KPJ Healthcare Berhad - Annual Report 2018

OUR BUSINESS & STRATEGY OUR PERFORMANCE AND OUTLOOK OUR RESULTS OUR GOVERNANCE APPENDICES ABOUT THIS REPORT 143 KPJ HEALTHCARE BERHAD www.kpjhealth.com.my • Joint Commission International (JCI) Accreditation In 2018, KPJ Ampang Puteri (3 rd cycle, 6 th Edition standards) received JCI re-certification for a further three years. • Clinical Survey 2018 The survey evaluates the compliance to Ministry of Health standards/guidelines, MSQH and JCI standards, Malaysian Medical Council (MMC) Guidelines and KPJ Governing Policies. In 2018, 24 KPJ hospitals (19 accredited and five (5) non- accredited) were surveyed in 14 service areas, with an average result of 92%. NO. SERVICE AREAS SURVEYED 1. Prevention and Control of Infection (PCI) 2. Haemodialysis Service (HD) 3. Central Sterilizing Supply Service (CSSS) 4. Paediatric/Nursery Service 5. Accident and Emergency Service (A&E) 6. Endoscopic Service 7. Intensive Care/Neonatal/Cardiac Intensive Care Service (ICU/NICU/CICU) 8. Labour Room/Maternity Service 9. Hospital Wide 10. General Ward Service 11. Operating Theatre Service (OT) 12. Pharmacy Service 13. Food and Dietetic Service 14. Medical Records Average Percentage: 92% • Survey on Management of Intravenous (IV) Therapy Intravenous therapy is treatment that infuses intravenous solutions, medications, blood, or blood products directly into a vein. Approximately 80% of all patients in the hospital setting will receive intravenous therapy. KPJ Nursing Service acknowledges the increasing importance of use of evidence in nursing care standards for patients receiving infusion therapies to enable sustainable improvements in quality and safety of patient care. Based on third party audit findings that was conducted among several KPJ Hospitals, IV Care Bundle guideline was developed, IV monitoring tools were standardised and the option of using vein viewers were discussed. MEDICAL ADVISORY COMMITTEES REPORT • Asia Pacific Hand Hygiene Excellence Award In 2016 KPJ Tawakkal, KPJ Selangor and KPJ Kajang attempted to achieve the Asia Pacific Hand Hygiene Excellence Award (APHHEA) and KPJ Tawakkal was shortlisted as a finalist. The survey findings showed that KPJ Hospitals already adhere to Ministry of Health and World Health Organisation (WHO) standards and guidelines. From the survey standards some best practices were identified for implementation at KPJ Hospitals. These have been implemented at various levels at the hospitals in 2018: - Using hand rub product from one supplier to prevent chemical interaction, gel form are preferred as it has moisturizing properties and prevent splashes; - Use of apps for hand hygiene audit using smart phone; - Enhance effective hand hygiene audit by giving infection control link nurses “protected time” and hand hygiene audit is announced before commencement of the audit; - Involve patient in hand hygiene activities to ensure healthcare providers compliance by displaying information to educate patients to question healthcare providers whether hand hygiene was done prior to patient engagement; and - Ensuring the WHO guideline is accessible to the staff. Performance and Patient Outcomes Measurement of outcomes of disease course and progression, quality of clinical care being provided, success of the procedure/ interventions carried out and actual benefit perceived by the patient can be used to strongly showcase the patients’ progress and the success of treatments, the continuous monitoring of outcomes provides an opportunity for both assessing and improving quality of patients’ health and care. These are some of the reports being monitored: • Performance Outcomes Two (2) outcomes indicators that are Interventional Cardiology Procedures and Caesarean Section are being monitored this year. Next year in 2019, Nephrology, Ophthalmology and Neurology will be monitored. • Clinical Indicators The clinical indicators were reviewed and in 2018 and nine (9) indicators are being monitored.