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KEMENTERIAN KESIHATAN MALAYSIA

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

2014

CLINICAL PERFORMANCE SURVEILLANCE UNIT MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION MINISTRY OF HEALTH MALAYSIA

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Content

Page 2

HPIA List

1 2 3 4 5 6

HPIA Element Internal Business Process Customer Focus Employee Satisfaction Learning And Growth Financial And Office Management Environmental (Technical/Community) Support

Indicators 1 - 19 20 - 25 26 - 27 28 - 29 30 - 34 35 - 38

6 34 43 46 49 56

LIST OF HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

INDICATOR

STANDARD

REPORTING FREQUENCY (Hospital to JKN)

INTERNAL BUSINESS PROCESS 1 2 3 4

5 6 7 8

STEMI Case Fatality Rate Non STEMI / Unstable Angina Case Fatality Rate Dengue Case Fatality Rate (for all categories of patients) Community-acquired pneumonia death rate (in previously healthy children aged between 1 month and 5 years) Percentage of paediatric patients with unplanned readmissions to the ward within 48 hours of discharge Percentage of cases with Massive Post Partum Haemorrhage (PPH) Percentage of ambulance preparedness and dispatch for primary response within (≤) 5 minutes Percentage of inappropriate triaging (under-

≤ 15%

Monthly

≤ 10%

Monthly

< 0.2 %

Monthly

≤ 1%

Monthly

≤2%

Monthly

≤ 1%

Monthly

≥ 90%

Monthly

≤ 0.5%

Monthly

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

10 11 12 13 14 15

triaging): Category Green patients who should have been triaged as Category Red Percentage of turnaround time within (≤) 45 minutes of Urgent plain radiographic examination requested by Trauma and Emergency Unit/ Department Percentage of laboratory turnaround time for urgent (STAT) Full blood count (FBC) within (≤)45 minutes Hospital possesses “current” accreditation or ISO certification (YES = 1; NO = 0) Hospital MRSA infection rate Hand hygiene compliance rate Percentage of intravenous (IV) line complications Rate of healthcare associated infections (HCAI) Percentage of Morbidity or Mortality Audits/ Meeting being conducted at the hospital level with documentation of cases discussed State & Specialist Hospitals: 12 times/year Other Hospitals: 6 times/year Cross-match transfusion ratio Percentage of bodies (non-police cases) released to the appropriate claimant within 3 hours at the forensic medicine department/ forensic unit Incidence of actual errors in blood transfusion

≥ 80%

Monthly

≥ 90%

6 Monthly

Yearly

≤ 0.3% ≥ 75%

Monthly 3 Monthly

≤ 0.9%

Monthly

< 5%

6 Monthly

≥ 80%

6 Monthly

≤ 2.5

6 Monthly

≥ 75%

6 Monthly

Monthly

≥ 95%

Monthly

≥ 80%

6 Monthly

CUSTOMER FOCUS 20

Percentage of prescriptions dispensed within 30 minutes Percentage of satisfied hospital customer (based on customer satisfaction survey) with the hospital services

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

22 23 24

Percentage of acknowledgement letters given upon receiving written complaint within one (1) working day. Percentage of MTC RED patients who were attended by ED staff IMMEDIATELY. Percentage of MTC Yellow patients whereby treatment was instituted by ED staff within (<) 30 minutes Percentage of medical reports prepared within the stipulated period: State& Specialist Hospitals: ≤ 4 weeks Other Hospitals: ≤ 2 week

≥ 80%

3 Monthly

100%

Monthly

≥ 85%

Monthly

≥ 90%

Monthly (Cohort)

EMPLOYEE SATISFACTION

Percentage of officer who was informed of their performance marks by the first evaluation officer (for Annual Performance Evaluation Report, (LNPT). Percentage of new staff who attended an Orientation Program within 3 months of being posted to the unit or department or hospital.

≥ 95%

Yearly

≥ 80%

6 Monthly

LEARNING AND GROWTH

Percentage of paramedics in acute care areas who have CURRENT TRAINED STATUS in Basic Life Support (BLS) in a year.

≥ 70%

6 Monthly

Percentage of staffs that successfully attained the requirement of 7 days compulsory training in a year.

≥ 75%

Yearly

FINANCIAL AND OFFICE MANAGEMENT

Percentage of hospital’s vehicles that conformed to the Planned Preventive Maintenance (PPM) schedule. Percentage of personnel who were confirmed in service within 3 years of their date of appointment.

≥ 80%

3 Monthly

≥ 95%

3 Monthly (3 years cohort)

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Percentage of bills paid within 14 working days from the date of acceptance receipt (of the bill) Percentage of assets and inventory in the hospital that was inspected and monitored at least once a year. Percentage of personnel with complete documentation at least 6 months prior to time-based promotion in the corresponding year.

≥ 95%

Monthly

100%

Yearly

≥ 90%

6 Monthly

ENVIRONMENTAL SUPPORT 35

Percentage of hazards identified whereby control measures had been taken. Percentage of equipment and engineering systems whereby “uptime” for facilities engineering and biomedical engineering was successfully achieved. Percentage of meetings with the Board of Visitors (Ahli Lembaga Pelawat) that were conducted by the Hospital in a year a) Psychiatric Hospital/Psychiatric Institution ≥ 12 times b) Other Hospital ≥ 4 times. Percentage of issues raised in the meeting with the Board of Visitors (Ahli Lembaga Pelawat) whereby response and action had been taken.

≥ 80%

6 Monthly

≥ 90%

Yearly

100%

Yearly

≥ 70%

6 Monthly

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) TECHNICAL SPECIFICATION OF HOSPITAL PERFORMANCE INDICATOR FOR ACCOUNTABILITY Indicator 1

: STEMI Case Fatality Rate

Element Rationale

: Internal Business Process :  Cardiovascular diseases accounted for the 25.6% of deaths in Ministry of Health (MOH) Hospitals in 2011. The majority of cardiovascular deaths are attributed to acute coronary syndrome (ACS). This is a spectrum of disease with 3 accepted classes: a) ST elevation Myocardial Infarction (STEMI) b) Non-ST elevation Myocardial Infarction (NSTEMI) c) Unstable angina (UA).  STEMI is a component of Acute Coronary Syndrome

which is a major cause of hospital death. Definition of Terms

Criteria

: STEMI: ST Elevation Myocardial Infarction (STEMI). It is diagnosed by: i. Clinical history of ischemic type chest pain ii. ECG changes – The following are integral to the diagnosis of STEMI: New onset ST-segment elevation of: - ≥ 0.1 mV in 2 contiguous limb leads, or V4 to V6 and/or - ≥ 0.2 mV in 2 contiguous precordial leads V1 to V3 Presumed new left-bundle branch block iii. Evidence of myocardial injury or necrosis as indicated by elevated serum cardiac biomarkers Diagnosis of STEMI is in accordance with the National CPG Management of Acute ST Segment Elevation Myocardial Infarction (2nd Edition) April 2007 : Inclusion criteria: 1. Patient with STEMI as the primary diagnosis. Exclusion criteria: 1. Death on arrival at Emergency Department/ Unit. 2. STEMI complicated with shock.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Type of indicator Numerator Denominator Formula Standard Data collection

Remarks

: Rate-based outcome indicator : Number of patients diagnosed and admitted with STEMI and who died from STEMI : Total number of patients diagnosed and admitted with STEMI : Numerator x 100% Denominator : ≤ 15% : 1. Where: Data will be collected in respective department/ward that caters to the above condition. 2. Who: Data will be collected by Officer/ Nurse incharge. 3. How frequent: Monthly data collection sent to the Clinical Quality Unit. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director before being submitted to the JKN. 5. How to collect: How to collect: Data will be collected from record book/ patient file.  For Hospitals with specialist, it is suggested that data to be collected in the Medical Ward only (inclusive of CCU or CRW or any sub-specialty of medical discipline).  For Hospitals without specialists, it is suggested that data to be collected in wards that cater to the above illness.

Indicator 2

: Non STEMI/ Unstable Angina Case Fatality Rate

Element Rationale

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) c) Unstable angina (UA).  Mortality rates quoted in the Malaysian Acute Coronary Syndrome (ACS) Registry maintained by the National Heart Association of Malaysia are 9% for NSTEMI

and

for

between

2006

and

2010.Survival is dependent on good monitoring with prompt and continued use of specific medication (antiplatelets, anti-thrombotics, hypolipidemic therapy, Bblockers and ACE-Inhibitors).  NSTEMI/UA is a component of Acute Coronary

Syndrome which is also a major cause of hospital death. Definition of Terms

: Non ST Elevation Myocardial Infarction (NSTEMI): A clinical syndrome of acute myocardial death defined by a rise in cardiac biomarkers in the absence of ST elevation on the Electrocardiograph (ECG). The biomarkers used may include any of the following; Troponin T/I, Creatinine Kinase or its MB fraction (CK, CKMB). Unstable Angina (UA): A clinical syndrome comprising chest pain or its equivalent with or without ST depression and T wave inversion on the ECG and in the absence of raised cardiac biomarkers.

Criteria

Diagnosis of NSTEMI/ UA is in accordance with the National CPG Management of Unstable Angina/Non ST Elevation Myocardial Infarction (UA/NSTEMI) June 2011. : Inclusion criteria: 1. Patient with NSTEMI/ UA as the primary diagnosis. 2. Patient who died from cardiovascular causes (STEMI, NSTEMI, ACS, pulmonary oedema, dysrhythmia, cardiac tamponade, valvular dysfunction, cardiac failure, and cardiogenic shock) Exclusion criteria: 1. Death on arrival at Emergency Department. 2. Patients with NSTEMI who died of a non-

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) cardiovascular diagnosis e.g. Sepsis, Pneumonia, Stroke. 3. Presumed NSTEMI (diagnosis was not confirmed). Rate-based outcome indicator Number of patients diagnosed and admitted with NSTEMI/UA and who died from NSTEMI/UA Total number of patients diagnosed and admitted with NSTEMI/UA Numerator x 100% Denominator ≤ 10% 1. Where: Data will be collected in respective department in the hospital or wards that cater the above condition. 2. Who: Data will be collected by Officer/ Nurse incharge. 3. How frequent: Monthly data collection and sent monthly to the Clinical Quality Unit. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director before being submitted to the JKN 5. How to collect: Data will be collected from registration book/patient file  For Hospitals with specialist, it is suggested that data to be collected in the Medical Ward only (inclusive of CCU or CRW or any sub-specialty of medical discipline).  For Hospitals without specialists, it is suggested that data to be collected in wards that cater to the above illness.

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

: :

Remarks

Indicator 3

: Dengue Case Fatality Rate (for all categories of patients)

Element Rationale

: Internal Business Process : Dengue fever has now become endemic in Malaysia and is a potentially fatal condition whose severity and frequency may be decreased by careful management planning. This indicator is a measure of the outcome of care of patients with dengue fever.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Definition of Terms

Criteria

: Dengue: Dengue fever (DF) and severe dengue. This is a clinical diagnosis decided by the medical doctor based on clinical findings as well as the relevant investigations. All categories of patients: Refer to all categories of patientâ&#x20AC;&#x2122;s age. The reporting will be inclusive of paediatric and adult patients. : Inclusion criteria: NA

Type of indicator Numerator Denominator Formula

: : : :

Standard Data collection

: :

Exclusion criteria: 1. Dengue is not the primary diagnosis e.g. Patients who had pre-existing serious medical illness besides dengue which was later the more dominant cause of the death (e.g. advanced cancer, patients with blood dyscrasias, etc.). 2. Patient dies within 24 hours admission. 3. Patient admitted 6 days after onset of illness. Rate based outcome indicator Number of dengue deaths Total number of dengue cases Numerator x 100% Denominator < 0.2 % 1. Where: For Hospitals with specialist, it is suggested that data to be collected in the Medical Ward and Paediatric Medical Ward however for Hospitals without specialist, it is suggested that data to be collected in all wards that cater for the above illness. 2. Who: Data will be collected by ward manager/staff incharge. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from registration book/patient file.

Remarks

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Indicator 4

: Community-acquired pneumonia death rate (in previously healthy children aged between 1 month and 5 years)

Element Rationale

: Internal Business Process : Pneumonia is a common childhood infection where mortality can be reduced by careful management planning. : Community acquired pneumonia (CAP): Community acquired pneumonia is pneumonia (lung infection) acquired from normal social contact as opposed to being acquired during hospitalization and confirmed by radiological or laboratory investigations.

Definition of Terms

Criteria

Previously healthy: Paediatric patients who are not known to have any serious medical illnesses before this (e.g. Chronic childhood asthma, severe malnutrition, etc.). : Inclusion criteria: NA Exclusion criteria: 1. Patients younger than 1 month and older than 5 years. 2. Hospital acquired pneumonia. 3. Children with co-morbid conditions e.g cardiac, chronic lung disease, severe neurological conditions causing restrictive lung disease, etc. 4. Epidemics of CAP.

Type of indicator Numerator

Denominator Formula Standard Data collection

: Rate-based outcome indicator : Number of deaths due to Community acquired pneumonia(CAP) in previously healthy children age between 1 month to 5 years : Total number of cases admitted for CAP in previously healthy children age between 1 month to 5 years : Numerator x 100% Denominator : â&#x2030;¤ 1% : 1. Where: For Hospitals with specialist, it is suggested that data to be collected in the Paediatric Medical Ward. For Hospitals without specialist, it is suggested

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

2. 3. 4.

that data to be collected in wards that caters for the above illness. Who: Data will be collected by ward manager/staff incharge. How frequent: Monthly data collection. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. How to collect: Data will be collected from registration book/patient file.

Remarks

Indicator 5

: Percentage of paediatric patients with unplanned readmission to the paediatric ward within 48 hours of discharge

Element Rationale

: Internal Business Process : Unplanned readmission is often considered to be the result of suboptimal care in the previous admission leading to readmission. : Unplanned readmission: Patient being readmitted for the management of the same clinical condition he or she was discharged with and the admission was not scheduled.

Definition of Terms

Criteria

Type of indicator

Same condition: Same diagnosis as refer to the ICD 10. : Inclusion criteria: 1. Readmission with similar conditions (primary diagnosis). Exclusion criteria: 1. Neonates. 2. Patients of > 12 years of age. 3. AOR (at own risk) discharge patients during the first admission 4. Patient with chronic illness 5. Patients re-admitted at different hospital (difficult in data collection and reporting). : Rate-based process indicator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Numerator

Denominator Formula Standard Data collection

Remarks

: Number of paediatric patients with unplanned readmission to the paediatric ward within 48 hours of discharge : Total number of paediatric patients discharged : Numerator x 100% Denominator : â&#x2030;¤2% : 1. Where: For Hospitals with specialist, it is suggested that data to be collected in the Paediatric Medical Ward. For Hospitals without specialist, it is suggested that data to be collected in wards/department that cater for the above illness. 2. Who: Data will be collected by ward manager/staff incharge. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from registration book/patient file/admission and discharge monitoring system. :

Indicator 6

: Percentage of cases Haemorrhage (PPH)

with

Massive

Element Rationale

: Internal Business Process : 1. The incidence of massive obstetric haemorrhage is reflective of the effectiveness of the management of haemorrhage at delivery. Post-partum haemorrhage occurs in 3-5% of pregnant mothers and is still the leading cause of maternal death in Malaysia. The use of this indicator would be reflective of prompt diagnosis and speed of instituting multidisciplinary care. References: a) Green-top Guideline No. 52, May 2009. b) CEMD Training Module for PPH. c) Hazra S et al. J Obstet Gynaecol 2004 Aug: 24 (5)

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

Post-partum

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 519-20. Definition of Terms

Criteria

Type of indicator Numerator Denominator Formula Standard Data collection

Remarks

: Massive PPH: Massive post-partum haemorrhage defines as total amount of blood loss of > 1.5 litres within 24 hour of delivery. Delivery includes both the vaginal and abdominal routes. : Inclusion criteria: 1. Inclusive of primary PPH (within 24 hours). Exclusion criteria: 1. Cases of PPH occurring as a result of deliveries outside the hospital. 2. Patients with adherent placenta. : Rate-based outcome indicator : Number of cases (patients) with Massive post-partum haemorrhage > 1.5 litres within 24 hours of delivery : Total number of patients delivered : Numerator x 100% Denominator : ≤ 1% : 1. Where: Data will be collected in Labour room/ward. 2. Who: Data will be collected by Officer/ Nurse incharge. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from registration or record book/ patient’s case note/OT notes. :  It is suggested that amount of blood loss were assess/estimate by the most experience personnel.

Indicator 7

: Percentage of ambulance preparedness and dispatch for primary response within (≤) 5 minutes

Element Rationale

: Internal Business Process : 1. Delay in ambulance dispatch and response time may contribute to increase morbidity and mortality. 2. The aim is to reduce the ambulance response time and

ensure an appropriate ambulance response in order to CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) improve pre-hospital care. Definition of Terms

: Ambulance preparedness: Appropriate ambulance that is capable of providing basic emergency medical and trauma care. Ambulance dispatch: The mobilization of ambulance to the designated destination after the activation call is terminated. Primary response: Initial response and care by emergency medical services (by an ambulance services).

Criteria

Within (≤) 5 minutes: Time taken from the ambulance call was terminated/ completed to the despatch of the ambulance from the hospital to the scene. : Inclusion criteria: NA

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Exclusion criteria: 1. Request for inter-hospital transfer. 2. Patient transportation. 3. Secondary response. 4. Mass Casualty Incident. 5. Non-emergency cases. 6. Diverted calls to other agencies. Rate-based process indicator Number of ambulance preparedness and dispatch for primary response within (≤) 5 minutes Total number of ambulance calls Numerator x 100% Denominator ≥ 90 % 1. Where: Data will be collected from Trauma and Emergency Department/ Transportation Unit. 2. Who: Data will be collected by manager /officer/staff in-charge at Trauma and Emergency Department. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 5. How to collect: Data will be collected from record book/transportation logbook/registration book/ Malaysia Emergency Response Service (MERS) Centre.

Indicator 8

: Percentage of inappropriate triaging (under-triaging): Category Green patients who should have been triaged as Category Red

Element Rationale

: Internal Business Process :  Triage is an essential function of Emergency Departments (EDs), whereby many patients may present simultaneously. Triage aims to ensure that patients are treated in the order of their clinical urgency and that treatment is appropriate. Triage also allows for the allocation of the patient to the most appropriate assessment and treatment area.  Studies have shown that the “under triaging” of critically ill patients can increase their morbidity and mortality due to delay in their resuscitation and the provision of definitive care. Urgency refers to the need for time-critical intervention.  This indicator measures the accuracy and appropriateness of the Triaging system in the Emergency Department (ED) to ensure that critically ill patients are not missed and categorized as “noncritical”.

Definition of Terms

Under-triaged: Critically ill patient (MTC Red) who was triaged as non-critical patient (MTC Green).

Criteria

: Inclusion criteria: NA Exclusion criteria: 1. Period of time when the hospital unable to function as usual because involved in mass casualty/ disaster/ crisis.

Type of indicator

: Rate-based outcome indicator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Numerator Denominator Formula Standard Data collection

Remarks

: Number of patients with MTC GREEN patients who should have been triaged as MTC RED : Total number of MTC GREEN patients : Numerator x 100% Denominator : ≤ 0.5% : 1. Where: Data will be collected in Trauma and Emergency Department (Red Zone and Green zone)/ Unit. 2. Who: Data will be collected by Manager/Officer/ Nurse in-charge. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/patient case notes  It is detected based on finding during the patient attending medical advice at the same setting.  Under-triaged will be certified by the Medical Officer or Senior Paramedic (other paramedics who did not triage the same case).

Indicator 9

: Percentage of turnaround time within (≤) 45 minutes of Urgent plain radiographic examination requested by Trauma and Emergency Unit/ Department.

Element Rationale

: Internal Business Process : For a radiological examination to have any impact on patient management, it should be available to the clinician in a timely manner. : Turnaround time: The time taken between receiving the order for the plain radiographic examination at the Diagnostic & Imaging Department/ X-ray Unit counter to the time the x-ray film is available for viewing by the doctor within 45 minutes.

Definition of Terms

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Plain radiographic examination: Is the use of x-rays (static x-ray and portable x-ray) to visualize the internal structures of a patient without using any contrast. This include chest x-rays, skeletal x-rays, abdominal x-rays etc.

Criteria

Type of indicator

Urgent Plain radiographic examination: Urgent x-ray that ordered by Emergency Department Medical Officer/ Paramedics (ordered/ requested due to emergencies). : Inclusion criteria: 1. All urgent plain radiographic examination performed on patients in Trauma and Emergency Unit/ Department. 2. Inclusive of portable x-rays. Exclusion criteria: 1. Period of time when the hospital unable to function as usual because involved in mass casualty/ disaster/ crisis. 2. If the delay was due to life-saving procedures that were being given in order to stabilize the patient’s condition (e.g. the x-ray cannot be done after ordering has been made because the emergency team is resuscitating the patient). : Rate-based process indicator

Numerator

: Number of urgent plain radiographic examination with turnaround time within (≤) 45 minutes requested by Trauma and Emergency Unit/ Department.

Denominator

: Total number of urgent plain radiographic examination requested by the Trauma and Emergency Unit/ Department

Formula

: Numerator x 100 % Denominator

Standard Data collection

: ≥ 80% : 1. Where: Data will be collected in the Diagnostic & Imaging Department/ X-ray Unit. 2. Who: Data will be collected by Officer/ staff in-charge in Diagnostic & Imaging Department/ X-ray Unit. 3. How frequent: Monthly data collection.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration book at Diagnostic & Imaging Department/ X-ray Unit. :  The Diagnostic & Imaging Department/ X-ray Unit are responsible on achieving the performance.  It is suggested that CLOCK IN time (time of the urgent plain radiographic examination request received) and CLOCK OUT time (time that plain radiographic examination is available) to be recorded at the Diagnostic & Imaging Department/ X-ray Unit.  The CLOCK IN time will be written in the request book by the medical personnel who send the request.

Indicator 10

: Percentage of laboratory turnaround time for urgent (STAT) Full blood count (FBC) within (≤) 45 minutes

Element Rationale

: Internal Business Process : 1. FBC is basic and commonly requested Haematology test for the assessment of blood cell parameters .FBC reports are crucial to the most clinical patient’s management. 2. A short timely availability (laboratory turnaround time) is one of the indicators of efficient laboratory service.

Definition of Terms

: Laboratory turnaround time: Interval between receiving of the FBC specimen and the results prepared by the lab. This is not inclusive of the time taken for collecting the blood (e.g. drawing the blood, dispatching to the lab)until the FBC specimen received by the laboratory and the time of result being despatched to the ward : Inclusion criteria: 1. All urgent (STAT) FBC request by Medical Personnel.

Criteria

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Remarks

Exclusion criteria: 1. During period of time when the hospital unable to function as usual because involved in mass casualty/ disaster/ crisis. Rate-based Process Indicator Number of urgent (STAT) FBC done and the results received within (≤) 45 minutes Total number of urgent (STAT) FBC ordered Numerator x 100 % Denominator ≥ 90% 1. Where: Data will be collected in the Pathology Department/ Laboratory Unit. 2. Who: Data will be collected by officer/personnel incharge. 3. How frequent: 6 Monthly data collection 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: In hospital without HIS to monitor the performance, it is suggested that 25% sampling of total urgent (STAT) FBC method be applied. In hospitals with HIS and feasibility of data collection, it is suggested that ALL urgent (STAT) FBC to be analysed. Data will be collected from record book/ registration book/request book.  It is suggested that CLOCK IN time (time of the urgent (STAT) FBC request received) and CLOCK OUT time (time that urgent (STAT) FBC is available) to be recorded at Pathology Department/ Laboratory Unit.  The CLOCK IN time will be written in the request book by the medical personnel who send the request.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Indicator 11

: Hospital possesses “current” accreditation or ISO certification (Yes = 1; No = 0)

Element Rationale

: Internal Business Process : Achieving Hospital Accreditation status or ISO certification demonstrates that the organisation has an effective and patient-centred Quality Management System. : “Current”: Valid and up-to-date.

Definition of Terms

Accreditation: 1 year, 3 years or 4 years status, by the MSQH.

Criteria

ISO certification: For whole or most part of organisation : Inclusion criteria: NA

Type of indicator Numerator Denominator Formula Standard Data collection

: : : : : :

Remarks

Exclusion criteria: 1. Hospitals that is not included in the contract agreement for accreditation between the MOH & MSQH for the current year. Outcome Indicator Current Accreditation or ISO status: Attained or Renewed NA Numerator Performance Achieved or Sustained Accreditation/ ISO status (1) 1. Where: Data will be collected from Hospital Director Office or Unit/Department assign by Hospital Director. 2. Who: Data will be collected by Officer/ staff of Unit/department in-charge and assign by Hospital Director. 3. How frequent: Yearly data collection. 4. Who should verify: All performance data must be verified by the Hospital Director. 5. How to collect: Data will be collected from record book/ Accreditation or ISO Certificate.  Hospitals are encouraged to go for Accreditation. However in the case of structural issues which prevent hospitals from undergoing accreditation survey, they are advised to go for ISO Certification.  If hospital/ institution are accredited by external body/

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)



organisation that approve by MOH also count in numerator. National Blood Bank (Pusat Darah Negara)/ regional blood centre use ISO 15189.

Indicator 12

: Hospital MRSA infection rate

Element Rationale

: Internal Business Process : Hospital Infection Control Committees must undertake intense surveillance of the incidence of sentinel organisms such as Methicillin-Resistant Staphylococcus Aureus (MRSA), which is a proxy indicator of the effectiveness of their infection control programme. : Methicillin-Resistant Staphylococcus Aureus (MRSA) is an organism that is resistant to a number of widely used antibiotics (multidrug resistant organism). It is also called a “superbug”. : Inclusion criteria: 1. New cases only.

Definition of Terms

Criteria

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Exclusion criteria: 1. Cases previously identified at other hospitals (known imported cases). 2. Cases from the Emergency Department, Clinic or Outpatient Department. 3. Cases re-admitted with the same organism within one year. 4. Screening culture. Rate-based outcome indicator Number of patients with MRSA (new cases) in the hospital Total number of patients admitted to the hospital Numerator x 100% Denominator ≤ 0.3% 1. Where: Data is collected from the lab 2. Who: Data will be collected by Officer/ Nurse incharge/ infection control unit/ team.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 3. How frequent: Monthly data collection sent to the Clinical Quality Unit. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data is collected daily from the lab by infection control staff/personnel/unit. The monthly compilation of data will be verified by the chairman of infection control committee or the Hospital Director.

Remarks

Indicator 13

: Hand hygiene compliance rate

Element Rationale

: Internal Business Process : To avoid the transmission of harmful germs and prevent health care-associated infections. : Hand Hygiene: Any action of hygienic hand antisepsis in order to reduce transient microbial flora (generally performed either by hand rubbing with an alcohol-based formulation or hand washing with plain or antimicrobial soap and water).

Definition of Terms

Criteria

The Opportunity: Is an accounting unit for the action; it determines the need to perform to hand hygiene action, whether the reason (the indication that leads to the action) be single or multiple. : Inclusion criteria: 1. Any health care worker involved in direct or indirect patient care.

Type of indicator Numerator

: :

Denominator Formula

: :

Exclusion criteria: NA Rate-based process indicator Number of hand hygiene actions (wash or rub) performed Total number of opportunities observed Numerator x 100 % Denominator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Standard Data collection

Remarks

: ≥ 75% : 1. Where: Data is collected from infection control unit/team 2. Who: Data will be collected by Officer/ Nurse incharge/infection control unit. 3. How frequent: 3 Monthly data collection sent to the Clinical Quality Unit. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director.  How to collect: Data is collected by infection control personnel based on policy and guidelines on Hand Hygiene Audit 2013. :  Number of samples for each hospital is based on policy and guidelines on Hand Hygiene Audit 2013.

Indicator 14

: Percentage of intravenous (IV) line complications

Element Rationale

: Internal Business Process : Incident of intravenous (IV) line complications can have an impact on the health of the patient as they can cause discomfort, pain and also prolong in-patient stay. Patient can also suffer from economic consequences.

Definition of Terms

: Intravenous line:  All line connected to the blood vessels.  Intravenous therapy or IV therapy is the infusion of liquid substances directly into a vein. Complications: Related to IV line, ranging from Grade 2 to 4. GRADING DESCRIPTION Grade 2 Pain at access site with erythema and/or oedema. Grade 3 Pain at access site with erythema and/or oedema, streak formation, palpable venous cord.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Grade 4

Criteria

Pain at access site with erythema and/or oedema, streak formation, palpable venous cord greater than 1 inch in length, purulent discharge. : Inclusion criteria: 1. All admitted patients with peripheral venous cannula. 2. Complications Grade 2 to 4. 3. The peripheral cannula that inserted in current admission.

Type of indicator

Exclusion criteria: 1. “Double counting” i.e. the complication that has been counted during previous admission. : Rate-based outcome indicator

Numerator

: Number of intravenous (IV) line complications

Denominator

: Total number of inserted peripheral venous cannula

Formula Standard

: Numerator x 100% Denominator : ≤ 0.9%

Data collection

Remarks

1. Where: Data will be collected from every ward of the hospital. 2. Who: Data will be collected by ward manager/ staff nurse/personnel in charge of the ward. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data willl be collected from record book/ patient case notes. :  For the State or Specialist Hospitals or Hospitals with >100 beds, it is suggested that 25% sampling is applied to the total number of peripheral venous cannula.  The 25% sampling means that 25% of peripheral venous cannula being taken as denominator.  The sampling is suggested to be randomised and the numbers of samples are based previous month total peripheral venous cannula.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Indicator 15

: Rate of healthcare associated infections (HCAI)

Element Rationale

: Internal Business Process : 1. Healthcare associated infections are preventable illnesses and the prevention of these infections continues to be a priority. 2. Surveillance is essential to assess the effectiveness of

the infection control programme. Definition of Terms

Criteria

: Healthcare associated infections: An infection occurring in a patient in a hospital or other healthcare facility in whom the infection was not present or incubating at the time of admission. This includes the infections acquired in the hospital but appearing after discharge, and also occupational infections among staff of the facility. The infections comprise of urinary tract infection, pneumonia, blood-stream infection, surgical site infection and clinical sepsis. (Point Prevalence Survey For Healthcare Associated Infection Surveillance, Second Edition 2013). : Inclusion criteria: 1. All patients admitted to the ward before or at 8.00am and not discharged from the ward at time of survey.

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

: :

Exclusion criteria: 1. Patient in Psychiatric Ward, Emergency Department, Labour Room, Outpatient Department, Day care. Rate-based Process Indicator Number of patient with HCAI in the hospital on the day of survey Number of hospitalised present in the hospital on the day of survey Numerator x 100% Denominator < 5% 1. Where: Data will be collected from every wards of the hospital except place in exclusion criteria. 2. Who: Data will be collected by the infection control personnel/team. 3. How frequent: 6 Monthly data collection. Data will be

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) sent to JKN within 1 month after the survey. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Chairman of the infection control committee or Hospital Director 5. How to collect: Data is collected through hospital wide cross sectional point prevalence survey which is conducted twice a year (i.e. One day in the month of March and September). Remarks

Indicator 16

: Percentage of Morbidity or Mortality Audits/ Meeting being conducted at the hospital level with documentation of cases discussed. ď&#x201A;ˇ State & Specialist Hospitals: 12 times/year ď&#x201A;ˇ Other Hospitals: 6 times/ year

Element Rationale

: Internal Business Process : 1. Regular morbidity and mortality meetings among department staff examine weakness and shortfalls in the overall management of patients.

Definition of Terms

2. These meetings are not punitive and serve to improve management of patients. : Morbidity: Incidence of ill health. Mortality: The quality or state of being mortal. Morbidity Audits/ Meeting: Discussion of case management regards to patient morbidity, incidence reporting, issue of patient safety, clinical audit (at the hospital level). Mortality Audits/ Meeting: Discussions related to management of the case and cause of death of the patient. (eg: Clinical audit, POMR, MMR, Dengue mortality, TB mortality, Mortality under 5 year of age, Perinatal Mortality Reviews, Inquiries) (At the hospital level).

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

“At the Hospital level”: meeting chaired by hospital director or person appointed by the hospital director and involvement of multi department during the meeting are encouraged. For district hospital/institution, not necessarily multi department involvement. “Conduct”: Audits/ Meeting can be conducted by Hospital Director/ Head of Department/ Appointed Specialist/ Medical Officer/ Paramedics in the hospital. “Documentation”: Certified official minutes or notes taken during the meeting with the list of attendance (certified by Hospital Director).

Criteria

“Official Minutes”: The minutes must be certified by the chairperson of the Meeting or Hospital Directors. : Inclusion criteria: NA

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

: :

Exclusion criteria: 1. During period of time when the hospital unable to function as usual because involved in mass casualty/ disaster/ crisis. 2. Grand Ward Rounds or any activities which don’t have any official documents (minutes) are excluded. Rate-based process indicator Numbers of documented morbidity or mortality audits/ meeting that were conducted in a year. Total number of morbidity or mortality audits/ meeting that scheduled in a year Numerator x 100% Denominator ≥ 80% 1. Where: Data will be collected from every department involve/Hospital Director office. 2. Who: Data will be collected by hospital director staff/personnel in charge in department. 3. How frequent: 6 Monthly data collection. 4. Who should verify: All performance data must be

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) verified by Hospital Director. 5. How to collect: The meeting must be organized at hospital level (i.e. it is open to hospital staff across disciplines or departments to join the Meeting). Frequency of Meeting must being scheduled in early of the year. Meeting must be minutes.

Remarks

Indicator 17

: Cross-match transfusion ratio

Element Rationale

: Internal Business Process : 1. Cross-match transfusion ratio is an indicator of appropriateness of blood ordering. A ratio of more than 2.5 reflects excessive ordering of blood cross matching tests thus imposing inventory problems for blood banks, increase in workload, cost and wastage.

2. This indicator is intended to assist in the enhancement of cost efficiency of the cross-matching process, avoid unnecessary additional workload on laboratory personnel and results in better management of blood stocks. Definition of Terms

: Cross-match: A compatibility test carried out on patientâ&#x20AC;&#x2122;s serum with donor red blood cells before blood is transfused. Transfusion: The infusion of cross-matched whole blood or red cell concentrates to the patient. Cross-match transfusion ratio: A ratio of the number of red blood cells units cross-matched to the number of red blood cells units transfused.

Criteria

: Inclusion criteria: 1. All cross-matches done in blood bank. Exclusion criteria: 1. Safe Group O blood given without cross-match in an

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) emergency. Rate-based Process Indicator Number of red cell units cross-matched Number of red cell units transfused Numerator Denominator â&#x2030;¤ 2.5 1. Where: Data will be collected from Blood Bank of the hospital. 2. Who: Blood bank staff/personnel will record and collect the data. 3. How frequent: 6 Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Blood Bank Unit/ Hospital Director. 5. How to collect: Data collected from the registration book/record books/information system in the Blood Bank of the hospital.

Type of indicator Numerator Denominator Formula

: : : :

Standard Data collection

: :

Remarks

Indicator 18

: Percentage of bodies (non-police cases) released to the appropriate claimant within 3 hours at the forensic medicine department/ forensic unit.

Element Rationale

: Internal Business Process : 1. To ensure that the process of management of the deceased is handled effectively, efficiently and with due respect for the dead by the forensic medicine department and forensic unit.

Definition of Terms

2. To expedite the release of bodies to the rightful claimant for burial or cremation in accordance with the respective religious beliefs. Body correctly released: Complete documents are given to the appropriate claimant within 3 hours from the time of receipt of body at the forensic department/ mortuary Appropriate Claimant: 1. Next-of-kin: spouse/s, daughter / son, parents,

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Criteria

siblings, grandparents, first degree relatives e.g. uncles, aunts, cousins, grand-uncles, grand-aunts, and the likes. 2. Authorised representative: representative of nextof-kin and relatives, representative of Embassy/ High Commission, religious authorities, employer. : Inclusion criteria: 1. All bodies (non-police cases) with availability of claimant.

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

: :

Remarks

Exclusion criteria: 1. Unidentified body (no identification/ decomposed body / mutilated body/ skeletonised remains). 2. Incomplete body (only body parts found/ fragmented human bones). 3. Police case Rate-based process indicator Number of bodies (non-police cases) released to the appropriate claimant within 3 hours from the time of receipt of body at the forensic department/ mortuary Total number of bodies (non-police cases) released to the appropriate claimants Numerator x 100% Denominator â&#x2030;Ľ 75% 1. Where: Data will be collected in Forensic Medicine Department/ Forensic Units. 2. Who: Data will be collected by Assistant Medical Officer/ personnel in-charge. 3. How frequent: 6 monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/request book. ď&#x201A;ˇ It is suggested that CLOCK IN time (time of the claim of the body received at forensic unit/department) and CLOCK OUT time (time release of body to the appropriate next-of-kin / authorized representative) be recorded at Mortuary Unit/ Forensic Department.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)  The CLOCK IN time will be written in the request book by the medical personnel who received the request.  Standard operating procedure (SOP) of releasing body to claimant: - Claimant to produce relevant documents such as marriage certificate, birth certificate, certificate from religious department. - Police report by claimant if necessary to ensure correct next of kin if no supporting documents available.  Penyerahan dokumen dianggap sebagai penyerahan mayat kerana terdapat pelanggan/waris yang menghendaki unit/jabatan forensik mengurus jenazah berkenaan bagi tujuan pengebumian.

Indicator 19

: Incidence of actual errors in blood transfusion

Element Rationale

: Internal Business Process :  Blood transfusion is a complex process which involves several personnel in the blood banks and clinical departments.  Transfusion error can occur at any phase of the transfusion chain. It can be divided into 3 phases: i.

Incidence of sampling and labelling error (clinical departments). Any error occurring from the time of collection to labelling of the patient sample.

ii.

iii.

Incidence of laboratory error Any errors occurring in the laboratory, from the time of the sample received, appropriated test performed till the blood and blood components are released for transfusion. Incidence of administrative error Any errors which occur after the blood released for transfusion, checking and confirmation of the

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) blood and blood components for transfusion by the personnel responsible till the completion of transfusion. Definition of Terms

: Actual errors: Defined as patient was transfused with wrong blood component which is not her/him.

Criteria

: Inclusion criteria: 1. All requests for blood and blood components. Exclusion criteria: 1. If blood / blood component was given upon advice by blood bank, in the following situations: i. Rhesus negative patient was given Rhesus positive blood in an emergency situation. ii. Group O was transfused to a non-group O recipient in an emergency. iii. Group AB recipient transfused with group A or B blood in the absence Group AB blood. 2. Near misses incidents.

Type of indicator Numerator Denominator Formula Standard Data collection

Remarks

: Outcome Indicator : Total number of cases where actual transfusion error occurred : NA : Sentinel event : 0 : 1. Where: Data will be collected from blood bank.(Ward need to inform Blood Bank) 2. Who: Data will be collected/ monitored by officer/ personnel in-charge of Blood Bank. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Blood Bank Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/Incident Reporting. :

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Indicator 20

: Percentage of prescriptions dispensed within 30 minutes

Element Rationale

: Customer Focus : Long waiting time can adversely affect patient’s satisfaction. : Dispense: Process of delivering medication to the patient.

Definition of Terms

Criteria

Dispensed within (≤) 30 minutes: Time taken from prescription being received by the staff at pharmacy counter to the time that the medication is delivered to the patient during office hours. : Inclusion criteria: 1. Prescription received from outpatient department/ specialist clinic/ follow up clinic.

Type of indicator Numerator Denominator Formula

: : : :

Standard Data collection

: :

Exclusion criteria: 1. Incomplete prescription. 2. Prescription received after office hours. 3. Prescription received during weekends/ public holidays. 4. Interruption of medicine supply due to medicines temporarily being out of stock or/and medicines not in the MOH Drug Formulary/facility formulary lists. Rate-based process indicator Number of prescriptions dispensed within 30 minutes Total number of prescriptions dispensed Numerator x 100% Denominator ≥ 95% 1. Where: Data will be collected from Pharmacy Department/ Unit. 2. Who: Staff/personnel in Pharmacy Department/ Unit will record and collect the data. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by the Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: In hospitals without QMS (Queue Management System)/ HIS (Hospital Information

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

System)/ other related system to monitor the performance, it is suggested that 25% sampling of total dispensing record is applied. In hospitals with QMS/ HIS/ other related system, it is suggested ALL dispensing time to be analysed. :  It is suggested that the CLOCK IN time (time of the prescription received) and CLOCK OUT time (time that prescription dispensed to patient) to be recorded at Pharmacy Department/ Unit.

Indicator 21

: Percentage of satisfied hospital customer (based on customer satisfaction survey) with the hospital services

Element Rationale

: Customer Focus : Customer satisfaction survey may help in recognizing areas of improvement in the services provided. : Hospital customer: Patients.

Definition of Terms

Satisfaction survey: Is a survey that conducted through SERVQUAL or any customer satisfaction survey that has been gazetted by the MOH.

Criteria

Type of indicator

Satisfied:  Responding to Question 18 as satisfied or very satisfied.  Based on latest accepted satisfaction status analysis by MOH. : Inclusion criteria: 1. Customer who participates in the customer satisfaction survey. Exclusion criteria: 1. Hospitals involved in mass casualty incidents/ disaster for more than 6 months. 2. Hospitals involved in major renovations/ structural problems which result in service displacement. 3. Psychiatric and paediatric patients. : Rate-based process indicator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Numerator Denominator Formula Standard Date collection

Remarks

: Number of participating hospital customer who are “satisfied” in the customer satisfaction survey : Total number of customers participating in customer satisfaction survey : Numerator x 100% Denominator : ≥ 80% : 1. Where: Data will be collected from hospital except at paediatric and psychiatric clinics/wards. 2. Who: Data will be collected/ monitored by officer/ personnel in-charge for the indicator assign by Hospital Director. 3. How frequent: 6 monthly data collection. Customer Satisfaction Survey must be conducted twice a year. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from patients follows customer satisfaction survey SERVQUAL methodology :

Indicator 22

: Percentage of acknowledgement letters given upon receiving written complaint within one (1) working day

Element Rationale

: Customer Focus : Any written complaint received by the hospital need to be taken seriously in order to improve quality of services. : Acknowledgement letter: A letter confirmed the complaint has been received by the hospital to the complainant.

Definition of Terms

Criteria

Written complaint: Complaint that is received in writing via letters or email. : Inclusion criteria: 1. The complaint must be complete with name and address (home/ office or email address) of the complainant.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2. The complaint must be received by the hospital through the complaint/ suggestion box or hospital staff or e-mail. 3. Integrated Sistem Pemantauan Aduan Agensi Awam (i-SPAAA) for hospital/institution involved.

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Remark

Exclusion criteria: 1. Incorrect name or address of the complainant which prevent the acknowledgment letter from being sent. 2. Verbal complaints. 3. Print media. 4. Complaints in facebook/blog. Rate-based process indicator Number of acknowledgement letter issued within (≤) 1 working day upon receiving written complaint Total number of written complaint received Numerator x 100% Denominator ≥ 80% 1. Where: Data will be collected from Hospital Director Office 2. Who: Data will be collected/ monitored by officer/ personnel in-charge for complaint. 3. How frequent: 3 monthly data collection. 4. Who should verify: All performance data must be verified by Hospital Director. 5. How to collect: Data collect from record/registration book/generated thru Integrated Sistem Pemantauan Aduan Agensi Awam (i-SPAAA).  All complaints are suggested to be taken as denominator.  Example, any complaint that received today (within office hour to the Hospital Administrative Unit) is suggested to be responded before 5 pm next working day.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Indicator 23

: Percentage of MTC Red patients who were attended by ED staff immediately.

Element Rationale

: Customer Focus : 1. Triage is an essential function of Emergency Departments (EDs), where many patients may present simultaneously. Triage aims to ensure that patients are treated in the order of their clinical urgency and that their treatment is appropriate and timely. It also allows for allocation of the patient to the most appropriate assessment and treatment area and is in line with the Circular of the Director-General of Health Malaysia No. 6/2004 – Steps to Reduce Waiting Time in MOH Facilities. 2. This indicator measures the time taken for the patient to be seen by Emergency Department staff (from the time of his/ her registration) based on the relevant waiting times of the Malaysian Triage Category (MTC).

Definition of Terms

: Immediately: Initiation of assessment and/or treatment within (≤) 5 minutes (as defined in MTC) by ED staff. Triage Category (TC): - The category assigned to a patient as a result of an initial assessment by medical or nursing staff in an Accident and Emergency Department. - The triage category is used to determine the patient's priority of treatment, and to inform the patient of their waiting time.

Criteria

ED staff: 1. Hospital with resident Emergency Physician: Emergency Physician/ Medical officers/ House officers. 2. Hospital without resident Emergency Physician: Medical officers/ Paramedics. : Inclusion criteria: 1. All MTC Red cases.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Exclusion criteria: 1. During Mass Casualty Incidence as defined by the local Disaster Action Plan. 2. Patients re-triaged from green/ yellow. Rate-based process indicator Number of MTC Red patients who were attended by ED staff immediately Total number of MTC Red patients Numerator X 100 % Denominator 100% 1. Where: Data will be collected in Trauma and Emergency Department/ unit. 2. Who: Data will be collected by Officer/ staff in-charge in Trauma and Emergency Department/ unit. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration book/patient file.

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Remark

:  In hospital without HIS to monitor the performance, it is suggested that 25% sampling of total attended patients is applied.  In hospital with HIS and feasibility of data collection, it is suggested ALL attended patient’s time is suggested to be analysed.

Indicator 24

: Percentage of MTC Yellow patients whereby treatment was instituted by ED staff within (<) 30 minutes

Element Rationale

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2. It also allows for allocation of the patient to the most appropriate assessment and treatment area and is in line with the Circular of the Director-General of Health Malaysia No. 6/2004 – Steps to Reduce Waiting Time in MOH Facilities. 3. This indicator measures the time taken for the patient to be seen by Emergency Department staff (from the time of his/ her registration) based on the relevant waiting times of the Malaysian Triage Category (MTC). Definition of Terms

: Institution of treatment: Initiation of assessment and minimal treatment rendered to the patient such as setting up of IV line, instituting oxygen therapy, placing immobilisation devices eg splints, cervical collar, etc. Within 30 minutes: ≤ 30 minutes (as defined in MTC) ED staff: 1. Hospital with resident Emergency Physician: Emergency Physician/ Medical officers/ House officers. 2. Hospital without resident Emergency Physician: Medical officers/ Paramedics.

Criteria

Triage Category (TC):  The category assigned to a patient as a result of an initial assessment by medical or nursing staff in an Accident and Emergency Department.  The triage category is used to determine the patient's priority for treatment, and to inform the patient of their waiting time. : Inclusion criteria: 1. All cases at the Emergency Unit/ Department categorized as “yellow” that were attended by ED staff. Exclusion criteria: 1. During Mass Casualty Incidence (as defined by the local Disaster Action Plan). 2. Patients re-triaged from red/ green.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Type of indicator Numerator Denominator Formula Standard Data collection

Remarks

: Rate-based process indicator : Number of MTC Yellow patients whereby treatment was instituted by ED staff within (<) 30 minutes : Total number of MTC Yellow patients : Numerator X 100 % Denominator : ≥ 85% : 1. Where: Data will be collected in Trauma and Emergency Department/ unit. 2. Who: Data will be collected by Officer/ staff in-charge in Trauma and Emergency Department/ unit. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration book/patient file. :  In hospital without HIS to monitor the performance, it is suggested that 25% sampling of total attended patients is applied.  In hospital with HIS and feasibility of data collection, it is suggested ALL attended patient’s time is suggested to be analysed.

Indicator 25

: Percentage of medical reports prepared within the stipulated period

Element

: Customer Focus

Rationale

: There is a need to hasten the preparation of medical reports in order to satisfy our customers (especially regards to their insurance claims, police investigations, court proceedings, etc). : Stipulated period: The preparation of medical report must meet the following norms (non-inclusive of public holidays and weekends):  State & Specialist Hospitals: ≤ 4 weeks  Other hospitals: ≤ 2 weeks

Definition of Terms

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Performance Measurement: The performance will calculated at the end the month on how many medical reports were completed within the stipulated period compared to the number of actual completed request.

Criteria

Type of indicator Numerator Denominator Formula Standard Data collection

Remark

Complete request: Application of medical report with complete documentation and requirements fulfilled. : Inclusion criteria: 1. Medical reports include “plain reports” and reports for insurance claims. Exclusion criteria: 1. Specialist report and requests for clarification of a report previously given. 2. Case managed by multidisciplinary team. 3. Report requested by patients who are still under treatment in the hospital. 4. Post mortem report. 5. Report required by Skim Perlindungan Insurans Kesihatan Pekerja Asing (SPIKPA). : Rate-based process indicator : Number of medical reports prepared within the stipulated period : Total number of medical reports prepared in the month : Numerator x 100 % Denominator : ≥ 90 % 1. Where: Data will be collected in medical record office/unit/department 2. Who: Data will be collected by Officer/ staff in-charge in medical record office/unit/department 3. How frequent: Monthly data collection (cohort of previous month) 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration book/monitoring system. :  To streamline the data collection method, the

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)



performance of this month will be calculated based on numerator and denominator of last month (retrospective cohort). Example, July performance were based on data in June.

Indicator 26

: Percentage of officer who were informed of their performance marks by the first evaluation officer (for Annual Performance Evaluation Report, (LNPT))

Element Rationale

: Employee Satisfaction :  The Annual Performance Evaluation Report is an assessment tool to ascertain annual work target, evaluation of behaviour and achievement within certain period of time.  This is important to improve the quality and productivity of the officer and also the department involved. : Officer: Pegawai Yang Dinilai (PYD).

Definition of Terms

First Evaluation officer: Pegawai Penilai Pertama (PPP). Notification: The PPP has notified the PYD about their LNPT mark through HRMIS.

Criteria

Type of indicator

Notified: The PYD has acknowledged through the system the marks they obtained from the evaluation system. : Inclusion criteria: 1. All staff whose evaluation was being carried out by the organization prior to the evaluation. Exclusion criteria: 1. Staff who were transfer to the organization for less than 3 months. 2. Staff undergoing training (e.g. master programme, post basic, PhD, etc) more than 6 months. 3. Staff that being evaluated through the different system or system whereby the acknowledgement component was not established. : Rate-based process indicator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Numerator Denominator Formula Standard Data collection

Remark

: Number of officer notified of their performance mark by PPP : Total number of officer evaluated by the PPP : Numerator x 100% Denominator : ≥ 95% 1. Where: Data will be collected in administrative unit/department. 2. Who: Data will be collected by Officer/ staff in-charge in HRMIS/ Human resource/ Administrative department/ unit. 3. How frequent: Yearly data collection 4. Who should verify: All performance data must be verified by Head of Department/ Head of Human Resource/Administrative Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration book/HRMIS system. :  Data can be collected inclusive to all hospital staff number as denominator OR data is collected thru a simple random survey by the hospital administrative unit to the 25% of the hospital staffs inclusive of all categories (the format of the survey can be created by own hospital).  If the sampling method was applied, the percentage of excluded staffs was also calculated and applied to the denominator.  Final performance must be verified by the Hospital Director.

Indicator 27

: Percentage of new staffs who attended an Orientation Program within 3 months of being posted to the unit or department or hospital

Element Rationale

: Employee Satisfaction : To ensure optimum productivity, the new personnel must be familiar to their environment and Orientation Program must be in place to enable this. : New staff: Personnel that newly registered (transferred in/ newly appointed) to the organization (unit/

Definition of Terms

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) department/ hospital). Orientation Program: Introduction of the new staffs to the system, process, environment of the organization. Orientation in the department can be conducted by Head of Department or senior staff in the department.

Criteria

3 months: Starting from staff’s reporting date/report for duty. : Inclusion criteria: 1. Orientation conducted in the unit/ department/ hospital.

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

Remarks

Exclusion criteria: 1. Staff who leave the department within (≤) 3 months of reporting for duty. 2. Staff who postponed their posting. Rate-based process indicator Number of new staffs who attended Orientation Program within (≤) 3 months of reporting of duty Total number of new staffs registered to the unit/ department/ hospital Numerator x 100% Denominator ≥ 80% 1. Where: Data will be collected in every unit/department/wards. 2. Who: Data will be collected by Officer/ staff in-charge for orientation program in each department/ unit/ wards (Administrative unit/department responsible for overall data collection) 3. How frequent: 6 monthly data collection 4. Who should verify: All performance data must be verified by Head of Department/ Head of Human Resource/Administrative Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/human resource record system.  Staff whom registered after the 31st March or 30th September of the year will be carried to the next term/

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)    

year of the denominator which mean; 1st Term Evaluation: 1st October of the previous year to the 31st March of the current year. 2nd Term Evaluation: 1st April of the current year to the 30th September of the current year. List can be generated once they have been registered. Final performance data must be verified by Hospital Director.

Indicator 28

: Percentage of paramedics in acute care areas who have CURRENT TRAINED STATUS in Basic Life Support (BLS) in a year

Element Rationale

: Learning and Growth : 1. Basic life support is an important skill for all healthcare personnel to possess and is an important element of Continuing Professional Development, which is a vital aspect of professionalism. 2. This requires the continuous updating of the healthcare professional’s knowledge-based in order for evidence-based medicine to be practiced, hence improving the quality and safety of care provided.

Definition of Terms

Criteria

: Acute care area: Trauma and Emergency Department, CCU, ICU, OT, HDW, Labour Room, and inclusive of Haemodialysis Unit. “Current trained” status: Valid period of BLS certification - 5 years according to Policy on Resuscitation Training for Ministry of Health Hospitals. : Inclusion criteria: 1. Personnel who had attended the BLS course are included in the numerator until the valid period of the certification. Exclusion criteria: 1. Staff that had just transfers in or who are in service in

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Remark

the hospital for less than 6 month. 2. Staff on medical leave for more than 6 months. Rate-based process indicator Number of paramedics in acute care areas who have “current trained” status in Basic Life Support (BLS) Total number of paramedics in acute care areas Numerator x 100% Denominator ≥ 70% 1. Where: Data will be collected in each acute care area. 2. Who: Data will be collected by Officer/ staff in-charge for acute care area. 3. How frequent: 6 monthly data collection 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/registration books each unit/department/wards.  Only staffs with “post reporting duty period” of 6 months and above were included as denominator.  Since the validity of the training period is for 5 years, the trained personnel are calculated throughout the 5 years.  It is advised that the training schedule were done properly dividing the denominator to a few months of the scheduled courses.  Since this indicator is an existing indicator, there are performances (numerator) that can be carried through.  Final performance data must be verified by the Hospital Director.

Indicator 29

: Percentage of staffs who successfully attained the requirement of 7 days compulsory training in a year

Element Rationale

: Learning and Growth As accordance to Surat Pekeliling Perkhidmatan Bil. 6/2005 : Dasar Latihan Sumber Manusia Sektor Awam : Staff : 1. Administrative and Professional Group.

Definition of Terms

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2. Support Group I. 3. Support Group II.

Criteria

7 days compulsory training: 1. Number of training days, which is compulsory to be completed by the personnel in the corresponding year. 2. Equivalent to 40 CPD points (MyCPD online). : Inclusion criteria: 1. All courses that organized by MOH, local or external organization/ private sector that are related to MOH/ job scope. 2. Cumulative time on CME attendances conducted at hospital level or departmental level (6 hours equivalent to 1 day course).

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

Exclusion criteria: 1. Staff transfers in less than 6 month by 31 December of corresponding year. 2. Staff who are unable to attend course due to medical reason. 3. Staff on leave or absent for more than 6 months and justified by the Hospital Director. Rate-based Process Indicator Number of staff who successfully attained the 7 days compulsory training requirement Total number of staff Numerator x 100% Denominator â&#x2030;Ľ 75% 1. Where: Data will be collected in each unit/ departments. 2. Who: Data will be collected by Officer/ staff in-charge for training/course in each department/unit (Administrative unit/department is responsible for overall data collection). 3. How frequent: Yearly data collection 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

5. How to collect: Data will be collected from record book each unit/department especially record from Administrative Unit/Department. :  Staff on maternity leave are only required to attend 4 days of compulsory training or proportionately calculated within the same year.  Since all staffs were included as denominator, the data analysis of this indicator only can be generated by end of the year, we do suggested that all staff went for 7 days training by 15th December of the year.  (If 6 month data is collected, it is to alert the hospitals on how many staffs they have to focus on the next sixth month).  Final performance data must be verified by the Hospital Director.

Indicator 30

: Percentage of hospital’s vehicles that conformed to the Planned Preventive Maintenance (PPM) schedule

Element Rationale

: Financial and Office Management : Hospital’s transportation fleet is one of the important assets owned by the hospital. The asset maintenance is important in ensuring optimum condition of the vehicles in order to ensure the safety of their passengers. : Hospital’s vehicles: All vehicles that are registered under hospital.

Definition of Terms

PPM schedule: Maintenance plan that should be followed for each vehicle in a particular period of time.

Criteria

Type of indicator Numerator

Corresponding period/ on schedule: Within +/- 5 working days or +/-500km. : Inclusion criteria: 1. All registered hospital’s vehicle including ambulances. Exclusion criteria: NA : Rate-based process indicator : Number of PPM done on schedule

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Denominator Formula Standard Data collection

Remarks

: Total number of PPM scheduled : Numerator x 100% Denominator : ≥ 80% : 1. Where: Data will be collected in transport unit/administrative unit/departments or unit/ department assign by Hospital Director. 2. Who: Data will be collected by Officer/ staff/unit incharge for Planned Preventive Maintenance (PPM) schedule. 3. How frequent: 3 monthly data collection 4. Who should verify: All performance data must be verified by Head of Department/ Head of Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/transport log book. :  Denominator is calculated based on 3 monthly schedules.  Every 3 month the hospital administrative unit/assign unit should revised the PPM need to the vehicles - all concerned vehicles will be put in the denominator for the performance.  Vehicles which miss the PPM schedule after 5 days or more 500km will be considered as “outlier”.  One vehicle may have many PPM schedules based on kilometres or date schedule.

Indicator 31

: Percentage of personnel who were confirmed in service within 3 years of their date of appointment

Element Rationale

: Financial and Office Management : Surat Pekeliling Suruhanjaya Perkhidmatan Awam Malaysia Bil. 3/ 2011 :(Prosedur dan Kaedah Pengesahan Dalam Perkhidmatan) Seorang pegawai layak disahkan dalam perkhidmatan apabila telah berkhidmat dalam tempoh percubaan bagi tempoh satu (1) hingga tiga (3) tahun dan memenuhi syarat-syarat perkhidmatan. Pengesahan dalam perkhidmatan adalah proses

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Definition of Terms

penting bagi memastikan pegawai yang sesuai dan berprestasi tinggi sahaja kekal dalam perkhidmatan awam. : Personnel: All staff identified in the above circular. Confirmation in service: Confirmation by the SPA/JPA or authorized agency upon receiving the confirmation letter. Date of appointment: The date that is stated in the appointment letter by SPA/JPA or authorized agency.

Criteria

Type of indicator Numerator Denominator

Formula Standard Data collection

Within 3 years: Less of equal to 3 years from the date of appointment. : Inclusion criteria: 1. Staff who are newly appointed or newly promoted to a higher post (Kenaikan pangkat secara lantikan, KPSL). 2. The staff must have a valid appointment or promotion letter by MOH. Exclusion criteria: 1. Staff with disciplinary problem/ under probation. 2. Staff transfers in within 6 months and not being process yet by previous Pusat Tanggungjawab (PTJ). : Rate-based process indicator : Number of scheduled personnel confirm in the service within 3 years from the date of appointment : Total number of personnel who were scheduled for confirmation in the corresponding year : Numerator x 100% Denominator : â&#x2030;Ľ 95% : 1. Where: Data will be collected in human resource /administrative unit/departments. 2. Who: Data will be collected by Officer/ staff/unit incharge for staff confirmation in service. 3. How frequent: 3 monthly data collection (3 years cohort). 4. Who should verify: All performance data must be

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

: 



verified by Head of Administrative Department/Unit/ Deputy Hospital Director (Administrative)/ Hospital Director. How to collect: Data will be collected from record book/ monitoring system in human resource/ administrative unit. Cohort: An aggregation of personnel who scheduled for confirmation within 3 years from the date of appointment. The Hospital Administrative Unit must generate the list of personnel that should apply to the above circular and group into the 3 monthly cohorts on 1st January each year. (The hospital should know in every 3 month whom of their staffs should receive their confirmation).

Indicator 32

: Percentage of bills paid within 14 working days from the date of acceptance receipt (of the bill)

Element Rationale

: Financial and Office Management : 1. Cepat, Tepat, Intergriti (CTI) and Productivity, Creativity, Innovation (PCI) are key directive for public services to ensure efficient and customercentred services that attain customer’s satisfaction. 2. Accordance with Surat Pekeliling Perbendaharaan Bil 7/2006, Bil dan tuntutan dibayar dengan segera tidak lewat daripada 14 hari dari tarikh ianya diterima. : Bill: Refer to the claim of payment for services that received by the hospital. Working days: exclude public holidays and weekend : Inclusion criteria: 1. All bills that fulfil the criteria.

Definition of Terms

Criteria

Type of indicator

Exclusion criteria: 1. Bill with approval issue. 2. System or equipment under testing or commissioning process or failure of the system. 3. Bills received beyond the scheduled date. : Rate-based Process Indicator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Numerator Denominator Formula Standard Data collection

Remarks

: Number of bills paid within 14 working days : Total number of bill issued to the hospital : Numerator x 100% Denominator : ≥ 95% : 1. Where: Data will be collected in Finance unit/administrative unit/departments. 2. Who: Data will be collected by Officer/ staff of Administrative/Finance unit in-charge for bill. 3. How frequent: Monthly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Administrative/Finance Unit/ Deputy Hospital Director (Administrative) / Hospital Director. 5. How to collect: Data will be collected from record book/ bill registrations book/monitoring system in administrative/ Finance unit.  Suggest the denominator will be calculated from 20th day of last month to the 19th day of this month as to acknowledge and absorb the working days issue.  The numerator will be derived from the denominator of the corresponding period.  Types of bills may change depends on latest applicable circular.

Indicator 33

: Percentage of assets and inventory in the hospital that were inspected and monitored at least once a year

Element Rationale

: Financial and Office Management : To ensure the safety and functionality of the asset, they must be regularly inspected and monitored. : Asset: Registered property of the hospital that requires maintenance.

Definition of Terms

Inventory: Registered items that do not need maintenance, furniture and furnishing. Inspect/ monitor: Location of property being assigned, CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Criteria

function being assessed and documentation is complete (eg KEW.PA documentation). : Inclusion criteria: 1. All registered assets that scheduled for monitoring/ inspection.

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Remarks

Exclusion criteria: 1. Property under process of beyond economic repair (BER)/ disposal/ under investigation due to it being lost. Rate-based process indicator Number of asset and inventory that were inspected and monitored Total number of asset and inventory that were registered Numerator x 100% Denominator 100% 1. Where: Data will be collected from administrative unit/departments. 2. Who: Data will be collected by Officer/ staff of Administrative unit in-charge for assets and inventory. 3. How frequent: Yearly data collection. 4. Who should verify: All performance data must be verified by Head of Department/ Head of Administrative/ Deputy Hospital Director (Administrative) / Hospital Director. 5. How to collect: Data will be collected from record book/ registration book/ monitoring system in administrative unit/ department.  By early of the year the list of all assets should be generated by the hospital. Those lists will be taken as a denominator.  Newly registered assets will be carried to the next year’s denominator list.  Since the need is a yearly inspection, the final performance measurement is suggested not later than 15th December of corresponding year.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Indicator 34

: Percentage of personnel with complete documentation at least 6 months prior to time-based promotion in the corresponding year

Element Rationale

: Financial and Office Management : To ensure all eligible officer/ staff are promoted according to schedule. : Complete documentation:  This means that all needed/ required documents for promotion have been prepared.  The monitoring and documents should be prepared by the Administrative/ Human Resource Unit : Inclusion criteria: 1. All eligible staff.

Definition of Terms

Criteria

Exclusion criteria: 1. Staff who transfer in < 6 months during the exercise. 2. Staff under disciplinary action/ investigation (Non competent staff). Type of indicator Numerator Denominator Formula Standard Data collection

: Rate-based structural indicator : Number of eligible staff with complete documentation at least 6 months prior to time-based promotion : Total number of staffs due for time-based promotion : Numerator x 100% Denominator : ≥ 90% : 1. Where: Data will be collected from administrative unit/departments. 2. Who: Data will be collected by Officer/ staff of Administrative unit in-charge for time based promotion. 3. How frequent: 6 monthly data collection. 4. Who should verify: All performance data must be verified by Head of Administrative/ Human Resource/ Department/Unit / Deputy Hospital Director (Administrative) / Hospital Director. 5. How to collect: Data will be collected from record book/ monitoring system in administrative /Human

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

: 



Resource unit/ department Example: Officer/ staff scheduled to get a promotion in July. Therefore, all documents need to be prepared by January. The monitoring and documents should be prepared by the Hospital Administrative/Human Resource Unit. By early of the year, the hospital must identify who are the staffs which eligible to be promoted as according to time based promotion. Both data of 1st and 2nd six months will be calculated separately at the beginning of the year to ensure the denominator is correctly applied. Selain melibatkan kenaikan pangkat time based laluan kerjaya Pegawai Perubatan, Pegawai Pergigian dan Pegawai Farmasi,turut serta pegawai/anggota terlibat dalam Pekeliling Perkhidmatan Bilangan 8 Tahun 2013 :Kenaikan Pangkat Secara Time-Based Berasaskan Kecemerlangan Bagi Pegawai Kumpulan Pelaksana Yang Berada Di Gred Lantikan.

Indicator 35

: Percentage of hazard identified whereby control measures had been taken

Element Rationale

: Environmental (Technical) Support : To ensure safety of the patient and healthcare workers involved. : Hazard: Something/ situation/condition which can cause harm to staff, patient or anyone within the premises. Hazards can be categorized into biological (e.g. blood), physical (e.g. electrical wiring), ergonomic (e.g. awkward posture or repetitive motion) and psychosocial (e.g. overworked).

Definition of Terms

Control measures: - Any effort to reduce the risk related to the hazard through various control measures such as elimination, CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Criteria

substitution, engineering control (e.g. use automation or LEV), administrative control (e.g. SOP, policies or work rotation) and personal protective equipment. Multiple control measure can be used.

Assessment: An assessment that is conducted by the hospital’s Safety and Health Committee (JKKK) to identify the presence of the hazard (Hazard identified thru assessment). : Inclusion criteria: 1. Hazardous areas e.g. CSSD, kitchen, laboratory, Radiology or Diagnostic Imaging Department/Unit, Cytotoxic Drug Reconstitution, Engineering Department (workshop), mortuary,wards, hospital compound

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Exclusion criteria: 1. Areas under construction. Rate-based process indicator Number of hazards identified whereby control measures had been taken within 30 days Total number of hazards that had been identified Numerator x 100% Denominator ≥ 80% 1. Where: Data will be collected from Safety and Health Committee/Occupational Safety and Health (OSH) unit/departments. 2. Who: Data will be collected by Officer/ staff of Safety and Health Committee/ OSH Unit in-charge. 3. How frequent: 6 monthly data collection. 4. Who should verify: All performance data must be verified by the Head of OSH Unit/ Head of Safety and Health Committee/ Hospital Director. 5. How to collect: Data will be collected from record book/ registration book/ Official Assessment report/ Monitoring system in Safety and Health Committee/ Occupational Safety and Health (OSH) unit/ departments.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Remarks

:  Based on requirement in Occupational Safety and Health Act 1994 (Act 514), Safety and Health committee must be establish in the hospital.  An assessment need to be conducted in the hospital to identify hazards.  After control measure had been taken, the Safety and Health Committee will need to discuss the effectiveness of the control measures.  Initiation of control measures needs to be implemented within 30 days of assessment.  The suggested time for assessment is February and August of the corresponding year.  All the hazards should be identified and registered during the assessment.

Indicator 36

: Percentage of equipment and engineering systems whereby “uptime” for facilities engineering and biomedical engineering was successfully achieved

Element Rationale Definition of Terms

: Environmental (Technical) Support : To ensure that all medical devices are optimally used. : “Uptime”: Active time assets being used/ can be used where equipment/ engineered system is fully operational or ready to perform its intended function.

Criteria

: Inclusion criteria: 1. Equipment registered under the QAP engineering system.

Type of indicator Numerator

: :

Denominator

Formula

Exclusion criteria: 1. Equipment that is under beyond economic repair (BER)/ being disposed. Rate-based structural indicator Number of equipment and engineered systems that are being monitored which achieved uptime Total number of equipment and engineered systems that are being monitored Numerator x 100% Denominator

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) Standard Data collection

Remarks

: ≥ 90% : 1. Where: Data will be collected from Engineering Unit/ Regulatory Unit or Unit/ Department assign by Hospital Director. 2. Who: Data will be collected by Officer/ staff in charge of Engineering Unit/ Regulatory Unit or Unit/ Department assign by Hospital Director. 3. How frequent: Yearly data collection. 4. Who should verify: All performance data must be verified by the Head of Engineering Unit/ Regulatory Unit/ Hospital Director. 5. How to collect: Data will be collected from record book/ registration book/ Monitoring system in unit/ departments. :  Collected uptime only can correctly interpret at the end of the year.  Engineering hospital unit must engage with QAP system of MOH Engineering Division.

Indicator 37

: Percentage of meetings with the Board of Visitors (Ahli Lembaga Pelawat) that were conducted by the Hospital in a year a) Psychiatric Hospital/ Institution ≥ 12 times b) Other Hospital ≥ 4 times

Element Rationale

: Environmental(Community) Support : To strengthen the function of an intermediary body between the patient and the hospital management. : Meeting with the Board of Visitors: 1) MOH Hospitals are expected to conduct at least 4 meetings in a year with the Board of Visitors based on the circular by the MOH Secretary General (Pekeliling KSU Bil. 2/ 2006).

Definition of Terms

2) Psychiatric Hospitals/Institution are expected to conduct at least 1 meeting in a month with the Board of Visitors based on Mental Health Act 2001,Psychiatric and Mental Health Services Operational Policy MOH 2011 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) and the circular by the MOH Secretary General (Pekeliling KSU Bil. 3/ 2011).

Criteria

Board of Visitors: Members that are appointed by MOH in accordance with the Secretary General Pekeliling KSU Bil. 2/ 2006 and Pekeliling KSU Bil. 3/ 2011. : Inclusion criteria: NA

Type of indicator Numerator

: :

Denominator

Formula

Standard Data collection

: :

Remarks

Exclusion criteria: 1. During period of time when the hospital unable to function as usual because involved in mass casualty/ disaster/ crisis. Rate-based structural indicator Number of Board of Visitors meetings that were conducted by the hospital in a year Number of Board of Visitors meetings that were supposed to be conducted by the hospital in a year Numerator x 100% Denominator 100% 1. Where: Data will be collected in Administrative unit/ departments. 2. Who: Data will be collected by Officer/ staff in-charge of Administrative unit/department. 3. How frequent: Yearly data collection. 4. Who should verify: All performance data must be verified by Head of Administrative Unit/ Department/ Deputy Hospital Director (Administrative) / Hospital Director. 5. How to collect: Data will be collected from record book/ Official meeting minutes in administrative unit/department.  Meeting is accepted as performance with the availability of official Meeting minutes.  All hospital/institution must establish Board of visitors according above circular/act.

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Indicator 38

: Percentage of issues raised in the meeting with the Board of Visitors (Ahli Lembaga Pelawat) whereby action had been taken.

Element Rationale

: Environmental (Community) Support : To strengthen the function of an intermediary body between the patient and the hospital management. : Board of Visitors: Members that being appointed by MOH as accordance to the Board Visitors Act 1946/ Secretary General (Pekeliling KSU Bil. 2/ 2006/ Bil 1/2007)

Definition of Terms

Criteria

Action taken: Issues/ corrective measures had been addressed in term of proposal or letter being issued within 1 month. : Inclusion criteria: 1. Pertaining to service matter and not against MOH policy/ act/ law.

Type of indicator Numerator

: :

Denominator Formula

: :

Standard Data collection

: :

Exclusion criteria: 1. Issues in which still under investigation or studies (e.g anonymous complaint through Members of Board Visitors). Rate-based process indicator Number of issues raised whereby response and action had been taken Total number of issues raised Numerator x 100% Denominator â&#x2030;Ľ 70% 1. Where: Data will be collected in Administrative unit/ departments. 2. Who: Data will be collected by Officer/ staff in-charge of Administrative unit/department. 3. How frequent: 6 monthly data collection. 4. Who should verify: All performance data must be verified by Head of Administrative Unit/ Department/ Deputy Hospital Director (Administrative) / Hospital Director. 5. How to collect: Data will be collected from record

CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION

TECHNICAL SPECIFICATIONS HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA)

Remarks

book/ Action report/ official meeting minutes/ monitoring system in administrative unit/department. :  The list of issues will be summed in Jun and December and the performance will be extracted accordingly  Administrative Unit is responsible to all issues that action needs to be taken.  Hospital Director must act upon the Minutes; - Writing a request letter (proposing a certain hospital requirement) to a certain party is considered an action. - Solving the issue by meeting a certain party with recorded document is considered an action.  But - Asking the subordinate to perform certain thing it is not considered as an action until the subordinate did the necessary action.

Nota: Sila rujuk Garispanduan Pengukuhan Pelaksanaan dan Aplikasi Hospital Performance Indicator for Accountability (HPIA) dan Petunjuk Prestasi Utama (KPI) Perkhidmatan Klinikal Program Perubatan. Jika terdapat sebarang pertanyaan/ maklumat lanjut berhubung pemantauan indikator HPIA sila hubungi; Urusetia/Sekreteriat HPIA Unit Survelan Pencapaian Klinikal Cawangan Kualiti Penjagaan Perubatan Bahagian Perkembangan Perubatan Kementerian Kesihatan Malaysia 03-88831180 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU) MEDICAL CARE QUALITY SECTION MEDICAL DEVELOPMENT DIVISION