC meeting quarterly.
Safety is a priority at KPJ. We focus on
reconnecting quality and patient safety
with clinical care. We are committed to
a just culture of safety in which
employees are encouraged to come
forward when they or others make
mistakes, allowing us the opportunity to
improve the care we deliver and prevent
potential errors. Reducing risk and
ensuring safety requires increased
attention to systems that prevent and
mitigate errors.
MAC overseas the clinical governance
and patient safety programs at the
hospitals focusing on continuous
enhancement of safety for all patients,
visitors and employees. Every employee
plays a critical role in ensuring the
safety of the patient and visitor.
T h e KP J ho s p i t a l s ’ s u c c e s s i n
continuously improving the culture of
safety can be shown by the various
initiatives by the KPJ Hospitals. For
example, reporting to the Ministry of
Health (MOH) on the compliance to the
National Patient Safety Goals, being
accredited by national and international
accreditation bodies, Risk Management
and Incident Reporting System is in
place, complying to Infection Control
standards and many other healthcare
initiatives that are monitored nationally.
KPJ ensures that all our hospitals are
continually in compliance with the
highest level of quality care and patient
safety standards as set by the Malaysian
“At the Group
level, the
Group Medical
Advisory
Committee
(MAC)
develops and
monitors
clinical
governance
activities and
guidelines for
the Group.”
199
KPJ Healthcare Berhad
Annual Report
2015
