PERANAN AKREDITASI RS DALAM

MENDUKUNG PENINGKATAN MUTU DAN

KESELAMATAN PASIEN DI MALAYSIA.
Hotel Grand Sahid Jakarta
01.09.2015.
Assoc. Prof. Dr. Kadar Marikar
Chief Executive Officer
MSQH
Outline Presentasi
1. Akreditasi: Senario Global
2. MSQH
3. Peningkatan Mutu dalam Akreditasi RS
4. Framework MSQH Standard
5. Sertificasi MSQH
6. Pemantauan dalam Process Akreditasi?
7. Expected Outcomes Proses Akreditasi?
8. Perkara2 Yang Ingin Di Capai?
9. What is found in MSQH Accredited Organisation
10. Accreditation Challenges in Malaysian Hospitals
11. Whats next for Accredited RS?
12. C0nclusion.
1.Akreditasi: Scenario global
Accreditation is an internationally recognised
evaluation process used to assess and improve the:

Quality
Efficiency and effectiveness of Healthcare Organisations
Patient safety
 Accreditation is based on the premise that adherence
to evidence based standards will produce higher
quality health care services in an increasingly safe
environment.

It is also a way to publically recognized that a

healthcare organisations has met
national/international quality standards.
Negara2 yang mempunyai Program Akreditasi RS

Countries with National Accreditation Services

Accreditation of Healthcare
An integral part of healthcare systems in over 70
countries
ISQua (International Society for Quality in
Healthcare) is the largest associated international
body that accredits national accreditation bodies
world wide
Voluntary in most countries
Later mandatory by default (due to Financing
Requirements)
Mandatory in some countries; e.g. France , Taiwan dan
Indonesia.
Accreditation of Healthcare (Contd)

Its rapid growth over the last 40 years is partially

attributed to media reporting of services inadequacies
in the quality and safety of healthcare services, and
escalating forces on Patient Safety
Healthcare Facilities & Services
Accreditation Program

Consists of periodic or cyclical assessment of

organisational and clinical practices

The measurement of their performance against pre-

established, evidence-based standards

3 to 5 year cycle
Healthcare Facilities & Services
Accreditation Program (Contd)
This is usually done through;
Self- assessments
Peer review/surveyor on site visits
Interviews by the surveyors
Careful study of administrative and clinical processes
documentation and data

The process typically culminates in the provision of

accreditation report and accreditation status
2.Overview of MSQH
Non-profit
Non-governmental
Formed 1997 (ROS)
Accredited over 142
hospitals

Enhancing
Patient Safety National
Formed through and Quality of Accreditation Body
smart partnership Care for healthcare
between public, Nationally facilities and services
private and Recognised by
professional bodies Standards Malaysia
Initiated by MoH Internationally
certified by ISQua
 Vision
The internationally recognised Malaysian
organisation for the promotion and
improvement of quality and safety in health.

Mission
Advocates and facilitate continuous quality
improvement and safety in healthcare
National Recognition
1. Ministry of Health 2006

2. Standards Malaysia 2009

International Recognition/Branding
1. ISQua Certification (2nd Cycle) 2012 - 2016
MOU with STANDARDS MALAYSIA 2009
ISQua Certification By representatif to the President of ISQua
2012
MSQH Accreditation Update
Hospital Accreditation Standards (edisi ke 4).
Medical Clinic Accreditation Standards
Chronic Dialysis Standards 1st Edition
Clinical Research Centre Standards
Dental Clinic Standards.
3.Peningkatan Mutu Dalam Akreditasi.
Improvement gradients are embedded into the
healthcare accreditation process
Improvements CQI

1st Ed 2nd Ed 3rd Ed 4th Ed

Time
Peningkatan Mutu Dalam Akreditasi
(Contd)

The standards encourage organizations to achieve particular

criteria.
Accrediting Agency/Bodies revise their standards over time so
they are based on up-to-date research and accepted best
practices (between 3 to 5 years)
Accreditation standards provide a common quality language
and common set of expectations to point the way forward.
Accreditation establishes a permanent organisational culture
of safe,quality care essential for sustaining improvement.
The effort is for your patients,not the certificate.
Peningkatan Mutu Dalam Akreditasi
(Contd)

All the above elements elicit continuous quality improvement

efforts

G
O
A
L

i. To contribute to the provision of high quality and safe

healthcare services and

ii. To improve patients health outcomes

4.Framework of MSQH Standards

STRUCTURE PROCESS OUTCOME

(What are the things (What do you do (What is the

that you have) With these things) result of what you
do with these
things that you
have)
Dimension of Quality in MSQH
Standards
Enhancing Patient Safety

Access
Appropriateness
Patient Centered
Safety
Effectiveness
Efficiency
Focus of MSQH Standards
Organization & Management
Human Resource Management and Development
Policies & Procedures
Facilities & Equipment
Quality Improvement Activities
Safety/Specific Requirements
5.Perjalan Sertificasi MSQH

Certification:
High Performance Organisation
(Safe Healthcare Facilities & Services)

Accreditation Survey:
Validation of Organisation-
Wide performance
Pre-requisite: Organisatonal
achievement in self-assessment and
CQI
Licensing (MOH)
Compliance to Private Health Care Facilities and
Services Act
1998 & Regulations 2006
Akreditasi MSQH
A voluntary process by which MSQH grants
recognition to healthcare facilities and services which
meet established national standards that require
continuous improvement in Structures, Processes and
Outcomes.
MSQH Standard Akreditasi RS 4th Edition

Organizational wide Service Standards

1.Governance, Leadership and Direction
2.Environmental and Safety Services
3.Facility and Biomedical Equipment Management and
Safety
4.Nursing Services
5.Prevention and Control of Infection
6.Patient and Family Rights
7.Health Information Management System (HIMS)
II. Service Standards
8. Emergency services
9. Clinical Services (Generic)
- Specific Requirements for Specialist Services
9A. Cardiology Services
9B. Oncology Services
10. Anesthetic Services
11. Operating Suite Services
12. Ambulatory Care Service
13. Critical Care Services (Generic) Applicable for: ICU,
CCU, NICU & PICU,
- Specific Requirements
13A Labor /Delivery Services
13B Chronic Dialysis Treatment
14. Diagnostic Imaging Services
15. Pathology Services
16. Blood Transfusion Services
17. Rehabilitation Medicine Services
- Specific Requirements
17A Allied Health Professional Services -Physiotherapy Services
17B Allied Health Professional Services - Occupational Therapy
Services
17C Allied Health Professional Services - Dietetics Services
17D Allied Health Professional Services Speech-Language
Pathology
17E Allied Health Professional Services Audiology
17F Allied Health Professional Services Optometry
18. Pharmacy Services
19. Central Sterile Supply Services
20. Housekeeping Services
21. Linen Services
22. Food Services
23. Forensic Medicine Services
23A Mortuary Services
24. Standards for General Applications
MSQH Standards
Requirements that define performance expectations
with respect to Structure, Process and Outcomes that
must be substantially in place/compliance in an
organisation to enhance patient safety and quality for
patient care.
Accreditation Standards and Performance
Measures are Complementary
Hospitals need to have
Hospital Operational Policy
Departmental Operational Policy
Medical Staff by Laws
Conformance to relevant Acts and Statutory requirements
National/International EVBS Guidelines
Measurement of Performances
Culture of Patient Safety
6. Pemantauan Dalam Proses Akreditasi
( What Aspects is Being Monitored?
6.1. Managerial Monitoring

Aspects of the following:

Procurement of routinely required supplies and
medications essential to meet patient needs
Reporting of activities as required by law and regulation
Risk management
Patient and family expectation and satisfaction
Staff expectation and satisfaction
Patient demographics and clinical diagnosis
Financial management
Prevention and control of events that jeopardize the
safety of patients, families and staff
6. What Aspects is Being Monitored? (Contd)
6.2.Clinical Monitoring

Aspects of the following:

Patient assessment
Laboratory services
Radiology and diagnostic imaging services
Surgical procedures
Antibiotic and other medication use
Use of blood and blood products
Availability, content , completeness and use of patient
records
Infection control, surveillance and reporting
Clinical research
Medication errors and near misses
6. What Aspects is Being Monitored? (Contd)
6.3.Facility and Environmental
Aspects of the following:
Compliance to Private Healthcare Facilities and Services
Act 1998 and Regulations 2006
Part X:
General Design Requirements

Accommodations for Patients

Plumbing and Water Supply

Electrical System, Emergency Light and Power

Telecommunication Device

Ventilation

Waste Disposal
6. What Aspects is Being Monitored? (Contd)
6.3.Facility and Environmental
Facility management
Maintenance management building, environmental
protection, risks management and supply service
Human resource management
Budgeting and priority setting of various maintenance
activities and service planning
Equipment
Power maintenance and calibration
Sufficient back up supply during outages
Are safe from particles
6. What Aspects is Being Monitored? (Contd)
6.3.Facility and Environmental
Special requirements
OT
Labour delivery services
Central sterilising supply services
Fire safety and safety programmes (hazardous areas)
Biomedical equipment maintenance
Ventilation and air conditioning
Water supply
Medical gases
Elevators
Building standards
Electrical systems
Sewage and sewerage treatment plan
Disaster management
6. What Aspects is Being Monitored? (Contd)
6.3.Facility and Environmental

Other Regulatory Requirements

Environmental Quality Act 1974

Occupational Safety and Health Act 1994

Electricity Supplies Act 1990

Atomic Energy Licensing Act 1984

Poison Act

Medical Device Act 2012

 WHO Patient Safety Goals Malaysian Patient Safety Goals
1 Identify patient correctly G5 To improve the accuracy of patient Identification
2 Improve effective communication G8 To improve clinical communication by implementing a critical test and
critical value program

3 Improve the safety of high-alert medications G7 To improve Medication Safety

4 Ensure correct-site, correct-procedure, correct-patient surgery G3 To implement 2nd Global Patient Safety Challenge-Safe Surgery
Saves Lives
5 Reduce the risk of healthcare associated infections. G2 To implement 1st Global Patient Safety Challenge- Clean Care is
G10 Safer Care
G12 To reduce the incidence of healthcare associated pressure ulcer
To reduce Ventilator Associated Pneumonia(VAP)

6 Reduce the risk of patient harm resulting from fall G9 To Reduce Patient Fall

Patient Safety Solutions

1 Look-Alike, Sound-Alike Medication Names G7 To improve Medication Safety
2 Patient Identification. G5 To improve the accuracy of patient Identification
3 Communication During Patient Hand-Overs. G8 To improve clinical communication by implementing a critical test and
critical value program

4 Performance of Correct Procedure at Correct Body Site. G3 To implement 2nd Global Patient Safety Challenge-Safe Surgery
Saves Lives
5 Control of Concentrated Electrolyte Solutions G7 To improve Medication Safety
6 Assuring Medication Accuracy at Transitions in Care. G7 To improve Medication Safety

7 Avoiding Catheter and Tubing Misconnections. G11 To reduce Catheter Related Blood Stream Infection(CRBSI)

8 Single Use of Injection Devices. G2 To implement 1st Global Patient Safety Challenge- Clean Care is
Safer Care
G1 To implement Clinical Governance
G13 To implement the Patient Safety Incident Reporting and Learning
System
List of Performance Indicators contd

17. REHABILITATION MEDICINE SERVICES

a)percentage of inpatients with timely establishment of an interdisciplinary
Rehabilitation Plan
b)percentage of inpatients receiving timely functional measure assessment
c)percentage of inpatients with functional measure assessment prior to cessation of
patient rehabilitation programme
d)percentage of spinal cord injury patients with tetraplegia whose length of stay for
rehabilitation was greater than four (4) months
17A. ALLIED HEALTH PROFESSIONAL SERVICES - PHYSIOTHERAPY SERVICES
a)incidence of burns sustained during delivery of electrotherapeutic modalities or
thermal agents (sentinel event)
b)percentage of patients with backache who achieved the highest level of function
within 24 visits (or 6 months period) in a single continuous episode of care
17B. ALLIED HEALTH PROFESSIONAL SERVICES - OCCUPATIONAL THERAPY SERVICES
a)percentage of stroke patients with improvement of activities of daily living (ADL)
independence after ADL intervention
b)percentage of patients restored back to their capabilities for activities of daily
living/working
17C. ALLIED HEALTH PROFESSIONAL SERVICES - DIETETICS SERVICES
a)percentage of urgent inpatient referrals (critical case) seen on time(24 hours) by the
dietitian
b)percentage of non- urgent inpatient referrals seen on time (48 hours)by the dietitian
7. Expected Outcomes of Accreditation Process
Creation of:
7.1. National Leadership
7.2. Good Governance
7.3. Good Clinical Governance
7.4. Enhancing Patient Safety through:
a. Safe structures
b. Safe working environment
c. Safe staff
d. Safe practices/process
e. Safe patient outcomes
7.1. National Leadership
Understanding the population priorities for healthcare
Aligning policy, strategy and resources to focus on
maximum overall population benefit
Engaging with managers, clinicians and patients to
mobilise for quality improvement activities building
a National Momentum on Patient Safety
Enhancing safer services and CQI
Making difficult/hard decisions for the right reason
7.2. Good Governance
Focusing on organization's purpose and outcomes for
patients and service users
Performing effectively in clearly defined functions, roles
and accountability
Promoting values for the organization and demonstrating
the values of good governance
Taking informed, transparent decisions and managing risk
effectively
Developing capacity and capability of the governing body
to be effective
Engaging stakeholders and making accountability real
7.3.Good Clinical Governance
Establish framework through which reliable, high
quality and safe services are governed, managed and
provided
Making all the ingredients of reliable healthcare
systems e.g. Credentialing and Privileging process
7.4. Enhancing Patient Safety
What is Patient Safety?

Freedom from accidental injury due to medical care

or medical error
[IOM 2000]
Medical Errors in American Hospitals:
44 000 and 98 000 deaths & > 1 000 000 injuries every year

TO ERR IS HUMAN: BUILDING A SAFER HEALTH

SYSTEM

WHO : World Alliance on Patient Safety Strategies

(2002 - 2004)

Ministry of Health Malaysia: Malaysian Patient Safety

Council (2003)/Patient Safety Goals July 2013.
Patient Safety
is a serious global public health issue
Magnitude of Problem:
Developed countries: 1 in 10 patients is harmed while receiving hospital
care.
50% of avoidable adverse events resulting in death or
disability are as a result of some surgical intervention.
Developing countries: No data but assumed to be many times higher
Risk of health care-associated infection 20 times
higher than in developed countries.
At least 50% of medical equipment in developing
countries is unusable or only partly usable.
Up to 70% of injections given with syringes or needles
reused without sterilization exposing millions of
people to infections.
Patient Safety
is a serious global public health issue (Contd)

Going to Hospital is More Dangerous Than Flying

Risk of Harm during Air Travel : 1 : 1 000 000

Risk of Harm during Healthcare : 1 : 300
Patient Safety
is a serious global public health issue (Contd)

World Health
Assembly
Resolution
WHA55.18 on
Patient Safety
[Geneva, May
2002]

World Alliance for

Patient Safety
[Washington, Oct.
2004]
Patient Safety
How to translate it to clinical practice?

PATIENTS / CONSUMERS
MUST
be engaged as partners;
its about them not about us as healthcare providers.

PATIENTS FOR PATIENTS SAFETY MALAYSIA

Country workshop; 5 & 6 September 2013
8.What MSQH Accreditation
Intends to Accomplish?
Involve patient and family in his/her care
Stimulate continuous improvement in patient care
Increase efficiency/reduce cost
Strengthen the public confidence
Improve the management of health services
Enhance staff recruitment and retention
Provide comparison of performance
Provide less government oversight
Institutionalizing the culture of safer practices
9.What is found in MSQH Accredited
Organizations.
A culture of patient rights, quality, safety and transparency
An integrated management structure
Safe providers: Qualified, Credentialed and Privileged
Staff
Lower risks and data on the risk are available and
analyzed.building a quality measurement database.
Up to date science used by medical staff
Quantifiable outcomes of care
Provide comparison with self, others and best practices
10.Accreditation Challenges in Malaysian Hospitals

Governance, Leadership & Direction

Changing medical directors impact of continuity of
implementation
More medical directors to be formally trained in Hospital
Services Management or other similar training programs
Better planning and preparation for accreditation survey
To increase the participation of senior managers and senior
clinicians in the accreditation program so as they become
champions and advocates the patient safety culture
Improve implementation and monitoring of the outsource
services. (presence of current pool of in-house engineers in
the right direction
10.Accreditation Challenges in Malaysian Hospitals
(Contd)
Human Resource
Sustaining and improving the current credentialing and
privileging processes, documentation and
implementation
Capacity building (numbers and expertise for
specialised critical care services)
Matching career development with current expertise

Policies and Procedures

Better compliance through enhancing education and
training
10.Accreditation Challenges in Malaysian Hospitals
(Contd)

Facilities and Equipment

Upgrading and renovation work should
commensurate with infrastructure and design
of hospitals
Long term planning for maintenance of the
facility infrastructure, utilities and equipments
11.Whats Next for Accredited Hospitals?

1. Becoming a high reliability hospital; HR is the

consistent performance at high levels of safety over long
periods of time.
Eg; Nuclear power, Aviation industry, Petroleum and
Chemical industries ,space flight..Where failure to
perform can mean the death of some or all of them.
BOOK by John J.Nance; 2008.
Why Hospitals Should FLY; The Ultimate Flight Plan
to Patient Safety and Quality Care.
Whats Next for Accredited Hospitals?
2.Promote and increase the online application of
targeted solution tools; To simplify process for solving
some of the most persistent quality and safety problems.
Eg. Auto pilot
3.Learn from what others have done well and adapt
the experience and best practices to the needs of
your organisation.
4. Request KARS for clarification with standards
interpretation.
5.Take advantage of available resources ; eg,
download electronic policies and plans and adapt
to your organisation.
12.Conclusion
Accreditation is the most comprehensive and powerful
tool for quality improvement and enhancing patient
safety

Accreditation has been found to be effective in many

cultures and countries with different systems

Accreditation is the appropriate answer to increasing

needs of quality and safety in a global society
 Quality is never an accident, it is always the
result of high intention, sincere effort,
intelligent direction and skillful execution it
represents the wise choice of many
alternatives
-William A. Foster

Quality may not be cheap but the return on

investment is valuable
THANK YOU
www.msqh.com.my
msqh@msqh.com.my