WHO Patients For Patient Safety In- Country Workshop Malaysia

WHO Patients For Patient Safety In- Country Workshop Malaysia Engaging Healthcare Consumers and Healthcare Providers in Partnership to Improve Patient Safety 5-6 September 2013 The Everly Hotel, Putrajaya This workshop was undertaken jointly by the Malaysian Society for Quality in Health and Ministry of Health Malaysia in collaboration with World Health Organisation

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 2 Table of Contents Workshop Planning Committee Introduction and Acknowledgement 2 3 Planning & Organising Committee WHO Patients For Patient Safety In- Country Workshop Malaysia 5-6 SEPTEMBER 2013 Workshop Participants Global Patients for Patient Safety Champion s Message Workshop Overview Objectives and Learning Outcomes Methodology Action Plans References Appendices Workshop Agenda Workshop Application Form Participants Acceptance Form Workshop Evaluation Results 4 5 6 6 6 9 13 14 Ms Nittita Prasopa Plaizier Chairman Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Assoc Prof Dr Kadar Marikar Joint Chairman Chief Executive Officer Malaysian Society for Quality in Health (MSQH) Members Dr Nor Aishah bt Abu Bakar Deputy Director, Quality in Medical Care Section, Medical Development Division, Ministry of Health Malaysia & Technical Coordinator, Patient Safety Council Malaysia Ms Stephanie Newell WHO Global Patients for Patient Safety Champion, Australia Ms Anna Lee Patients for Patient Safety, WHO Patient Safety Programme, Geneva Dr Ken-ichiro Taneda Technical Officer (Patient Safety& Quality) Western Pacific Regional Office (WPRO), Manila Ms Rebecca John Project Manager, Malaysian Society for Quality in Health (MSQH)

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 3 Introduction And Acknowledgement The inaugural Patients for Patient Safety Malaysia in- country workshop took place from 5-6 September 2013 in the Federal Territory of Putrajaya, immediately after the Malaysian Society for Quality in Health (MSQH) annual conference which was aptly themed Engaging Patients in the Delivery of Care: Patients for Patient Safety. A group of thirteen (13) selected participants comprising patients and healthcare professionals, many of whom had experienced harm in healthcare and policy makers came together for two days to share their experiences, develop partnerships and strategies and action plans for taking patient safety forward in Malaysia. The Patients for Patient Safety workshop was a collaboration between WHO Global Patients for Patient Safety, Malaysian Society for Quality in Health (MSQH) and the Ministry of Health Malaysia. The international perspectives for the workshop came from Ms Nittita Prasopa Plaizier, Program Manager and Technical Lead Patients for Patient Safety WHO Geneva, Dr Ken-ichiro Taneda, Technical Officer (Patient Safety& Quality) Western Pacific Regional Office (WPRO), Manila and Ms Stephanie Newell WHO Global Patients for Patient Safety Champion Australia who were the main facilitators of the workshop besides members of the Organising Committee that comprised of Dr Kadar Marikar and Ms Rebecca John representing the MSQH and Dr Nor Aishah Abu Bakar, Acting Deputy Director, Quality in Medical Care Section & Technical Coordinator Patient Safety Council Malaysia, represented the Ministry of Health, Malaysia. Funding for the workshop was provided by the Malaysian Society for Quality in Health. This workshop was held to facilitate a sharing of ideas, experiences and network locally, nationally and globally on patients for patient safety as well as to provide a forum for discussion and a means to turn feelings of frustration and anger to positive action. Besides, it is also to introduce individuals to the concept of collective action and empowerment and patient engagement to achieve health care improvements. This workshop also aims at raising awareness on patient safety and the importance of patient and community engagement in health-care services and quality and safety initiatives. The idea for the Patients for Patient Safety Workshop was mooted by Dr Kadar Marikar, the Chief Executive Officer of the Malaysian Society for Quality in Health (MSQH) to compliment the implementation of the MSQH standards on Patient and Family Rights in the National Hospital Accreditation Program. Armed with this idea, the MSQH approached Ms Anna Lee from the WHO - Patients for Patient Safety Program and later Ms Nittita Prasopa Plaizier. Both were supportive of the idea and planning of the actual workshop agenda and logistics started in June 2013. To ensure that this remains a regional effort, representation from the Ministry of Health, Malaysia was sought through Dr Nor Aishah Abu Bakar while Dr Ken-ichiro Taneda Technical Officer (Patient Safety& Quality) represented the Western Pacific Regional Office (WPRO), Manila. Several skype sessions were held between the members of the planning committee until the final agenda was ready. The involvement of the key facilitators from WHO as well as Ms Stephanie Newell was central to the success of the program, and spearheaded the constructive partnership which the workshop seeks to model and inspire. During the workshop actions plans were developed in small groups guided by the facilitators who helped immensely to set the road map for Patients for Patient Safety in Malaysia. The organisers of this workshop would like to acknowledge and thank YBhg Dato Dr Azmi Shapie, Director Medical Development Division, Ministry of Health and Dr Graham Harrison, WHO Representative for Malaysia, Brunei Darulsalam and Singapore for officiating the opening of the workshop. We also appreciate and extend our special thanks to YBhg Dato Hisham bin Abdullah, Director General of Health Malaysia for officiating the closing of the workshop and taking time to engage with the participants at the end of the workshop. Thanks also to the MSQH Committee members led by YBhg Datin Paduka Siti Sa diah Sheikh Bakir, the MSQH President for supporting this program strategically and financially. Finally, we wish to thank the workshop participants who took time from their work to contribute their experiences, ideas and passion for making a difference towards engaging in patient safety. We also take this opportunity to thank the many others who played a role in organising this event. We believe that the action plans that the teams developed, the intangible collaboration, respect, teamwork and trust will go forward to make patients for patient safety truly sustainable in Malaysia. Dr Kadar Marikar Chief Executive Officer Malaysian Society for Quality in Health (MSQH) Ms Rebecca John Project Officer Malaysian Society for Quality in Health

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 4 Workshop Participants - Patients For Patient Safety, Malaysia Dato Dr Kuan Geok Lan Consultant Paediatrician Hospital Melaka Dr Heric Corray Hospital Director Queen Elizabeth Hospital Kota Kinabalu, Sabah Siti Irynn Ching Nursing Staff Pantai Hospital Ayer Keroh, Melaka Ms Rebecca John Project Manager Malaysian Society for Quality in Health Level 6, Menara Wisma Sejarah Jalan Tun Razak, Kuala Lumpur Mr Manvir Jesudasan Chief Executive Officer Soccergurus Sdn Bhd Plaza Damas Sri Hartamas, Kuala Lumpur Dr Milton Lum Obs &Gynae Consultant M-3-4 Plaza Damas, 60 Jalan Sri Hartamas 1 50480 Kuala Lumpur Dr Subramaniyam C&NI Corporation Multilevel Marketing No. 7, Jalan Gelana 7/24, Section 7 40000 Shah Alam, Selangor Ms Rose Paul Retired State Matron 268, Jalan 5/46 Petaling Garden 46000 Petaling Jaya Datin Paduka Siti Sa diah Sheikh Bakir Director & Corporate Advisor KPJ Healthcare Bhd & MSQH President Ms Daram Kaur d/o Kirpal Singh Nursing Staff (Matron) Tuanku Mirzan Armed Forces Hospital Wangsa Maju Section 2, Kuala Lumpur Assoc Prof. Dr Kadar Marikar Chief Executive Officer Malaysian Society for Quality in Health Level 6. Wisma Sejarah, Jalan Tun Razak, Kuala Lumpur Dr Nor Aishah bt Abu Bakar Deputy Acting Director, Quality in Medical Care Section, Medical Development Division Ministry of Health & Technical Coordinator Patient Safety Council, Malaysia Dr Mark Prabaharan Raman Lecturer UITM & Universiti Pertahanan Malaysia No 44, USJ 9/3 P, USJ 9 Subang Jaya, 47500 Selangor

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 5 Global Patients For Patient Safety Champion s Message The Patients for Patient Safety workshop is a cornerstone of the World Health Organization s Patients For Patient Safety program s mission of ensuring the health consumer experience leads the person-centred design and delivery of health care worldwide. The goal of partnerships between health consumers and health professionals to ensure health care is safe seeks to drive this. Since the 2005 foundational London Patients for Patient Safety workshop, 27 Patients for Patient Safety workshops have been held in individual countries and also within World Health Organization regions of the world. Malaysia, by holding her first Patients for Patient Safety workshop in September 2013, joins with the growing network of countries and individuals worldwide in the effort to advance the Patients for Patient Safety mission and goals locally and globally. The Patients for Patient Safety workshop is unique and transformational. Each workshop is a collaborative undertaking of key leaders from the host country or region, World Health Organization Patient Safety staff and Patients for Patient Safety Champions. At the Patients for Patient Safety workshop selected healthcare consumers (patients, family members and carers of patients), clinicians, health care administrators and policy makers from a country or countries within a region come together to commence planning to positively impact patient safety and reduce preventable health care harm to patients. The workshop process dissolves the unseen walls that often distance health care consumer from health professional and health policy maker and provides a safe space for participants to speak and be listened to. The bonds established and developed between workshop participants sow the seeds of partnership creation that underpins the focus of the ongoing work participants commit to beyond the workshop. I have had the privilege of being involved in a number of Patients for Patient Safety workshops including the workshop held by Malaysia. In each workshop, I have had the honour of being witness to people speaking about their experience of health care harm and the immediate and ongoing impact to them, their family and their life. I am profoundly moved by the experiences of harm that have been inflicted upon people in the course of receiving their health care and continually marvel at people s strength and resilience. A strength and resilience to not only rebuild and lead their lives but also to make a difference, to making health care better for others so that what happened to them will not be repeated and others will not have to experience what they did. The safe space of the Patients for Patient Safety workshop is often the first time participants have had the opportunity to speak about their experience. It is very telling that the very health system that we as patients trust to provide for us and keep us safe does not seek or assist our voice to be heard at the very time when it is crucial to do so. Therefore further harm is inflicted, opportunities for personal healing are thwarted and improvement and solutions for patient safety progress are never heard or seen. This is where the Patients for Patient Safety workshop is unique as it highlights and begins to address this gap in unison with partnership creation for future improvement to health care. With this knowledge the participants create robust forward action plans together to work on after the workshop. Carrying on the work initiated within the workshop was given much thought and planning by the workshop host, the Malaysian Society for Quality in Health. This support is key to the workshop actions being further developed and progressed in an ongoing and sustainable manner and all of those involved to ensure this is occurring in Malaysia are to be congratulated. It is with much pleasure and anticipation for the future I welcome our Malaysian partners to the Patients for Patient Safety community. Stephanie Newell Patients For Patient Safety Champion, Australia. February, 2014.

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 6 Workshop Overview Workshop Objectives: Introduce participants to the local health-care systems, patient or consumer networks and /or local resources relevant to healthcare quality and patient safety initiatives; Introduce individuals to the concept of collective action and empowerment and engagement to achieve health care improvements; Raise awareness about patient safety and the importance of patient and community engagement in health-care services and quality and safety initiatives; Train and orientate individuals in advocacy skills for patient safety and to promote positive engagement and partnerships between patients, health-care professionals, policymakers and health-care leaders; Facilitate the sharing of ideas, experiences and network locally, nationally and globally; Provide a forum for discussion and a means to turn feelings of frustration and anger to positive action. Expected Outcomes: Following the workshop, participants will be expected to work to: Become aware of patients roles and responsibilities in working collaboratively and/or in partnership with stakeholders on health-care quality and safety; Better understand the local and national health systems and able to identify relevant stakeholders, including the community, health-care providers and policy makers for healthcare services and improvement; Methodology Malaysia is the first country to have used the new WHO Guide for Patients for Patient Safety Training and Orientation. The WHO Application Pack and Workshop Agenda were adopted for the local workshop, whereas the Acceptance Form was modified from the Australia Patients for Patient Safety Workshop to invite applications from potential participants and make the final selection. The workshop agenda was adapted from the Canadian workshop with some modifications i.e. on the number of days and contents to suit the local scenario. Participants for the workshop were selected based on a set criteria provided by WHO (Application Pack) and they were filtered with a set of questionnaires to be answered. The participants were all qualified and are believed can bring changes and influences to Patients for Patient Safety in Malaysia. Most of the workshop participants were from Kuala Lumpur and Selangor but being conscious of our approach of working with healthcare consumers in particular patients, participants were invited from the other states in Malaysia through an announcement in the local newspaper and the MSQH website. The workshop adopted a group process methodology to get the participants to interact with their stories of harm in healthcare and examine the reasons for their participation and what they want to achieve. Past tragedies are respected and losses are acknowledged and appreciated but the focus is on what these painful experiences have produced that is positive and future oriented. This can be challenging in the patient safety context, given the traumatic impact of medical error and negative feelings of both the consumers and healthcare professionals who have experienced system failure. This process inspires change at both the group level and for the individuals participating in the group. Build positive partnerships and work collaboratively with stakeholders; Contribute to the national and global PFPS network and learning; Provide regular feedback and report activities as requested or required by the national organisation and /or WHO through established national Road Map for PFPS.

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 7 Workshop Overview AGENDA The full workshop agenda is found in the appendices section of this document. A brief description on the workshop proceedings is as follows: PRE - WORKSHOP Each person attending the workshop had to do some pre-workshop reading on patients for patient safety materials. WHO brochure on Patients for Patient Safety Partnerships for Safer Healthcare were distributed to them couple of days before the workshop and the participants were also encouraged to access WHO website on Patient Safety for more information on the subject. DAY 1 - MORNING The day started with registration activities and followed by welcome addresses by Dr Kadar Marikar, the CEO of the Malaysian Society for Quality in Health and Ms Nittita Prasopa Plaizier, Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva and introductions of participants and facilitators. The opening of the workshop was officiated by YBhg. Dato Dr Azmi bin Shapie, Director Medical Development Division, representing the Director General of Health, Malaysia and Dr Graham Harrison, WHO Representative for Malaysia, Brunei Darussalam and Singapore. Key points of their speeches dwelt on patient safety activities nationally and globally and in particular the role of the patients in enhancing patient safety. DAY 1 - AFTERNOON The afternoon provided time for all participants to share their experiences and reasons for participating in the workshop facilitated by Ms Stephanie Newell. They openly shared their experiences of harm in healthcare that had a profound impact on themselves and their families and which motivated them to come together to bring about improvements in patient safety. It was an emotional and the occasional outburst of grieve session for some. Participants also engaged in some discussion about the relative importance of accountability in making health care safer. This session brought the participants to the understanding of the WHO Patients for Patient Safety (PFPS) Global Programme as presented by Ms Nittita Prasopa Plaizier and Dr Kenichiro Taneda, Technical Officer Patient Safety, Western Pacific Regional Office (WPRO), Manila. The day concluded with an emotional viewing of video on the PFPS Workshop 2009, Australia. The first day had such an impact hearing each other s stories and there was commitment to bring improvement in healthcare in a collaborative manner to enhance patient safety. In the latter part of the morning the participants were oriented to the WHO Patient Safety and Patients for Patient Safety (PFPS) programmes as well as the global and national status of patient safety and patient engagement. Presentations included WHO Patient Safety Programme and Overview of Patient Safety Globally by Ms Nittita Prasopa and Patient Safety Nationally in Malaysia by Dr Nor Aishah Abu Bakar. The Concept of Patient Engagement was presented by Ms Stephanie Newell.

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 8 Workshop Overview DAY 2 - MORNING Part of the objectives of the 2nd day of the workshop was to introduce participants to the local health-care systems and local programs relevant to healthcare quality and patient safety initiatives. Understanding of national health systems and local policies is important for effective patient advocacy. Besides, it is also to introduce individuals to the idea of patient engagement locally to achieve health care improvements. The topic on the Malaysian Healthcare system was presented by Dr Nordin bin Salleh Deputy Director Planning and Development Division Ministry of Health Malaysia followed by Ms Nittita Prasopa Plaizier on Patient Engagement for Patient Safety. Participants also learned from the Canadian experience through the webinar presentations by Carol Kushner and Ioana Popescu who were much appreciated for creating a network and taking a PFPS group forward. In the second part of the morning session, the participants were grouped in three groups, each with a WHO facilitator and brain stormed on Goals Setting - Development of Mission, Values, Goals and Strategies. The participants forged bonds, shared vision and ideas and developed Action Plans. The small groups circulated through three topics to complete the goals setting and Action Plans. Several goals were set and divided into four stages which are short term (6th September 2013 to 31st December 2013), Medium (1-2 years), Long term (more than 3 years) and Succession Period. Goals discussed covered Establishing a PFPSM Network, Promoting Capacity Building and Communication Plan. The goals planned starts from the very beginning stage and need to be followed up and show progress from time to time in the way to ensure success of Patients for Patient Safety Malaysia (PFPSM) in the future. DAY 1 - AFTERNOON Presentations, Debriefing and Looking Forward The afternoon of the 2nd day of the workshop saw presentations on Goals setting and Action Plans by the three groups and discussion on What can we create to achieve Big Dreams? All the goals set were captured for future planning of Patients For Patient Safety Malaysia s Vision and Action Plan. The session ended with an opportunity for every participant to share their thoughts and provide feedback on their experiences during the two days workshop and personal commitment for the future. The participants also provided a written evaluation on the workshop (see appendices). The day concluded with a wrap up of the two days workshop. The closing of the workshop and presentation of certificates to the participants and facilitators was officiated by YBhg. Datuk Dr Noor Hisham Abdullah, Director General of Health Malaysia and Chairman Patient Safety Council, Malaysia who took time to engage with Day 2: 5.00 pm: Patients for Patient Safety Malaysia Workshop ended. The engagement of patients in patient safety is really important in achieving the goals set as they are free to voice out and stand up for the other patients who have no ability in being heard. A short discussion followed this on Effective Advocacy and Communication facilitated by Ms Stephanie Newell. The importance of the word ENGAGEMENT in Patients for Patient Safety became the keyword of the workshop participants to create partnership for safe healthcare.

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 9 Patients For Patient Safety Malaysia Goal Setting (Action Plan) Goal 1 : ESTABLISHING a PFPS NETWORK Short Term (6th Sept 31st Dec 2013) Medium Term (1 2 years) 2014 Long Term (3 years +) Success Period 1. Meetings discuss ideas, common goals, vision, mission, objectives volunteer as a contact person, establish Protem Committee/TOR, roles & responsibilities of members, management of conflict of interest 2. Recruit members 3. Contact person: focal/secretary Protem Committee 4. Delegation of tasks MSQH to initiate MOH to endorse/support 5. Patient led (non-healthcare) registered organization/state requirements 6. Proposal for funding 7. Sensitizing of the network Report to Patient Safety Council Malaysia (November) 1. Committee all stakeholders Recruitment Delegation 2. Funding (operational) 3. Develop action plans 4. Training and Capacity Building 5. Implement/Pilot activities through MSQH 6. Awareness raising activities 7. Patient as representative in Patient Safety Council, Malaysia & MSQH 8. Patient involvement in Patient Safety Goals 1. Finalize action plan/promotional plan 2. Implementation of action plans, resources and support 3. Patient presentation at conferences 4. PFPSM organizing patient education 5. Meaningful engagement in MOH/Hospital /Healthcare/Organization 6. Identify & enlist patron(s) 1. Network- TOR, Malaysian PFPS Committee 2. Participation in healthcare facilities and agreement selection for the pilot 3. Patient participation in facility s activities, committee 4. Evaluation/products 5. Secured Resources continuing support 6. PFPSM registered Committee with TOR & Plan 7. Structure & Governance 8. Buddying with other PFPS groups 9. Secured & continuing funding/resource Note: If MOH funded, no strings attached

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 10 Patients For Patient Safety Malaysia Goal Setting (Action Plan) Goal 2: Promoting Capacity Building Short term (Sept-Dec 2013) Structure exists/what is it? 1. Communication channel: Media: radio, TV, newspapers, advertising (posters, campaigns, web page) Health facilities Medium (1 2 years) 1. Identify other established organizations: NGO Consumers Associations MOH Schools (parents, teachers) Universities Professional associations Consumer groups 2. Identify experts Who we could invite and build to join us Patron prominence Training Identify existing programs Join PFPSM to increase their knowledge Opportunities to deliver information on the group/patient safety topics Information/ orientation / training package For potential and new members Piggy back on Corporate Social Responsibilities/activities Funding for conference attendance Local Council assistance

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 11 Patients For Patient Safety Malaysia Goal Setting (Action Plan) Goal 3: Communication Plan Short Term (Sept-Dec 2013) 1. Communication Plan 2. Contents for planning session & contributors 3. Create web page Social media Facebook/personal Press release 4. Dissemination of plan Who we are? What we do? Thanks to speakers at PFPS workshop Database 5. Assign duties to group members 6. Membership Medium Term (1 2 years) 1. Identify other established organizations 2. Identify experts/potential patron 3. Recruit information and approach strategy 4. Patient Safety Week March 2014 Long Term (3 years +) 1. MOH & MSQH Patient Safety International Conference 2. Awards: Recognition for Patient Safety Commitment Success Period 1. Relationship Patient Safety emphasis Week - MOH & WHO Structured program set parameters Combined approach 2. Publish results in health/medical journal

WHO Patients for Patient Safety In- Country Workshop, Malaysia Page 12 Comments From Workshop Participants I was very excited about the PFPS workshop and it went beyond my expectation. The open and frank exchange of experiences and views had never happened before. The facilitators made the whole process very comfortable to talk First time attending such an event, need to make it a public awareness program to give the public confidence in medical care The team work concept of generating ideas and thought process was excellent The sharing of the Canadian PFPS experience via webinar was very exciting and encouraging. Will need more exposures to such experiences to move forward Gained a lot of information which in turn would allow me to share with friends from various people groups The workshop gave an opportunity to network with patients and other healthcare professionals There was open communication among all the participants in voicing their concerns and ideas on patient safety The facilitators were excellent and kept the focus on ensuring objectives of the workshop were in the fore front

References The Chicago Patient Safety Workshop- Engaging Healthcare Consumers, Professionals and Leadership Organizations in Partnership to Improve Safety, June 19-21, 2008 World Health Organization- PFPS News: Patients for Patient Safety Winter 2013, PFPS Malaysia Workshop: N new network of patient champions established by Stephanie Newell and Nittita Prasopa-Plaizier World Health Organization- Patients for Patient Safety News, August 2009: Australian PFPS Workshop

Appendices 1. Workshop Agenda... Appendix I 2. Workshop Application Forms. Appendix II 3. Participants Acceptance Form... Appendix III 4. Workshop Evaluation Results... Appendix IV

Appendix I

In collaboration with 5-6 September 2013 OBJECTIVES 1. Introducing participants to the local health-care systems, patient or consumer networks and /or local resources relevant to healthcare quality and patient safety initiatives; 2. Introducing individuals to the concept of collective action and empowerment and engagement to achieve health care improvements; 3. Raising awareness about patient safety and the importance of patient and community engagement in health-care services and quality and safety initiatives; 4. Training and orienting individuals in advocacy skills for patient safety and to promote positive engagement and partnerships between patients, health-care professionals, policymakers and health-care leaders; 5. Facilitating a sharing of ideas, experiences and network locally, nationally and globally; 6. Providing a forum for discussion and a means to turn feelings of frustration and anger to positive action. EXPECTED OUTCOMES Following the workshop, participants will be expected to work to: 1 Become aware of patients roles and responsibilities in working collaboratively and/or in partnership with other stakeholders for health-care quality and safety; 2. Better understand the local and national health systems and able to identify relevant stakeholders, including the community, health-care providers and policy makers for healthcare services and improvement; 3. Build positive partnerships and work collaboratively with stakeholders; 4. Contribute to the national and global PFPS network and learning; 5. Provide regular feedback and report activities as requested or required by the national organisation and /or WHO through established national Road Map for PFPS. PROGRAMME BOOK PLANNING & ORGANISING COMMITTEE Chairman Dr. Nittita Prasopa Plaizier Programme Manager and Technical Lead, Patients for Patient Safety (PFPS), World Health Organization, Geneva Joint Chairman Assoc. Prof. Dr. M. A Kadar Marikar Chief Executive Officer, Malaysian Society for Quality in Health Members Dr. Nor Aishah Abu Bakar Public Health Physician, Acting Deputy Director Quality in Medical Care Section, Ministry of Health, Malaysia Technical Coordinator, Patient Safety Council Malaysia Ms. Stephanie Newell WHO Patients for Patient Safety Champion, Australia Chairman Australian Patients for Patient Safety Ms. Anna Lee Lead, Patients for Patient Safety, WHO Patient Safety Programme Malaysian Society for Quality in Health B.6-1, Level 6, Menara Wisma Sejarah, 230 Jalan Tun Razak, 50400 Kuala Lumpur, Malaysia Telephone: 03 2681 2232 Fax: 03 2681 3199 Website: www.msqh.com.my Dr. Ken-ichiro Taneda Technical Officer (Patient Safety and Quality), WHO Western Pacific Regional Office (WPRO) Ms. Rebecca John Project Manager, Malaysian Society for Quality in Health

FACILITATORS DAY 1 THURSDAY, 5th SEPTEMBER 2013 Ms. Nittita Prasopa Plaizier Programme Manager and Technical Lead, Patients for Patient Safety (PFPS), World Health Organization, Geneva Dr. Nittita joined the World Health Organization (WHO) Patient Safety Programme in 2007 as a technical officer for research. In 2008, she developed from concept into a funding scheme the WHO Patient Safety Research Small Grants programme, for which she is a founding manager, now supporting 24 research projects in 22 countries. She has collaborated with many groups of experts, institutions and non-governmental organizations. Since August 2012, Dr. Nittita has been responsible for the Patients for Patient Safety Programme (PFPS), which supports a global network of patient advocates in 52 countries across all WHO regions. Dr. Nittita has a background in public health with about 20 years experience working in both government and non-government sectors, including Health department, NGOs, research institutions and in refugee camps. Nittita holds a Masters of Public Health (MPH) from the University of Sydney, a Masters of Health Sciences in Public Health Practices from La Trobe University (Australia) and is a PhD candidate for health policy Stephanie Newell WHO Patients for Patient Safety Champion, Australia Chairman Australian Patients for Patient Safety Stephanie Newell is a leading Australian health consumer advocate and educator on partnerships with patients and health consumers to improve patient safety and the quality of health care. The death of Stephanie s son, Marcus, in hospital in 2002, was the catalyst for Stephanie focusing on patient safety issues and improvement. Highly regarded across multiple industry sectors for her collaborative approach and innovative thinking, Stephanie is a member of a number of international, state and federal safety and quality related committees. Stephanie is the current Chair of the Clinical Excellence Commission of New South Wales, Partnering with Patients Advisory Committee and is a Master of Clinical Science by Research candidate at the University of Adelaide, in partnership with the Joanna Briggs Institute. Stephanie is a foundational member and Patient Safety Champion of the World Health Organization (WHO) Patient Safety programme, Patients for Patient Safety (PFPS). In 2009, Stephanie organized and co-facilitated the inaugural Australian Patients for Patient Safety 3 day Workshop, bringing together health professionals, policy makers and health consumers, who had experienced harm whilst receiving their health care, to work in partnership. Ken-ichiro Taneda Technical Officer (Patient Safety and Quality), WHO Western Pacific Regional Office (WPRO) Dr. Taneda was a former Medicine Chief Resident at St. Luke's International Hospital in Tokyo. He had health services research training in the US as a Health Services Research & Development fellow at Seattle VA Hospital, a General Internal Medicine fellow at University of Washington (UW), and completed Master of Public Health as well as certificate program of Health Informatics at UW. During his training in the US, he also worked for APEC Emerging Infections Network and participated in WHO Global Outbreak Alert & Network (GOAN) meeting. For the last 10 years, Dr. Taneda worked for Japan National Institute of Public Health under Ministry of Health, where he was in charge of hospital management courses including 5-week course for hospital directors from developing countries, and patient safety trainings including the evidence-based team training (TeamSTEPPS) as a Master Trainer. He worked on various patient safety activities in collaboration with patient families who experienced incidents in Japan and the US. He was also Clinical Instructor, School of Public Health and Community Medicine, University of Washington and WHO Technical Adviser for Development of International Classification for Patient Safety (ICPS). Since early 2012, Dr. Taneda has been working for WHO/WPRO on patient safety and quality including HAI (Healthcare Associated Infection) and AMR (Antimicrobial Resistance), under Division of Health Sector Development. 7.00-8.00 8.00-8.30 8:30-9:00 9.00-9.15 9:15-10:00 10:00 10:30 10.30-11.00 11.00-12:00 12.00 13:00 13:00 14:00 14:00-15:30 15:30-16:00 16:00 16:30 16:30-17:00 17:00 Registration of Workshop Participants Welcome & Opening Remarks by Organizing Committee: Associate Professor Dr M.A Kadar Marikar CEO, Malaysian Society for Quality in Health Ms Nittita Prasopa Plaizier, Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Introductions All Welcome by Dr Graham Harrison, WHO Representative for Malaysia Official Opening of Workshop by: YBhg. Dato Dr Azmi bin Shapie Director Medical Development Division Representative of Director General of Health, Malaysia WHO Patient Safety Programme Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Tea Break Overview of Patient Safety: Globally by Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Nationally by Dr Nor Aishah Abu Bakar, Acting Deputy Director, Quality in Medical Care Section Ministry of Health, Malaysia & Technical Coordinator, Patient Safety Council Malaysia Concept of Patient Engagement Ms Stephanie Newell WHO Patients for Patient Safety Champion, Australia Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Lunch Break Sharing of Patients /Participants Experiences: Why are we here? Ms Stephanie Newell WHO Patients for Patient Safety Champion, Australia WHO Patients for Patient Safety (PFPS) Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Dr Kenichiro Taneda, Technical Officer Patient Safety, Western Pacific Regional Office (WPRO), Manila Patients for Patient Safety Network The Canadian experience Video Clip Show End of Day 1

DAY 2 FRIDAY, 6th SEPTEMBER 2013 8:00 8:30 8:30 9:00 9:00-9:30 9:30-10:00 10:00-10:30 10:30-11:00 11:00-11:30 11:30 12:30 Review of Day 1 - All Health Systems in Malaysia Dr Nor Aishah Abu Bakar, Acting Deputy Director, Quality in Medical Care Section Ministry of Health, Malaysia & Technical Coordinator, Patient Safety Council Malaysia Reporting of Adverse Events Dr Kenichiro Taneda, Technical Officer Patient Safety, Western Pacific Regional Office (WPRO), Manila Patient Engagement for Patient Safety Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Tea Break Patients for Patient Safety (PFPS) Global Network Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva How to make our Efforts Measurable? Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Goal Setting - Development of Mission, Values, Goals and Strategies Ms Nittita Prasopa Plaizier Program Manager and Technical Lead Patients for Patient Safety, WHO Geneva Ms Stephanie Newell WHO Patients for Patient Safety Champion, Australia FACILITATORS Dr. Nor Aishah Abu Bakar Public Health Physician, Acting Deputy Director Quality in Medical Care Section, Ministry of Health, Malaysia Dr. Nor Aishah Abu Bakar is a Public Health Physician and is currently the Acting Deputy Director, Quality in Medical Care Section, Ministry of Health, Malaysia and Technical Coordinator, National Patient Safety Council Malaysia. 1. Public Health Physician (Occupational Health), Assistant Director: Occupational Health Unit, Disease Control Division Ministry of Health Malaysia, Putrajaya from 2004 to 2007, 2. Public Health Physician (Occupational Health), Principa Assistant Director: Head, Medical Staff Safety & Health Unit Quality In Medical Care Section, Medical Development Division Ministry of Health Malaysia, Putrajaya from June 2007 to March 2010, 3. Public Health Physician (Occupational Health), Senior Principa Assistant Director: Head, Medical Staff Safety & Health Unit Quality In Medical Care Section, Medical Development Division Ministry of Health Malaysia, Putrajaya from March 2010 till Sept 2011, 4. Public Health Physician (Occupational Health), Senior Principa Assistant Director from Sept 2011 till now. - Head, Patient Safety Unit, Quality In Medical Care Section Medical Development Division, Ministry of Health Malaysia Putrajaya - Head of Secretariat, Patient Safety Council Malaysia 5. Public Health Physician (Occupational Health), Acting Deputy Director: Quality In Medical Care Section, Medical Development Division, Ministry of Health Malaysia, Putrajaya from Sept 2011 till now. Dr. Nor Aishah Abu Bakar had also attended several WHO fellowship and short courses overseas including Occupational Epidemiology and Medical Assessment of Commercial Drivers in United Kingdom and World Health Organization Fellowship In New South Wales, Australia - Occupational Health and Safety In Agricultural Sector in 2006. She has also participated in research such as Workers Satisfaction Survey for Medical Program - Medical Staff Safety & Health Unit, Quality in Medical Care Section, Ministry of Health Malaysia 2010 and Patient Safety Culture in MOH Hospitals 2012, Institute of Health Management & Patient Safety Unit, Quality in Medical Care Section Ministry of Health Malaysia and author and co-author publication and technical reports the Ministry of Health, Malaysia and journal in particular Malaysian Journal and Community Health. 12:30-13.00 13:00 14:00 14:00-14.45 14:45-15:30 15:30 16:00 Effective Advocacy and Communication Speaker: Australia Lunch Break Fish Bowl : What we can create to achieve Big Dreams Looking forward - the Patients for Patient Safety Malaysia Group Vision and Action (All) & Wrap Up Official Closing & Presentation of Certificates YBhg. Datuk Dr Noor Hisham Abdullah Director General of Health, Malaysia Chairman Patient Safety Council, Malaysia Assoc. Prof. Dr. M. A Kadar Marikar Chief Executive Officer, Malaysian Society for Quality in Health Dr Kadar Marikar is the CEO since 2008 of Malaysian Society for Quality in Health (MSQH); the Malaysian Accreditation Organisation for Healthcare Facilities and Services. A physician by training with a post graduate degree in Hospital & Health Services Management (UK) and MPH and also a Fellow of the Royal Australasian College of Medical Administration. Served the Ministry of Health Malaysia since 1982 to 2001 in various levels from Clinicians, Medical Director and Head of Quality Standards Unit in the Ministry. Involved directly in the development and implementation of the Malaysian Hospital Accreditation Programme since 1996. Appointed as a TQM Consultant; serving the Military Health Services, Kingdom of Saudi Arabia from 2001 to 2007 and currently a visiting consultant. Appointed as Associate Professor at the Department of Community Medicine, Faculty of Medicine University Putra Malaysia since 2004. Represents Malaysia, as a committee member of the ISQua Accreditation Federation Council since 2002.

LIST OF PARTICIPANTS Dato Dr Kuan Geok Lan Consultant Paediatrician Hospital Melaka Dr Heric Corray Hospital Director Queen Elizabeth Hospital Kota Kinabalu, Sabah Siti Irynn Ching Nursing Staff Pantai Hospital Ayer Keroh, Melaka Ms Rebecca John Project Manager Malaysian Society for Quality in Health Level 6, Menara Wisma Sejarah Jalan Tun Razak, Kuala Lumpur Mr Manvir Jesudasan Chief Executive Officer Soccergurus Sdn Bhd Plaza Damas Sri Hartamas, Kuala Lumpur Dr Milton Lum Obs &Gynae Consultant M-3-4 Plaza Damas, 60 Jalan Sri Hartamas 1 50480 Kuala Lumpur Dr Subramaniyam C&NI Corporation Multilevel Marketing No. 7, Jalan Gelana 7/24, Section 7 40000 Shah Alam, Selangor Ms Rose Paul Retired State Matron 268, Jalan 5/46 Petaling Garden 46000 Petaling Jaya Datin Paduka Siti Sa diah Sheikh Bakir Director & Corporate Advisor KPJ Healthcare Bhd & MSQH President Ms Daram Kaur d/o Kirpal Singh Nursing Staff (Matron) Tuanku Mirzan Armed Forces Hospital Wangsa Maju Section 2, Kuala Lumpur Assoc Prof. Dr Kadar Marikar Chief Executive Officer Malaysian Society for Quality in Health Level 6. Wisma Sejarah, Jalan Tun Razak, Kuala Lumpur Dr Nor Aishah bt Abu Bakar Deputy Acting Director, Quality in Medical Care Section, Medical Development Division Ministry of Health & Technical Coordinator Patient Safety Council, Malaysia Dr Mark Prabaharan Raman Lecturer UITM & Universiti Pertahanan Malaysia No 44, USJ 9/3 P, USJ 9 Subang Jaya, 47500 Selangor The In-country Patients for Patient Safety Workshop Planning and Organising Committee extends its sincere thanks to: - Director General Health Malaysia - WHO Geneva - WHO Western Pacific Regional Office (WPRO) - WHO Representative Malaysia, Brunei Darussalam & Singapore - Director Medical Development Division, Ministry of Health Malaysia - Facilitators and Participants - Members of the Secretariat and all others for their contribution and support to the success of this PFPS Workshop

Appendix II

APPLICATION FORM Only eligible applications will be considered INCOUNTRY PATIENTS FOR PATIENT SAFETY WORKSHOP 5 th 6 th September 2013 The Everly Hotel, Putrajaya Salutation (Dato/Professor/Dr/Mr/Mrs/Ms/Others. Please Specify: Gender Male Female First Name Surname Address Street 1 Street 2 City Postcode State/Province Contact Information Phone Home H/P Office Email Employment Information Profession Are you currently employed? Yes No

1 Can you attend the workshop for the entire duration from 5 th 6 th September 2013? Yes No 2 Are you committed to the vision and values stated in the London Declaration and selection criteria (in this application pack)? Yes No 3 Please list any languages you speak and level of competency (basic, intermediate or advanced) No Language Basic/Intermediate/Advanced 1 2 3 4 Please confirm you have read, understood and signed the attached consent form Yes No 5 If you have special requirements or need support to attend this workshop please give details 6 Do you have access to internet facilities? Yes No 7 Please give contact details for two people with whom you have worked in partnership to improve the safety of patient care. (We may contact one or both of these people to discuss your application) Reference 1 Reference 2 Name Capacity in which you know them Address Name Capacity in which you know them Address Organization (if applicable): Phone No Email Organization (if applicable): Phone No Email

PLEASE GO ON TO ANSWER QUESTIONS A I ON THE FOLLOWING PAGES. PLEASE TRY TO KEEP EACH ANSWER TO A MAXIMUM 500 WORDS. A. If you or a family member has had a direct experience of an adverse event or incident causing harm in health care, please summarize your experience below: B. Please describe your reasons for wanting to be involved in health care improvement C. Please describe your involvement in efforts to improve health-care. Please include your experience in partnering and collaborating with stakeholders. Include detail such as who you partnered with, what were your aims and how you engaged with them. D. Please list the three most significant accomplishments that have come as a result of your efforts. E. What are the most important lessons you have learned through your experiences in partnering/collaborating with stakeholders? F. What are the biggest challenges you have experienced in your efforts to improve patient safety? Please tell us how you overcame those challenges. G. What are the healthcare/patient safety issues in the country that you are aware of? H. How would participation in the workshop help your future work to improve health-care? I. What would you hope to learn from the workshop?

Annex A: London Declaration LONDON DECLARATION Patients for Patient Safety WHO Patient Safety We, Patients for Patient Safety, envision a different world in which healthcare errors are not harming people. We are partners in the effort to prevent all avoidable harm in healthcare. Risk and uncertainty are constant companions. So we come together in dialogue, participating in care with providers. We unite our strength as advocates for care without harm in the developing as well as the developed world. We are committed to spread the word from person to person, town to town, country to country. There is a right to safe healthcare and we will not let the current culture of error and denial, continue. We call for honesty, openness and transparency. We will make the reduction of healthcare errors a basic human right that preserves life around the world. We, Patients for Patient Safety, will be the voice for all people, but especially those who are now unheard. Together as partners, we will collaborate in: Devising and promoting programs for patient safety and patient empowerment. Developing and driving a constructive dialogue with all partners concerned with patient safety. Establishing systems for reporting and dealing with healthcare harm on a worldwide basis. Defining best practices in dealing with healthcare harm of all kinds and promoting those practices throughout the world. In honor of those who have died, those left disabled, our loved ones today and the world s children yet to be born, we will strive for excellence, so that all involved in healthcare are as safe as possible as soon as possible. This is our pledge of partnership. March 29, 2006

Appendix III

Dear Sir/Madam, ACCEPTANCE FORM Malaysian Patients for Patient Safety Workshop, Putrajaya 5 th - 6 th September 2013 Please confirm you still wish to and are able to commit to the entire Patients for Patient Safety Workshop being held in Putrajaya on 5 th -6 th September 2013. All participants should make themselves available from 7.00 am - 8.00 am (registration) to 5.00 pm daily during these two days. Yes No 1. Do you have any special personal needs or requirement you feel we should be aware of or anything you need to provide for you during the workshop? If Yes, please provide details here: 2. Do you have any particular food requirements we need to be aware of? Yes No If Yes, Provide details here: 3. Please inform us of any other details you think we should know regarding your attendance at this event? I hereby confirm that I am able to attend the entire Workshop. I undertake to notify the Workshop Secretariat immediately should any circumstance occur that will prevent me from attending. Date.. Please return by email to: rebecca@msqh.com.my by Friday 30 th August 2013. Thank you Assoc Prof Dr. M.A. Kadar Marikar Joint Chairman Planning Committee

Appendix IV

ANALYSIS OF EVALUATION ON MSQH TRAINING Patient Safety Workshop 14th March 2011 Patient Safety Workshop was conducted at MSQH Training Centre on 14 th March 2011. The workshop was attended by the number of 53 participants from both public and private hospitals. However, a total of 52 responses of evaluation on the Patient Safety Workshop were returned. The number of participants feedback on Patient Safety Workshop Statements Strongly Agree Agree Neutral Disagree Strongly Disagree 1. The information presented enables me to understand Safety and Patient Care issues in health care 21 29 1 0 1 52 2. The information presented enables me to identify specific activities to promote WHO Patient Safety 21 28 2 0 1 52 Goals 3. The information presented enables me to apply the 'Fish Bone' Diagram in solving healthcare related 25 23 3 0 1 52 issues 4. The information presented enables me to do Root Cause Analysis (RCA) of an identified risk 23 26 2 0 1 52 5. The information presented enables me to apply the PDCA in my Quality Improvement Activities 16 29 4 0 1 50 6. The information presented enables me to use the Quality Improvement Tools to solve patient safety issues 14 31 4 0 1 50 7. The information presented enables me to understand, identify and develop problem solving 17 30 2 0 1 50 process to enhance improvement in Patient Safety Grand Total 137 196 18 0 7 358 Grand Total