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1) SABAH 24 2) SARAWAK 22 3) PERAK 15 4) SELANGOR 13 5) JOHOR 12 6) PAHANG 10 7) KEDAH 9 8) KELANTAN 9 9) TERENGGANU 6 10) NEGERI SEMBILAN 6 11) PULAU PINANG 6 12) MELAKA 3 13) PERLIS 1 140 14) WILAYAH PERSEKUTUAN 4 (KUALA LUMPUR, PUTRAJAYA, LABUAN) Source: Ministry of Health Website

NO SPECIALIST HOSPITAL NON-SPECIALIST HOSPITAL 1 QUEEN ELIZABETH STATE HOSPITAL KUDAT 2 QUEEN ELIZABETH II MAJOR SPECIALIST PITAS 3 DUCHESS OF KENT, SANDAKAN MAJOR SPECIALIST KOTA MARUDU 4 TAWAU MAJOR SPECIALIST KOTA BELUD 5 WANITA & KANAK-KANAK, LIKAS - INSTITUTION TUARAN 6 MESRA BUKIT PADANG - INSTITUTION RANAU 7 LAHAD DATU MINOR SPECIALIST PAPAR 8 KENINGAU MINOR SPECIALIST BEAUFORT 9 KUALA PENYU 10 SIPITANG 11 TENOM 12 TAMBUNAN 13 BELURAN 14 KINABATANGAN 15 KUNAK 16 SEMPORNA

CHAIRMAN Dr. William Gotulis, Deputy Director, Sabah State Health Department (Medical Division) STATE COORDINATOR Dr. Mohd Ferous Bin Alias, Principle Assistant Director, Sabah State Health Department (Medical Division) ASSISTANT STATE COORDINATOR Matron Fauziah Muhammad, Sabah State Health Department (Medical Division)

All hospitals in Sabah will be accreditated in 2020 To sustain and ensure strong accreditation implementation by having strong leadership & excellent monitoring system

1. To identify hospitals with strong implementation accreditation program 2. To identify personnel with strong character, good knowledge, skills and experience with accreditation 3. To improve method of implementing accreditation in Sabah 3.1 Work Flow 3.2 Training 3.3 Mock Survey 3.4 Financial Support

STRATEGY 1:- Identify hospitals with strong implementation accreditation programme 1. Hospital Mesra bukit Padang (5 th cycle) - 1972 2. Hospital Tenom (5 TH cycle) - 1959 3. Hospital Sipitang (5 th cycle) - 1995 4. Hospital Tambunan (5 th cycle) - 1977 5. Hospital Keningau (4 TH cycle) - 2004 6. Hospital Kudat (3 rd cycle) - 1984 7. Hospital Kota Belud (3 rd cycle) 1982 8. Hospital Kunak (3 rd cycle) - 2006 REASON: To strengthen the accreditation implementation and making them to be the benchmark for other hospital (advantage to non accreditated hospital which has the similar category / design / workload with accreditated hospital)

NO SPECIALIST HOSPITAL NON-SPECIALIST HOSPITAL 1 DUCHESS OF KENT, SANDAKAN 1952 TENOM - 1959 2 QUEEN ELIZABETH 1957 SEMPORNA - 1970 3 TAWAU 1968 PAPAR - 1971 4 MESRA BUKIT PADANG - 1972 RANAU - 1974 5 LAHAD DATU 2002 TAMBUNAN - 1977 6 KENINGAU 2004 BELURAN - 1979 7 WANITA & KANAK-KANAK SABAH, LIKAS - 2005 KOTA BELUD - 1982 8 QUEEN ELIZABETH II 2012 KUDAT - 1984 9 BEAUFORT - 1985 10 KOTA MARUDU - 1994 11 SIPITANG - 1995 12 KINABATANGAN -1999 13 PITAS - 2003 14 KUALA PENYU - 2006 15 KUNAK - 2006 16 TUARAN 1994 / 2015

BASED ON YEAR IT WAS BUILT 1950 s 1. HOSPITAL DUCHESS OF KENT 400 beds 1952 2. HOSPITAL QUEEN ELIZABETH 587 beds - 1957 3. HOSPITAL TENOM 92 beds - 1959 (5 TH CYCLE) 1960 s 1. HOSPITAL TAWAU 401 beds - 1968 1970 s 1. HOSPITAL SEMPORNA 70 beds - 1970 2. HOSPITAL PAPAR 77 beds - 1971 3. HOSPITAL MESRA BUKIT PADANG 302 beds - 1972 (5 TH CYCLE) 4. HOSPITAL RANAU 110 beds - 1974 5. HOSPITAL TAMBUNAN 49 beds - 1977 (5 TH CYCLE) 6. HOSPITAL BELURAN 52 beds - 1979

1980 s 1. HOSPITAL KOTA BELUD 172 beds - 1982 (3 RD CYCLE) 2. HOSPITAL KUDAT 180 beds - 1984 (3 RD CYCLE) 3. HOSPITAL BEAUFORT 275 beds - 1985 1990 s 1. HOSPITAL KOTA MARUDU 97 beds - 1994 2. HOSPITAL SIPITANG 93 beds - 1995 (5 TH CYCLE) 3. HOSPITAL KINABATANGAN 68 beds - 1999 2000 s 1. HOSPITAL LAHAD DATU 268 beds - 2002 2. HOSPITAL PITAS 48 beds - 2003 3. HOSPITAL KENINGAU 212 beds - 2004 (4 TH CYCLE) 4. HOSPITAL WANITA & KANAK KANAK SABAH 504 beds - 2005 5. HOSPITAL KUALA PENYU 48 beds - 2006 6. HOSPITAL KUNAK 48 beds - 2006 (3 RD CYCLE) 7. HOSPITAL QUEEN ELIZABETH II 291 beds - 2012 8. HOSPITAL TUARAN 76 beds - 1994 / 2015

STARTEGY 2:- Identify personnel with strong character, good knowledge, skills and experience with accreditation Identify healthcare personnel from different service categories Hospital directors, specialist, medical officers, nurses, medical assistants, pharmacists, science officer, lab technicians, engineers Include them in the state team (facilitator / mock surveyor) Sharpening their knowledge, skill & experience each time they visit other hospitals Become accreditation champion in their own hospital / zone / state

STATE FASILITATOR & STATE MOCK SURVEYOR 1)DR MOHD FEROUS PRINCIPLE ASSISTANT DIRECTOR, MEDICAL DIVISION 2)DR RAZAK DIRECTOR OF HOSPITAL QUEEN ELIZABETH II 3)DR ESMAR DIRECTOR OF HOSPITAL KUALA PENYU 4)DR ASBULLAH DIRECTOR OF HOSPITAL KUNAK 5)DR CAMMIE DIRECTOR OF HOSPITAL PITAS 6)DR QABIL PSYCHIATRIST IN HOSPITAL DUCHESS OF KENT, SANDAKAN 7)MS WONG SEE WAN PHARMACIST IN HOSPITAL MESRA BUKIT PADANG 8)MS VIVILA BUBUYAN - PHARMACIST IN HOSPITAL KENINGAU 9)MR LUI KOK SEONG - PHARMACIST IN HOSPITAL PITAS 10)MATRON FAUZIAH MEDICAL DIVISION, JKN SABAH 11)MATRON CATHERINE ENGKIAS HOSPITAL MESRA BUKIT PADANG 12)MATRON STELLA STEPHAN HOSPITAL QUEEN ELIZABETH 13)MATRON RUKIAH HOSPITAL QUEEN ELIZABETH II 14)MATRON HELEN JOHN CHUAN - HOSPITAL QUEEN ELIZABETH II 15)MATRON FLORINE TOIDIN HOSPITAL KENINGAU

16) MATRON TARIAH HOSPITAL KOTA BELUD 17) SISTER TAN PHAIK TEE HOSPITAL TENOM (HAEMODIALYSIS SERVICE) 18) SISTER RITA GEORGE HOSPITAL TENOM 19) SN INDOITUWO MEDICAL DIVISION, STATE INFECTION CONTROL COORDINATOR 20) PPP U36 MR HILARIUS RAYMOND HOSPITAL KOTA BELUD 21) PPP U36 MR DENIS ONG HOSPITAL TAWAU 22) PPP U36 MR MARCUS HOSPITAL KENINGAU 23) PPP U36 MR SHKIR HOSPITAL SIPITANG 24) PPP U32 MR ZAIDIN ENDUT HOSPITAL MESRA BUKIT PADANG 25) MLT U36 - MS LUCY CHONG HOSPITAL TENOM 26) MR ROMMY RAMLEE OCCUPATIONAL THERAPIST U41 HOSPITAL MESRA BUKIT PADANG 27) MR AZRI ENGINEER J41 HOSPITAL BEAUFORT 28) MS NORAILIN ENGINEER J41 HOSPITAL KENINGAU 29) MR ETHELRED ADOLF NAINTIN ASSISTANT ENGINEER J29 HOSPITAL SIPITANG

STRATEGY 3:- To improve method of implementing accreditation in Sabah 3.1) Identify the work flow A) PRE MSQH SURVEY B) POST MSQH SURVEY > 1 YEAR CERTIFICATION > 4 YEARS CERTIFICATION

PRE MSQH SURVEY WORK FLOW 1. ACCREDITATION WORKSHOP - 3 DAYS - 6 MONTHS BEFORE MSQH SURVEY 2. MOCK SURVEY - 3 DAYS - 2-3 MONTHS BEFORE MSQH SURVEY 3. MONITORING VISIT 4. MSQH SUMMATION REPORT - 1 DAY (STATE COORDINATOR & ASSISTANT STATE COORDINATOR) - WITHIN 2 WEEKS BEFORE MSQH SURVEY - OTHER HOSPITAL DIRECTOR & STAFFS COME TO LISTEN & LEARN - REPRESENTATIVE FROM HOSPITAL SUPPORT SERVICE COMPANY (SEDAFIAT OFFICERS) - STATE COORDINATOR & ASSISTANT STATE COORDINATOR - STATE HEALTH DIRECTOR OR DEPUTY DIRECTOR

POST MSQH SURVEY WORK FLOW FOR HOSPITAL WITH 1 YEAR CERTIFICATION 2 X MONITORING VISITS - 1 DAY - PRESENTATION & DISCUSSION ON PCs - CHECKING & COACHING SPECIFIC WORKSHOP TO ADDRESS CERTAIN ISSUE Eg: 1) CREDENTIALING & PRIVILEGING WORKSHOP 2) ASSETS MANAGEMENTS WORKSHOP 3) INFECTION CONTROL WORKSHOP

POST MSQH SURVEY WORK FLOW FOR HOSPITAL WITH 4 YEAR CERTIFICATION 1 X MONITORING VISIT - 1 DAY - STATE COORDINATOR & ASSISTANT STATE COORDINATOR - PRESENTATION & DISCUSSION ON PCs COMPLIANCE SURVEY IN 2 ND & 3 RD YEAR - 2 DAYS - MINIMUM 10 COMPLIANCE SURVEYORS MOCK SURVEY IN 4 TH YEAR - 3 DAYS - MINIMUM OF 12 MOCK SURVEYORS

3.2) Training Training is conducted as a workshop for 3 days ( 1 day theory & 2 days practical) in the respective hospital for all leaders including head of department, head of unit, head of committee and manager of Hospital Support Service (HSS) Other hospital staffs and HSS employee working in that hospital will attend 2 hours course Introduction & motivation in accreditation program. Target coverage for other staffs to attend this 2 hours course in respective hospital is 80% Night practical session is also be conducted (9.30pm 12.00pm) Emphasize on safety of the patients, patient s family members, healthcare workers, public properties and infrastructure;- lighting, signage, security guard, fencing, access route used by healthcare staff & non-healthcare staffs and etc. Minimum of 10 state facilitators involved in the accreditation workshop Training module used in the accreditation workshop was developed by Sabah State Accreditation Coordinator

1) INTRODUCTION OF ACCREDITATION AND COMPARING OWN HOSPITAL WITH OTHER NEIGHBOURING HOSPITAL IN SABAH, IN TERM THE STATUS OF HOSPITAL QUALITY PROGRAMS IMPLIMENTATION (MS ISO, 5S / EKSA, GMP & HACCP, BREAST FEEDING HOSPITAL INITIATIVE) 2) UNDERSTANDING THE 5 PILLARS IN ACCREDITATION STANDARD 1) ORGANISATION & MANAGEMET 2) HUMAN RESOURCE DEVELOPMENT & MANAGEMENT 3) POLICY & PROSEDURES 4) FACILITY & EQUIPMENTS 5) SAFETY & CONTINUOUS QUALITY IMPROVEMENT ACTIVITY 3) INTERPRETING THE ACCREDITATION STANDARD & CREATIVITY IN IMPLEMENTING IT 1) LEADERSHIP PERSONALITY

3.3) Mock Survey Conducted for 3 days and headed by State Coordinator Minimum number of mock surveyor is 12 peoples More time spend in each department / unit Approach used: Pointing out weaknesses Coaching and solving problems Summation report: Written report handed to hospital (softcopy) Base on the scale of findings, the state coordinator, who is also the Principle Assistant Director in Medical Division will give direct specific instruction to hospital director to ensure the smoothness preparation before MSQH survey

3.4) Financial Allowances / claims for facilitators and mock surveyors are paid by the Medical Division, Sabah State Health Department. If other hospital send their staffs to be an observer during mock survey in other respective hospital, the allowances / claims will be paid by their own hospital Application on Assets (medical / non-medical) & projects from hospital are submitted to State Coordinator for Accreditation Program (Head of Planning Unit, Medical Division, Sabah State Health Department)

TRAINING (3 days) FASILITATOR ALLOWANCE FOR 10 PEOPLES RM 12,000 (OS 29,000) JOURNEY ALLOWANCE FOR 10 PEOPLES RM 6,000 (OS 21,000) MOCK SURVEY (3 days) JOURNEY ALLOWANCE FOR 12 MOCK SURVEYORS = RM 7,200 (OS 21,000) BUDGET ESTIMATION FOR 8 HOSPITALS (TRAINING & MOCK SURVEY) IN 2015 0S 29000 (FACILITATOR ALLOWANCE) = RM 72,000 0S 21000 (JOURNEY ALLOWANCE) = RM 105,600 TOTAL = RM 177,600.00

ZON SANDAKAN ZON PANTAI BARAT UTARA 1. HOSPITAL KOTA MARUDU 2. HOSPITAL KUDAT 3. HOSPITAL PITAS ZON PANTAI BARAT SELATAN 1. HOSPITAL QUEEN ELIZABETH*** 2. HOSPITAL QUEEN ELIZABETH II *** 3. HOSPITAL WANITA & KANAK- KANAK SABAH*** 4. HOSPITAL MESRA BUKIT PADANG*** 5. HOSPITAL RANAU 6. HOSPITAL TUARAN 7. HOSPITAL KOTA BELUD 8. HOSPITAL PAPAR 1. HOSPITAL DUCHESS OF KENT*** 2. HOSPITAL BELURAN 3. HOSPITAL KINABATANGAN ZON TAWAU 1. HOSPITAL TAWAU*** 2. HOSPITAL LAHAD DATU*** 3. HOSPITAL SEMPORNA 4. HOSPITAL KUNAK ZON PEDALAMAN 1. HOSPITAL KENINGAU*** 2. HOSPITAL TENOM 3. HOSPITAL TAMBUNAN 4. HOSPITAL BEAUFORT 5. HOSPITAL KUALA PENYU 6. HOSPITAL SIPITANG

1) To integrate accreditation into the state nursing / state medical assistant / state committee (infection control & etc) monitoring tool 2) To integrate accreditation knowledge & skills into all leadership courses for new appointed hospital sisters, matrons, medical assistants, lab technicians, engineers, hospital directors, head of departments & etc 3) To organize yearly Sabah state accreditation workshop focusing on accreditation standards