Update EDUCATOR ENABLER EVALUATOR VOL.18 NO. 18/2015

TM Celebrate Update EDUCATOR ENABLER EVALUATOR VOL.18 NO. 18/2015 YEARS OF MSQH HOSPITAL ACCREDITATION PROGRAM What s Inside? President s Message... CEO s Message... Calendar of Activities 2014... H ighlights Perfor ance Measurement and Specific Indicators - MSQH Hospital Accreditation Standards 4th Edition... MSQH Elect onic Hospital Accreditation Prog am (My e-hap) Update... MSQH Chronic Dialysis Accreditation Training Prog am... 16th Annual General Meeting... 10th MSQH Sur eyor s Training... Healthcare Associated Infection Training... Elect ical Safet (EST) for Biomedical Equipment... Waste Management Training... APHM 22nd Inter ational Conference and Exhibition 2014... Taiwan Joint Conference in Health Care and ASQua s Annual Conference 2014... Seminar Navigating the Convergence of Clinical and Infor ation Tecnolog : Benefits and Risks to Patients... MSQH Chief Sur eyor s Update... MSQH Sur eyor s Update for Engineers... Calendar of Activities 2015... Cour esy visit from Triona For ne, Deput Chief Executive Officer of ISQua to the MSQH... Par icipation in World Health Day For m... Patient Safety News National Healthcare Leaders Summit on Patients for Patient Safet Malaysia... Post Healthcare Leaders Summit: Seminar on Medical Device Adverse Event Investigation and Management for Healthcare Leaders... Capacit Development Consultation to Improve Patient Safet in the Wester Pacific Region... 2nd Incount WHO Workshop: Patients for Patient Safet... Hospital Accreditation Award Ceremony and Ex erience Sharing: Mahkota Medical Cent e... Hospital Tengku Ampuan Jemaah... Chronic Dialysis Accreditation News Davita Seri Setia Dialysis Cent e, Kuala Lumpur... MSQH Standards for Chronic Dialysis Treat ent... List of Clinics with cur ent Accreditation Stat s... List of Dialysis Cent es with cur ent Accreditation stat s... New Staffs of MSQH... ISQua Fellowship... List of hospitals with cur ent accreditation stat s... 02 03 04 06 06 06 07 07 07 08 08 08 09 10 11 11 12 13 13 14 16 16 17 19 20 21 22 22 22 23 23 24 Hospital Award Ceremony Mahkota Medical Centre Highlights National Healthcare Leaders Summit on Patients for Patient Safety Malaysia Page 14 Page 17 Hospital Tengku Ampuan Jemaah, Sabak Bernam Page 19 Page 20

Commitee Members 2015-2016 ADVISOR YBhg. Tan Sri Dato Dr. Abu Bakar Suleiman Vice-Chancellor and President of International Medical University PRESIDENT YBhg Datin Paduka Siti Sa diah Sheikh Bakir Director and Corporate Advisor, KPJ Healthcare Berhad DEPUTY PRESIDENT YBhg Puan Sri Datuk Dr Suraiya Hani Hussein Consultant Dermatologist, KPJ Damansara Specialist Hospital VICE PRESIDENT Ministry of Health, Malaysia YBhg Dato Dr. Hj. Azman Abu Bakar Director Medical Development Division, Ministry of Health, Malaysia VICE PRESIDENT Association of Private Hospitals of Malaysia Mr Anwar Anis Chief Executive Officer, Pantai Hospital Kuala Lumpur VICE PRESIDENT Malaysian Medical Association Dr H Krishna Kumar President, Malaysian Medical Association CHIEF EXECUTIVE OFFICER Assoc. Prof. Dr. M.A Kadar Marikar Chief Executive Officer, Malaysian Society for Quality in Health TREASURER Pn. Norhaizam Mohammad Senior Manager Group Finance, KPJ Healthcare Berhad COMMITTEE MEMBERS Dr. Milton Lum Siew Wah Consultant Obstetrician & Gynaecologist Alpha Specialist Centre, Petaling Jaya, Selangor. YBhg Professor Dato Dr. Ravindran Jegasothy Dean Faculty of Medicine, MAHSA University Dr. Yoong Fook Ngian ENT Surgeon, KPJ Ipoh Specialist Hospital EX OFFICIO Datuk Fadilah Baharin Director General, STANDARDS MALAYSIA Mr Manvir Jesudasan Chairman, Patients for Patient Safety Malaysia President s In conjunction with the MSQH 15th Anniversary, I welcome all MSQH members, Committee members, surveyors, councilors, partners, vendors and members of the public together to capture the journey of MSQH through this Special Edition of MSQH newsletter. Since its inception in 1997, MSQH has grown to achieve many milestones and has raised the bar of healthcare quality and safety in Malaysia as the nation s lead accrediting organization, recognized locally and internationally. We are extremely proud to have successfully hosted the 2nd Patient for Patient Safety Malaysia (PFPSM) workshop on 29th and 30th September 2014 where the PFPSM is the first in the world to have used the WHO Guide for Patients Training and Orientation to encourage patient engagement in the Malaysian public and private hospitals in ensuring patient safety. The establishment of PFPSM has created positive engagement and partnerships between patients and families, healthcare professionals, healthcare leaders and policy makers towards achieving Patients for Patient Safety mission and goals. As Patient Safety becomes an increasingly major concern in healthcare, the need for the accreditation of hospitals, medical clinics and dialysis centres has multiplied as the years go by. This is evident as patient safety has been incorporated and formed as an important standard in the MSQH Accreditation Standards for Hospitals, Medical Clinics and Chronic Dialysis Centres. MSQH has currently surveyed a total of 157 Malaysian hospitals, 8 medical clinics and 2 dialysis centers. The number of international visitors to MSQH have also increased over time from various countries namely Bhutan, Indonesia, Bangladesh, Mongolia, etc. This year, MSQH aims to work on its Strategic Plan for 2015-2020 with the participation of Committee Members, Councilors, Chief Surveyors and Surveyors which is expected to be tabled later as a guide for MSQH continued growth from the current year through 2020. It is anticipated that the strategic plan will be facilitated by Mr Len Payne, who is a WHO international consultant. In line with our vision, it is important that the strategic plan builds on the Society s sound reputation and continues to lead as a world-class establishment in advocating quality and safety in healthcare. MSQH will continuously engage with international professional organisations by contributing its expertise in healthcare and accreditation programs. This is evident where MSQH is represented as a council member in the International Society for Quality in Health Care (ISQua), Asian Society for Quality in Health Care (ASQua), World Health Organisation Expert Panel and WHO Western Pacific Region (WPRO). MSQH has successfully established strategic partnership with BMJ, ASQua and ECRI Institute for its educational programs to promote quality and safety namely through conferences & exhibition. I am delighted to invite all of you to actively contribute to MSQH as this contributes to the Society s success. Please also participate in activities to support its peer review process particularly in standards development and improvement in the number of surveyors pool. On behalf of the MSQH Committee, I am also pleased to welcome our new members to the Society and heartfelt appreciation to our existing members who had dedicated many years of support and actively involved in MSQH programmes all this while. It is very rewarding to know that many of our members continuously want to make a difference in providing safe and quality care to our patients. Thank you everyone! Happy reading! Datin Paduka Siti Sa diah Sheikh Bakir President Malaysian Society for Quality in Heatlh (MSQH) MESSAGE 2 MSQH UPDATE VOL 18

CEO s Message A NON-PROFIT PROFESSIONAL ORGANISATION ROS 470 People are often at their most vulnerable phase when they are accessing healthcare. They put their trust in the hands of the clinical staff caring for them. But how do they know they will be safe? Over the last decade we have seen significant progress made in addressing the major problem of patient safety across the Malaysian Healthcare. There have been great progress in some specific areas, for example reducing hospital-acquired infections. However, progress has been slower than might have been hoped. The Patient Safety movement has recognised that we need new approaches to ensure people will receive the same high standard of care and safety wherever and whenever they access healthcare services. We need to make healthcare systems more reliable. Those working to improve Patient Safety need to address the complexities of system issues and human factors. By taking a systems approach, healthcare staff can start to define which parts of the clinical process might be compromising safe care. They need to look at all steps along the care pathway, finding potential risks for safety and identifying how improvements can be made. This means focusing on the clinical care of the patient, but also on the systems that support clinical care, such as supply of equipment, access to test results or transfer of clinical information. Engaging clinicians, building the necessary skills and leadership and allowing enough time and resources could lead to the desired excellence. We also need to be much more effective at learning from each other and identifying and sharing good practices, which is why we are now moving to the creation of the Patients for Patient Safety Movement in Malaysia. This was launched last April 2014 by the Minister of Health Malaysia, Datuk Sri Dr Subramaniam. MSQH with the Ministry of Health Malaysia in collaboration with World Health Organisation is currently working on a project to see how patient and families participation in the healthcare system could further enhance safer care for all patients. It is sincerely hoped that these participating hospitals can enlighten and provide innovative ways in saving more lives. The 7th & 8th September 2015, MSQH Conference will showcase some of the successes in this Patient for Patient Safety Malaysia initiatives. If successful this will also be highlighted to the WHO Patient for Patient Safety Movements to be shared across the globe. Address B.6-1, Level 6, Menara Wisma Sejarah, 230 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia Tel : +6 03 2681 2232 Fax : +6 03 2681 3199 E Mail msqh@msqh.com.my Website www.msqh.com.my Scan these QR Codes to access MSQH Website Assoc. Prof. Dr M.A Kadar Marikar Chief Executive Officer, Malaysian Society for Quality in Health Permission MSQH 2015. All rights reserved Request for permission to reproduce or translate MSQH publications - whether for sale or for non commercial distribution - should be addressed to MSQH at the above address. 3 MSQH UPDATE VOL 18

January 13 21 27 Patient Safety Council Meeting (PSCOM) Bilik Gerakan, 4th Floor, Block E7, Putrajaya Goods and Services Tax (GST) Workshop for Healthcare Services Main Hall, 8th Floor, Block E7, Putrajaya. 2014 February 10-11 11 12 18-19 Workshop on Hospital Accreditation Program 4th Edition ISQua Accreditation Council (IAC) Teleconference Meeting Training on Performance Measurement & Specific Indicators - MSQH 4th Ed Hospital Accreditation Standards March 11 24-25 26 April 3 7 22-23 29 29 30 Workshop on Hospital Accreditation Program 4th Edition Training on Performance Measurement & Specific Indicators - MSQH 4th Ed Hospital Accreditation Standards MSQH Chronic Dialysis Accreditation Training Program Medication Error Conference 2014 Prince Hotel & Residence Kuala Lumpur National Leaders' Summit on Patients for Patient Safety Malaysia Putrajaya Marriott Hotel & Spa MSQH 16th Annual General Meeting Putrajaya Marriott Hotel & Spa Post Healthcare Leaders' Summit Seminar on Medical Device Adverse Event Investigation & Management for Healthcare Leaders Putrajaya Marriott Hotel & Spa May 6 7 8-9 20 24-25 26 27 26-30 28-29 Healthcare Associated Infection Training MSQH 10th Surveyor Training Hospital Sungai Buloh, Selangor Workshop on Hospital Accreditation Program 4th Edition Waste Management Training Electrical Safety Test (EST) for Biomedical Equipment Consultancy Visit from Ministry of Health, Bhutan MSQH Office, Kuala Lumpur Training on Professional Communication and Interpersonal Skills for Nurses 4 MSQH UPDATE VOL 18

June 3 5 5-6 11-12 16 20-22 24-25 25 26 27 APHM 22nd International Conference and Exhibition 2014 Sunway Pyramid Convention Centre, Petaling Jaya, Selangor B Braun Aesculap Academy Asia Pacific Regional Workshop on Surgical Instrument Management Care & Maintenance Traders Hotel Penang Healthcare Associated Infection Training Training on Hygiene and Sanitation (Standards 2, 20 and 21) Palm Garden Resort, Putrajaya 30th Malaysian Society of Nephrology Annual Congress Shangri-La Hotel Kuala Lumpur Malaysian Productivity Corporation (MPC) Productivity Competitiveness Conference 2014 Setia City Convention Centre Shah Alam, Selangor Electrical Safety Test (EST) for Biomedical Equipment Waste Management Training Study Visit from Ministry of Health Bangladesh MSQH Office, Kuala Lumpur 2014 August 4-8 7-8 11-13 12-14 18-20 19-20 22-24 Internal Assessor Training Pantai Hospital Kuala Lumpur B Braun Aesculap Academy Asia Pacific Regional Workshop on Surgical Instrument Management Care & Maintenance Traders Hotel Penang Kursus Pengenalan dan Aplikasi MSQH Service Standard No. 2, 3, 20 and 21 Sunway Hotel, Seberang Jaya, Penang Patient Care Malaysia Sunway Pyramid Convention Centre, Petaling Jaya, Selangor Kursus Pengenalan dan Aplikasi MSQH Service Standards No. 2, 3, 20 and 21 Tower Regency Hotel, Perak Healthcare Associated Infection Training KPJ Healthcare Conference & Exhibition 2014 Putrajaya Marriott Hotel & Spa September 8 9-10 11-12 28-29 29 October 18 November MSQH Chronic Dialysis Accreditation Training Programme 10th Allied Health Scientific Conference Malaysia 2014 Berjaya Times Square, Kuala Lumpur B Braun Aesculap Academy Asia Pacific Regional Workshop on Surgical Instrument Management Care & Maintenance Traders Hotel Penang 2nd Incountry WHO Workshop Patients for Patient Safety The Everly Hotel, Putrajaya Seminar Navigating the Convergence of Clinical and Information Technology The Everly Hotel, Putrajaya Chief Surveyor s Update 15 Surveyor s Update for Engineers December 3-4 Kursus Kefahaman dan Aplikasi MSQH Hospital Service Standards No.3 Palm Garden Hotel, IOI Resort City, Putrajaya 5 MSQH UPDATE VOL 18

H H ighlights Seminar Room, Wisma Sejarah 12 Feb 2014 26 Mac 2014 PERFORMANCE MEASUREMENT AND SPECIFIC INDICATORS MSQH HOSPITAL ACCREDITATION STANDARDS 4TH EDITION 21 Jan 2014 18 Feb 2014 19 Feb 2014 11 Mar 2014 3 Apr 2014 MSQH ELECTRONIC HOSPITAL ACCREDITATION PROGRAM (MY E-HAP) UPDATE The e-hap update for hospitals were held in six (6) sessions at. The sessions began with the introduction of MSQH Electronic Hospital Accreditation System as an assessment tool. Hospitals undergoing MSQH 4th Edition Hospital Accreditation survey should complete the Self-Assessment Survey Questionnaires using MSQH Electronic Hospital Accreditation Program (My e-hap) At the end of the workshop, participants can expect to have an understanding of the functionality and features of MSQH Electronic Assessment Tools at administrator level and respondent level. Participants were able to complete all components of MSQH e-hap documentation such as how to access and select service standards, assign respondent, submit the survey questionnaires and complete the 12th & 36th month compliance report. The training program facilitators were; Puan Rozana Osman (IT Officer), Ms Noramiza Md Nasir (Sr. Technical Officer); Mohd Ridhwan Azahar (IT Assistant) and Faizul Hasnizam Hosni (Technical Officer) MSQH conducted a series of workshop on Performance Measurement and Specific Indicators MSQH Hospital Accreditation Standards 4th Edition from January to June 2014 The main objectives of this training program were to: provide the participants with training on the performance indicators incorporated under the Safety and Quality Improvement Activities of the MSQH Hospital Accreditation Standards 4th Edition. To enable healthcare facilities preparing to undergo accreditation survey to implement performance measurement to ensure continuous quality improvement and compliance to the standards. The learning outcome of the training program was to understand performance measurement and the use of specific performance indicators. The training program also assisted the participants to interpret, plan and implement the processes for monitoring specific performance indicators incorporated in the MSQH Hospital Accreditation Standards 4th edition for individual services that include data collection, monitoring, analysis, tracking and trending, evaluation of performance, action plan for improvement, implementation of action plan and re-evaluation for further improvement. The workshop was facilitated by Assoc. Prof Dr Kadar Marikar, Chief Executive Officer, MSQH and Ms Rebecca John, Project Manager, MSQH. For further information, visit our website at:- www.msqh.com.my/ehap 7 Apr 2014 8 Sep 2014 MSQH CHRONIC DIALYSIS ACCREDITATION TRAINING PROGRAM The MSQH Chronic Dialysis Accreditation Training was conducted by MSQH to provide knowledge and better understanding of Chronic Dialysis Standards and how to prepare for a successful accreditation program. MSQH Chronic Dialysis Accreditation program was designed for all facilities that provide Chronic Dialysis Services. The purpose of these standards is to ensure safe practices, patient safety and quality services at chronic haemodialysis facilities. The training provided an opportunity for participants to understand the philosophy and process for implementing the MSQH Chronic Dialysis Accreditation program. The training program also helped participants to understand and interpret the 1st Edition of MSQH Chronic Dialysis Standards for implementation in their facility. The training was conducted by Assoc. Prof. Dr Kadar Marikar (CEO, MSQH) and Dr Rosnawati Yahya (Consultant Nephrologist, Hospital Kuala Lumpur) For further information, please visit our website at:- www.msqh.com.my 6 MSQH UPDATE VOL 18

H H ighlights The 10th Surveyors Training took place at Hospital Sungai Buloh on 8th and 9th May 2014. The surveyors training program is part of MSQH Hospital Accreditation program. Grand Ballroom, Putrajaya Marriott Hotel & Spa 29 Apr 2014 MSQH ANNUAL GENERAL MEETING On 29th April 2014, 192 members attended the 16th Annual General Meeting of the Malaysian Society for Quality in Health (MSQH) at Grand Ballroom, Marriott Hotel & Spa Putrajaya. The AGM was chaired by the President, Y.Bhg Datin Paduka Siti Sa diah Sheikh Bakir The Annual General Meeting agreed fifteen (15) out of sixteen (16) of the resolutions proposed by the committee members with the required majority. MSQH SURVEYOR'S TRAINING The main objective of the training program was to train the trainee surveyors to understand the roles and functions of a surveyor and internalise the values, philosophy and principles of MSQH Accreditation program. The training also assisted the surveyors to interpret and apply the MSQH Hospital Accreditation Standards 4th Edition in the survey process. The long term expected result of the training program is to enhance surveyor skills to conduct accreditation surveys in the hospitals, prepare survey reports and make appropriate recommendations for improvement of relevant services. Seminar Room, Wisma Sejarah 6 7 May 2014 11 12 Jun 2014 19-20 Aug 2014 HEALTHCARE ASSOCIATED INFECTION TRAINING A two days training on Healthcare Associated Infection Training was conducted by MSQH to enable participants to understand the MSQH Hospital Accreditation Standards 4th Edition on prevention and control of infection and requirements for compliance. The training began with an overview of healthcare associated infections delivered by Dr Zubaidah Abd Wahab. The training also covered various topics such as preventive and control measures, surveillance studies, surgical site infection, role of HIACC and infection control team, role of ICN and link nurses, standard precaution and hand hygiene and catheter-related infection - UTI & BSI. REGISTER NOW YEARS OF MSQH HOSPITAL ACCREDITATION PROGRAM Speakers at the training consisted of 5 experts, including engineers and public health professionals from industries, universities, consulting and state and federal government agencies. Among the speakers at this training were Dr Muhammad Nazri Abdul Aziz, Dr Tuan Suhaila Tuan Soh and Assoc. Prof. Dr Kadar Marikar, CEO, MSQH. For further information, please visit our website at www.msqh.com.my 7 MSQH UPDATE VOL 18

H H ighlights Seminar Room, Wisma Sejarah 27 May 2014 25 Jun 2014 ELECTRICAL SAFETY TEST (EST) FOR BIOMEDICAL EQUIPMENT On 25 June 2014 MSQH conducted the training on Electrical Safety Test (EST) for biomedical equipment at Seminar Room, Wisma Sejarah. The training was intended to ensure that participant are conversant with the basic guidelines for EST and to provide participants with sufficient level of competence so that they will be able to work safely, efficiently and legally. Seminar Room, Wisma Sejarah 20 May 2014 26 Jun 2014 WASTE MANAGEMENT TRAINING The training on Waste Management was successfully organised by MSQH in collaboration with Advance Pact Sdn Bhd The objectives of the workshop was to meet IEC requirement and Malaysian Hospital Accreditation service standards no. 2 and 3. The training also fulfilled the standard of industries and MS2058:2009 Code of Practice for Good Engineering Maintenance Management of Active Medical Devices recommendations. These very successful series of training were conducted to meet ISO 14001 requirements and Malaysian Hospital Accreditation Service Standard No. 2 on Environmental and Safety Services. Furthermore, the training also helped participants to get better understanding on implementation in ensuring compliance to the EQA (scheduled waste) regulations 2005. The training discussions focused on mismanagement of hazardous wastes to establish best practices and safer solutions for waste disposal, one of the big problems of modern times due to the ever expanding volume and complexity of discarded domestic and industrial waste. Sunway Pyramid Convention Centre, Petaling Jaya, Selangor 3 5 Jun 2014 The APHM 22nd International Conference and Exhibition with the theme, Smart Partnerships in Managing Hospitals Building Bridges to Win was held at the Sunway Pyramid Convention Centre from 3rd to 5th June 2014. The Conference was organised by APHM with strong support from MSQH, MOH, MMA, MIDA and Asian Hospital Federation. Dr Kadar attended the conference representing MSQH. The event was declared open by YB Datuk Seri Dr Hilmi Bin Haji Yahaya, Deputy Minister of Health Malaysia. APHM 22nd International Conference and Exhibition 2014 A total number of 418 delegates attended the conference while more than 386 visitors visited the exhibition area. MSQH participated in the booth exhibition where visitors visited our booth during the conference. 8 MSQH UPDATE VOL 18