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GENERAL HOSPITAL
OPERATIONAL POLICY
MEDICAL DEVELOPMENT DIVISION
MINISTRY OF HEALTH MALAYSIA
1. PREAMBLE
General Hospital Operational Policy: Specific statement of intent and direction in order to meet
the function of the hospital
Purpose: The purpose of this document is primarily to assist and facilitate hospital management
team to effectively manage the hospital. This serves as guidance and maybe adapted to local
needs. The policies are general statement of intent and direction that cut across the whole
organization in order to achieve the obective of the hospital.
Scope: The scope shall cover ! main components of the hospital i.e. people" technology" wor#
process and structure.
1. MOH VISION & MISSION
MOH Vision
$ nation wor#ing together for better health.
MOH Mission
The mission of the %inistry of Health is to lead and wor# in partnership:
i. to facilitate and support the people to:
attain fully their potential in health
appreciate health as a valuable asset
ta#e individual responsibility and positive action for their health
ii. to ensure a high &uality health system that is:
customer centred
e&uitable
affordable
efficient
technologically appropriate
environmentally adaptable
innovative
iii. with emphasis on:
&uality
innovation
health
promotion
respect for human dignity
iv. which promotes individual responsibility and community participation towards an enhanced
&uality of life.
2.1 Hospital Vision & Mission
Vision ' Hospital vision (if available) in line with %OH
Mission ' hospital mission (if available). *t should be dynamic and reviewed regularly
. OR!ANISATION
.1 Hospital O"#ani$ation C%a"t
.2 Hospital O&'"&i'(
+ac#ground
,acilities available
Services provided
%anpower
-hallenges and $chievement
.ay forward
. Co))itt''s
i. The hospital shall establish a %anagement -ommittee" a %edical $dvisory
-ommittee and several other committees as re&uired by the %inistry of Health or
the -entral $gency.

ii. $ management committee chaired by the director shall discuss management
issues and ma#es decision on resource allocation and distribution.
iii. -linical matters shall be discussed at the %edical $dvisory -ommittee chaired by
the specialists.
iv. Other committees shall be headed by the director or an officer appointed by the
director. The members shall consist of officers from relevant departments and
units. /ach committee shall have its own terms of reference.
*. CORPORATE !OVERNANCE
D'+inition an, P-"pos' o+ Co"po"at' !o&'"nan.'
-orporate governance is a term that refers broadly to the rules" processes" or laws by which
businesses are operated" regulated" and controlled. The term can refer to internal factors defined
by the officers" stoc#holders or constitution of a corporation" as well as to e0ternal forces such as
consumer groups" clients" and government regulations.
*t provides a structure that" at least in theory" wor#s for the benefit of everyone concerned by
ensuring that the enterprise adheres to accepted ethical standards and best practices as well as
to formal laws.
*.1 !'n'"al A,)inist"ation
!.1.1 2etters and 3ocuments
i. The General $dministration 4nit shall be responsible for the management of all
incoming and outgoing official letters5
ii. The hospital shall have a common and systematic hospital filing system of all
official documents. +oth incoming and outgoing letters shall be filed accordingly.
iii. *ncoming letters6documents shall be registered" minuted and dispatched to the
respective department6unit within specified time. 4rgent letters shall be
dispatched immediately and the respective department6unit informed by phone.
iv. $ll outgoing official letters shall use the standard letterhead of the hospital.
v. 2etters for internal circulation shall be circulated as %emo.
vi. 2etters6documents classified under the Official Secret $ct shall be handled
according to the re&uirement of the $ct and #ept in separate file.
vii. 2etters6documents shall be #ept for the re&uired number of years.
3isposal of letters and documents shall be in accordance to the procedures and
guideline issued by 7ational $rchive 3epartment (Jabatan Arkib Negara).
viii. $ll valid service circulars shall be adhered accordingly.
!.1.8 Office /&uipment and Supplies
i. The General $dministration 4nit shall coordinate the re&uirement of office
e&uipment e.g. stationeries of the hospital and distribution to units6departments.

ii. The department6unit head shall be responsible for maintaining the asset and
inventory list and to ensure proper use of e&uipment and supplies.
iii. -ertain office e&uipment shall be shared among several departments6units.
Shared e&uipment shall be under the responsibility of the department6unit where
the e&uipment is6are located.
!.1.9 %eeting :oom ,acilities
i. The use of meeting rooms and other facilities li#e auditorium" seminar rooms etc.
shall be coordinated. $ designated person or 4nit shall be responsible for
coordinating these services.
ii. %eetings shall be well organized and documented. -all letters shall be sent out
well in advance and minutes of meeting shall be sent out within specified time. $
copy of the minutes shall be #ept in the relevant file. (refer to Pekeliling Kemajuan
Pentadbiran awam, bil 2/1991)
*.2 Finan.'
!.8.1 $llocation and e0penditure
i. Hospital fund shall be allocated according to $ctivity
ii. The head of the $ctivity shall be responsible for preparing the programme
agreement" carry out evaluation and prepare e0ceptional report" if re&uired" at the
end of the budget year.
iii. The head of the $ctivity shall be responsible for putting up ustifications for
additional budget.
iv. $ ,inance -ommittee shall be established to discuss financial and account issues
including e0penditure status" budget reallocation and additional re&uirement.
!.8.8 Procurement
i. Procurement of hospital supplies or specific items shall be coordinated by the
relevant department
ii. Procurement shall be carried out in accordance to Treasury *nstructions.
!.8.9 -laims and loans
i. Staff shall be re&uired to submit claims within the first ten days of the following
month. *t shall be completed" signed and attached with the necessary documents.
ii. Head of department6unit shall be responsible for verifying and validating the
claims before submitting to the ,inance 4nit.
iii. Government loan application shall be submitted based on eligibility and attached
with the necessary forms and document.
*. R'&'n-' Coll'.tion /Hospital "'&'n-'0
!.9.1 Hospital -harges
i. ,ees shall be charged in accordance to the ,ee Order (%edical) 1;<8" ,ee Order
(%edical) ($mendment)(,oreigner) 8==9" ,ee Order (%edical) (full paying patient)
8==> and the %OH ,inance circular. Procedures not listed in the ,ee Order shall
be forwarded to the ,inance 3ivision for approval of fee. The hospital shall ma#e
available the information on hospitals fees6charges to all parties.
ii. 3eposit shall be collected prior to admission with the e0ception of emergency
cases where deposit may be collected later.
iii. Hospitals shall ta#e all possible measures to collect payment from patients.
iv. /0emption of payment to certain group of patients or individuals may be e0ercised
according to the Treasury *nstruction6%OH -irculars.


!.9.8 +illing ? Payment
i. ,or paying patient" the hospital bill shall be given upon discharge and they are
re&uired to settle the bill at the revenue counter before going home. *nterim bill
maybe given 1 day prior to discharge.
ii. ,or patients with valid Guarantee 2etter on admission" Hospital bill shall be sent to
the employer.
iii. The hospital shall receive payment in cash" money order" postal order" ban# draft"
ban#ers@ che&ues" online ban#ing or credit6debit card. Personal che&ues are not
accepted. :eceipts shall be issued upon payment.

iv. Hospital bed for patient shall be allocated according to class of entitlement and
billed accordingly.
v. :evenue collection shall be carried out by authorised personnel at a designated
revenue counter which shall be open 8! hours.
*.* H-)an "'so-".'

!.!.1 Human :esource Planning
The hospital management shall ensure there are systems and procedures available to
ensure that the appropriate numbers of people with re&uired s#ills are available in the
hospital.
!.!.1.1 Orientation
i. 7ewly appointed Staff shall be informed about the terms and conditions of
appointment as in the General Order and PAP$.
ii. Orientation programme shall be organized for all new staff which includes overall
briefing on the hospital policies" procedures" rules and regulation and their roles
and responsibilities.
iii. Specific briefing shall be given by the departments and units.
iv. HandsBon on *-T s#ills for *T hospitals.
!.!.1.8 Placement
i. Placement of staff to departments or units shall be based on &ualification"
specialized training received and service needs.
ii. The department6unit head shall be responsible for the placement and ob
description within the department6unit.
iii. 3eployment and rotation of staff to other department and unit may be carried out
as and when necessary.

!.!.1.9 .or# $ttendance
i. Staff shall record their daily attendance and movement within wor#ing hours
(using the appropriate person attendance system e.g. punch card" record boo#"
access card etc).
ii. 3epartment6unit head shall be responsible for monitoring their staff daily
attendance6movement.
iii. Staff shall submit leave form in advance before ta#ing leave. They shall ma#e
sure the leave has been approved before ta#ing the leave. H:%*S for leave
application is mandatory.
iv. Staff shall inform their department6unit head immediately if they are not well and
has been given Sic# -ertificates.
v. Staff re&uesting for timeBoff during office hours shall complete the form
(Aebenaran 4ntu# %eninggal#an Peabat 3alam .a#tu +e#era 3ibawah Perintah
$m C +ab G: Borang Permohonan Kebenaran eninggalkan Pejabat !alam
"aktu Bekerja)
!.!.8 Professional 3evelopment
i. Staff shall be responsible for their own professional development to improve wor#
performance. The Head of 3epartment 6 4nit shall suggest appropriate training for
individual staff to develop their #nowledge and s#ill.
ii. Staff shall be re&uired to attend -%/6-P36training programmes session for at
least > days in a year.
iii. The hospital management shall facilitate -P3 activities in the hospital.
iv. .here applicable" log boo# or online PTAB-P3 should be updated regularly.
!.!.8.1 Performance evaluation
i. /very staff shall have a D#ail meja@ which contain the ob description"
responsibilities and wor# procedures.
ii. Staff with the respective Head of 3epartment shall prepare the $nnual .or#
Targets ($a%aran Kerja &ahunan) and indicators e.g. Aey Performance *ndicators
for measuring achievement at the beginning of the year.
iii. 3epartment6unit shall have its own system to %onitor and evaluate staff technical
competencies.
iv. Performance evaluation shall be carried out annually and at appropriate intervals
using the standard format.
!.!.9 /thics ? 3iscipline

!.!.9.1 3ress code ? wor# behaviour
i. Staff shall wear their respective uniform or proper wor#ing attire when they are at
wor#. +ati# shall be worn on Thursdays.
ii. 7ame tags and hospital identification card shall be worn at all time as part of the
uniform6wor#ing attire.

iii. 3uring wor#ing hours" staff shall render services in a professional manner so as to
uphold the image of the hospital.

!.!.9.8 3isciplinary Problem
%onitoring of staff performance shall be continuous. Staff with disciplinary
problems shall be given counseling before being referred for disciplinary action.
,or disciplinary action please refer to General Orders (Perintah $m +ab 3
Tatatertib)
!.!.! Staff .elfare ? Safety
!.!.!.1 Staff .elfare
i. The hospital shall establish clubs or associations e.g. Kelab $ukan dan Kebajikan
to provide opportunity for staff to get together" participate in sports or carry out
other recreational activities and staff welfare.
ii. Hospital shall establish .ellness -linic or health clinic for staff.
!.!.!.8 Safety
i. .or#ing in a conducive environment is important for the staff to achieve
organizational goal.
ii. Staff must at all time adhere to universal precaution and all guidelines regarding
infection control.
iii. Hospital must provide safe wor#ing environment to protect staff from possible
harm and inury e.g: fall" needle pric# inury and fire.
iv. Occupational Safety and Health $ct (OSH$) -ommittee must be established to
facilitate safety regulations and minimize ris# to staff" visitors and contractors. :efer
to OSH$ guideline
*.1 Hospital Sa+'t2 an, S'.-"it2
*.1.1 Hospital Sa+'t2
!.C.1.1 3isaster Preparedness
i. $n organizational structure shall be established for disaster management.

ii. The hospital shall develop disaster preparedness plans and policies for events such
as fire" flood" tremors" earth&ua#e" bomb threats" chemical threats" biological
threat" mass casualty and others.
iii. 3isaster preparedness plans shall be communicated to all staff.
iv. Staff shall be trained on use of special e&uipment" patient transportation and
evacuation etc.
v.3rill 6 moc# trial should be carried out yearly and evaluated.
!.C.1.8 ,ire Safety
i. The Hospital shall appoint a fire safety officer and prepare a fire contingency
plan

ii. $ppropriate fire e&uipment shall be made available in all areas and regularly
maintained.
iii. The person in charge of the respective areas shall ensure regular inspections
are carried out on all the fire fighting facilities" fireBretardant doors and escape
routes. The person shall also be responsible for the fire safety procedures and
ensure the staff adheres to these procedures.
iv. ,ire retardant doors shall be #ept closed at all times but not loc#ed. *f e0it
doors need to be loc#ed" the #eys shall be made readily available.
v. *n the event of fire" patients shall be evacuated in accordance to the principle
of horizontal evacuation and if the fire continues to spread" to move vertically
down.
vi. $ll staff shall receive training on fire safety" evacuation procedures and use of
fire fighting e&uipment. ,ire drill shall be conducted regularly" at least once a year.
!.C.1.9 :adiation Protection
i. The hospital shall establish a :adiation Protection -ommittee and appoint a
:adiation Protection Officer to oversee and coordinate activities related to
radiation protection.
ii. Policies and procedures pertaining to radiation safety and protection shall be
made available to all the relevant department and units.
iii. :e&uest for radiological imaging shall be done by a medical practitioner in
writing using the standard form. The re&uesting doctor shall be responsible to
screen patient for ris# factors prior to the e0amination.
iv. ,acilities or rooms where 0Bray e0aminations are carried out shall have the
necessary safety features such as lead lined screen" walls or doors.
v. Staff in the *maging 3epartment and in other department where ionizing
radiation machines are used shall be briefed on the policies and procedures on
radiation safety and protection.
vi. Staff shall adhere to the regulation and guideline regarding the use" storage
and disposal of ionizing radiation and the guideline on diagnostic imaging for
pregnant women and women of childbearing age.
vii. Only &ualified and trained personnel shall be allowed to operate the 0Bray
e&uipment. The radiographer and the assisting person involved shall wear the
necessary attire for protection such as lead gown" thyroid shield etc.
viii. Staff wor#ing in 0Bray controlled areas shall have radiation dose monitoring
done. Outside the main imaging department" the radiation dose monitoring shall
be carried out using pen dosimeter.
i0. Staff e0posed to radiation shall have their blood count chec#ed regularly and
undergo necessary medical e0amination.
!.C.1.! *nfection -ontrol
i. Hospital *nfection -ontrol -ommittee shall be established to monitor and
coordinate all activities related to infection control. *ssues pertaining to hospital
infection shall be presented to the -ommittee for ac#nowledgement and further
action.
ii. $n infection control coordinator shall be appointed. The coordinator together
with the liaison officer (lin# nurse6staff) from each area6ward shall form the
infection control team.
iii. The team shall monitor the implementation of infection control procedures"
carry out surveillance activities" monitor antibiotic resistance pattern and conduct
training of hospital staff.
iv. *nfectious patients shall be placed and nursed in single rooms wherever
possible. The use of multi ' bedded rooms for the same type of infection is
acceptable.
v. %edical personnel shall wash their hands before and after e0amining patient
at the wash sin#s available in all patient care areas.

vi. Staff shall be instructed to adhere to the barrier nursing and standard
precaution guidelines all the times. This includes fre&uent hand washing and the
use of gowns by those having direct contact with an infectious patient.
vii. $ll instruments and linen used by infectious patients shall be placed in special
bags (without washing or soa#ing).
viii. $ll clinical waste from infectious patients shall be double'bagged in yellow
plastic bags for disposal by incineration. %anagement of the clinical waste shall
be as in the privatisation contract.
!.C.8 General
i. The different areas in the hospital shall be identified either as high" and low
security. /0amples of high security areas are the entrances" stores" revenue unit"
wards" delivery suites and the -entral Sterile Supply 4nit.
ii. $reas identified as high or medium security shall have security measures
installed and security guards placed full time. Other areas shall have a regular site
patrol by the security guards.
iii. -lear Dno entry@ signs shall be placed in areas and on doors to the rooms"
which are restricted for staff or authorized personnel only.
iv. The department6unit heads shall be responsible for the security procedures
within the department and staff compliance to the procedures.
*.3 P-4li. R'lations An, M',ia Mana#')'nt /P-4li. R'lations0
!.>.1 *nformation -ounter
i. $n information counter shall be made available during office hours to provide
information and directions to patient and public.
ii. $ppropriately trained and suitable staff shall be placed at the counter.
!.>.8 -omplaints and ,eedbac#s
-ommon source of complaints are:
Eerbal -omplaints consists of complaints received in person" through 9
rd
party"
and via telephone communication.
.ritten -omplaints are complaints received through letters" fa0es" eBmails"
feedbac# forms from suggestion bo0 and others. (Biro Pengaduan Awam)
%ass %edia are complaints received through newspaper" radio and television.
ii. These complaints can be categorised into clinical and nonBclinical including
medicoBlegal issues and shall be managed according to urgency irrespective of
the source of complaint.
iii. $ll complaints received shall be registered" documented" investigated and
appropriate action ta#en. $c#nowledgement letter shall be issued within 8! hours
and reply within 9 wor#ing days of receiving the complaint.(refer to %%-
guidelines6 AA%)
iv. *nvestigation report shall be submitted to the relevant authority within 8 wee#s
of receiving the complaint. *ndependent *n&uiry report for medicoBlegal cases
should be submitted to the %edical Practices 3ivision within 8 wee#s of the
meeting.
v. The hospital management shall have in place a system whereby client
grievances or complaints will be ade&uately addressed.
vi. The subse&uent management of complaints shall be carried out in accordance
with Guidelines on management of complaints and medico legal cases" %edical
Practice 3ivision %inistry of Health %alaysia %arch 8==>.
!.>.9 Suggestion +o0
i. Suggestion bo0es shall be placed at strategic locations to get feedbac# and
comments from the public. The suggestion bo0 shall be inspected daily.
ii. The General $dministration 4nit shall be responsible for monitoring of comments
or complaints received through the suggestion bo0 and complaints in the
newspaper.
iii. -omplaints in the newspapers shall be notified to the Hospital 3irector and the
relevant department6unit" as soon as possible.
!.>.! :elease of information
i. The hospital shall not ma#e any statement on policy matters and on issues of
public interest" to the public or media.
ii. Patient information shall not be released without prior approval (written consent)
from the patient.
!.>.C Photography6filming6interview
i. The media shall be allowed to interview or ta#e the patient@s photograph only on
consent of the patient and 6or the relative and the hospital director.
ii. -ommercial filming or drama shooting in the hospital compound is not
encouraged. However" hospital director may give permission subect to the
%inistry of Health regulation. /0emption may be given for %OH health promotion
documentaries.
iii. 4se of hospital personnel" ambulances or e&uipment shall not be allowed for
filming.
!.>.F Public ,orums $nd /0hibition
i. Hospital shall organize tal#s or e0hibition to provide health education to the
public.
ii. Health promotional activities shall also be organized to create public
awareness and encourage public participation.
*.5 Boa", o+ Visito"s
!.<.1 Hospital +oard of Eisitors
i. The hospital shall establish a +oard of Eisitors as re&uired by the %inistry of
Health. The +oard members shall be appointed by the %inistry of Health and
appointed members shall be provided with an identification card.
ii. The +oard of Eisitors shall act as a lin# between the hospital and the community.

iii. The +oard members shall be briefed on the hospital organizational structure and
services" the rules and regulations and the +oard of Eisitors roles and
responsibilities.

iv. +oard members shall be allowed to ma#e visits to the wards and other public
areas during or after office hours. The hospital management shall ta#e appropriate
actions on the feedbac# received or issues raised by the +oard.
v. +oard members shall be invited to attend hospital functions and activities
including the relevant -%/ session.

!.<.8 +oard of Eisitors for Psychiatric Hospitals
i. $ll hospitals gazetted as psychiatric hospitals shall appoint a +oard of
Eisitors as re&uired under %ental Health $ct 8==1.
ii. The appointment of a +oard of Eisitors for Psychiatric Hospitals by the
%inister of Health shall consist of not more than 8C members depending on the
number of hospital beds and number of admissions.
iii. The members shall include at least 9 medical officers or :egistered
%edical Practitioners preferably a psychiatrist who does not wor# in that particular
hospital. One of the doctors has to be female. The +oard of Eisitors shall consist
of at least 9 female members.
4.9 T"anspo"t S2st')
!.;.1 General Transport System
i. The ambulances shall be under the responsibility of the /mergency 3epartment
whilst the other vehicles will be by the $dministration 4nit. The number and type
of vehicles supplied shall conform to the norms of the %inistry of Health.
ii. The hospital shall provide ambulance services for patient and public and
transportation for both patients and staff.
iii. Hospital vehicles shall be used for specified purpose as follows:
$mbulances shall be used for preBhospital care and for interBhospital
transportation of patients.
Hearses shall be used for the transportation of dead bodies.
Eans shall be used to transport supplies and materials.
%inibuses shall be used to transport staff and ambulant patient.
Saloon cars shall be used to transport staff.
2orry shall be used to transport bul# items such as furniture and
e&uipment.
$ll relatives accompanying patients are re&uired to sign an indemnity form.
The occupancy of the vehicle shall be in accordance with the manual of
each type of vehicle.
The usage of the appropriate transport 3uring emergency it is under the
discretion of the Hospital 3irector
iv. Hospital vehicles shall be driven by hospital drivers with valid driving license.
!.;.8 -entral Porter Service
i. The central porters shall be responsible for the:
transfer of patients between wards and clinics
despatch of medical records between wards" clinic and %edical :ecord 4nit
transport of pathology specimen that cannot go into the pneumatic tube for
e0ample urine specimen" blood bags etc.
ii. The central porter service shall be available from >am to Cpm. $fter office hours
the function shall be carried out by Pembantu Perawatan Ke%ihatan of specific
wards6areas
iii.$ porter service manager shall be appointed to manage and coordinate the central
porter service.
!.;.9 Pneumatic Tube System
i. Pneumatic tube shall be used to transport pathology specimens" medicines"
documents and medical records" less than 8#g weight.
ii. *tems shall be placed in the special container provided before being transported in
the pneumatic tube.
iii. The department using the pneumatic tube (sender) shall be responsible for the
proper and safe transfer of items and to trace the items in case of delay or nonB
arrival at the receiving end.
iv. Hospital shall identify list of items that shall not be allowed to be transported in the
pneumatic tube e.g. food" blood bag etc.

*.16 Visitin# %o-"s

!.1=.1 General
i. The visiting hours shall be as follows:
.ee#days
18.9= pm B 8.== pm
!.9= pm B >.== pm
Saturday" Sunday and public holidays
18.9= pm B >.== pm
ii. 3uring visiting hours" relatives shall be allowed to visit patients in the general
wards.
iii. Eisit to the critical care areas shall be restricted to two per patient at any time.
iv. -hildren aged below 18 shall not be allowed to visit patients in the critical care
areas and isolation rooms.

!.1=.8 Outside Eisiting Hours
i. 7umber of visitors shall be restricted after visiting hours and only 8 visitor per
patient at a time. $fter visiting hours a visit shall not e0ceed more than half an
hour. $ll visits after visiting hours shall be recorded .
ii. $ relative shall be allowed to accompany patient subect to the approval of the
ward staff. $ special pass ('a% menunggu) shall be issued to one person in the
following situation:
:elatives to accompany critically ill and bed ridden patients. Only female
relative shall be allowed to accompany patient in the female ward6cubicle.
%others or guardians to accompany children in the pediatric wards.
%others of babies admitted to the special care nursery for breastfeeding.
!.1=.9 Other Hospital Eisitors
i. :egistered hospital volunteers and shall be allowed to enter the hospital up to
;.== pm
ii. %embers of the +oard of Eisitors with identification cards may be allowed to
enter the hospital at anytime for formal duties.
iii. E*Ps on official visit shall be accompanied by the hospital staff.
*.11 T"a++i. Cont"ol
i. The hospital shall implement a traffic system within the hospital to avoid traffic
congestion. :oad to the /mergency 3epartment shall only be used by
ambulances and public6private vehicles bringing emergency cases" for e0it
and entry.
ii. 3ropBoff and pic#Bup zone shall be provided near the entrance to the
Specialist -linic6 /36 P$- B 2abour :oom for patients@ convenience.
iii. Par#ing outside the designated par#ing areas shall be strictly prohibited.
1. CLINICAL !OVERNANCE
-linical governance is the term used to describe a systematic approach to maintaining and
improving the &uality of patient care within a health system.
*t was originally elaborated within the 4nited Aingdom 7ational Health Service (7HS)" and its
most widely cited formal definition describes it as G$ framewor# through which 7HS organisations
are accountable for continually improving the &uality of their services and safeguarding high
standards of care by creating an environment in which e0cellence in clinical care will flourishH.
This definition is intended to embody three #ey attributes:
i. :ecognisably high standards of care"
ii.Transparent responsibility and accountability for those standards" and
iii.$ constant dynamic of improvement.
This section will focus on policies directly related to patient and patient care
PATIENT RELATED POLICIES
1.1. Co-nt'" S'"&i.'s
i. Hospitals shall have General *nformation counter and dedicated counters e.g.
registration counters" clinic counters" ward counters etc. whose function include:
Providing information
Providing assistance
:eceive complaint etc.
ii. The counter shall be manned by competent persons with good Public :elations
s#ill.
iii. Patient :elation Officer shall supervise the effective delivery of counter
iv. $ll counters shall be operational according to determined schedule.
v. Priority 2ane at the counters maybe provided to the following clients
-hildren age one year and below
Senior citizen (F= and above)
Government servants and pensioners
+lood donors (according to e0isting guidelines)
3isabled persons ()rang Kurang *'a+a)
Per%on% in ,u%tod+ (&ahanan)
1.2 Appoint)'nt an, S.%',-lin#
i. $ppointment may be made by phone" fa0 or coming personally to the clinic.
ii. Services shall be given on an appointment basis e0cept for /mergencies and
General Outpatient 3epartment.
iii. :escheduling for early appointment" shall be upon approval by the relevant
Head of 3epartment 6 4nits.
iv. $ll clients shall be informed of the relevant document6item to facilitate
registration process e.g. referral letter" appointment card" guarantee letter (e-./)
etc.

1. R'#ist"ation
i. Patients shall be given only one medical record number (%:7) for personal
identification. The %:7 shall be used in all forms6 documents pertaining to patient
care.
ii. :egistration format shall be as specified by the %inistry or the hospital. The staff
at the registration counter shall be responsible for ensuring the completeness of
the information.
iii. $ll clients re&uiring registration must present relevant documents at the
designated registration counters.
iv. 4n#nown patient shall be temporarily registered using designated running
number. :egistration process shall be updated when information is available.
1.* Cons-ltation
i. Patients at the Specialist -linic shall be managed by the doctor relevant to
the particular illness 6 specialty.
ii. The assessment of patients shall be documented in the designated cler#ing
forms ( manual 6 *.T.) comprising a full medical history and physical
e0amination.
iii. The hospital shall ensure safety" confidentiality and privacy of the client
throughout consultation and e0amination.
iv. 7ursing assessment and entries by other allied health personnel shall be
documented in the patient@s case notes as integrated case notes.
v. *nBpatients shall be reviewed at least once a day by a medical officer 6
specialist and when necessary according to the patient@s clinical condition.
1.1 A,)ission
C.C.1 Patient $dmission ,low
i. Patient@s admission formalities shall be carried out by the $dmission 4nit.
$ll patients shall be admitted to the respective wards according to their
eligibility
ii. Stable patients from the referring hospital 6 health clinic can be admitted
directly to the relevant ward after consultation with the ward doctor. $ll referrals
for admission shall be in accordance with e0isting guidelines as stated in the
Pekeliling Ketua Pengarah Ke%ihatan 1168==;5 0ujukan !an Per'indahan
Pe%akit !iantara 1o%'ital-1o%'ital Kementerian Ke%ihatan
iii. $ll unstable patients shall be stabilized in the /mergency 3epartment
before admission to the ward. 3irect admission to the *ntensive -are for very ill
patient shall be arranged with prior consultation and agreement by the
Specialist in charge.
iv. $ll maternity cases (8< wee#s and above) shall be sent directly to the
Screening :oom6 Patient $ssesment -entre and the necessary admission
formalities attended to subse&uently.
v. Patients or their relatives shall pay a deposit or produce a guarantee letter
on admission in accordance with the ,ees I%edicalJ Order 1;<8 and the
:evised -ircularsH 2No3 455 dlm3KK 267/26 Jld3 89 Panduan Perlak%anaan
Perintah :i 4 Perubatan 9 Pindaan 2667 ; <aj Baru Bagi Pe%akit )rang A%ing=3
vi. Patients shall be transported on mobile beds" transport trolleys (cot bed 6
bassinet) or wheelchairs. $mbulant patients may be escorted by medical staff
Patients aged 18 years and below shall be admitted to the Paediatric .ard.
vii. The ward or department personnel shall be responsible for transporting 6
accompanying patients within the department as well as to other departments.

C.C.8. $rrival $t .ard
i. $n identification wristband shall be provided to all inpatients. $ll
inpatients shall be re&uired to wear an identification wristband all the time during
the hospital stay.

ii. $ssignment of beds shall be done by the respective ward nurse.
iii. 7urse shall inform the doctors within 1C minutes for newly
admitted patient.
iv. *ndividual patient shall be provided with a bed" chair and a
loc#er. ,acilities li#e toilet" bath and rest area shall be shared.
v. Patient shall be provided with the hospital clothes to wear.
vi. $ll patients who are admitted shall be given an orientation which
includes information in relation to house #eeping" ward and hospital facilities by
the ward staff.
vii. Patients are advised against wearing ewelry or bring along
valuable items including large amount of cash for admission. They shall be
informed that the ward staff shall not be responsible for any loss of valuable
items.
viii. The hospital management shall have in place a system to
temporarily #eep the patient@s belongings or valuable " when re&uested by
patient. Patient shall be adviced to immediately give it to the ne0tBofB#in to bring
home.
C.C.9 $dmission of 4n#nown Patients Icomatose" psychiatric" amnesic" etcJ:
i. $ll available information pertaining to the un#nown patient admitted shall
be documented into the admission boo# as Dun#nown patient@ and a registration
number 6 %edical registration number ' %:7 given.
ii. The police shall be notified immediately and reBnotified if the patient
remains unidentified after 8! hours.
iii. *f the patient is still unidentified after !< hour information may be
disseminated through the mass media via the %edical Social 3epartment 6
hospital management.
C.C.! $dmission to ,irst -lass .ards:
i. Patients shall be admitted to ,irst -lass wards when the necessary
financial circulars have been complied with.
ii. Patients shall be admitted on a Dfirst come first serve@ basis.
iii. 3ecision to admit the patient to ,irst -lass shall be determined 6 verify by
a specialist according to the patient@s clinical condition.
iv. $dmission of :oyalties 6 EE*Ps 6 E*Ps shall be based on the respective
state 6 national protocol.
C.C.C 3angerously *ll Patient (3*2)
The %edical Officer 6 Specialist in charge of all patients deemed seriously ill shall
be responsible for communicating this information to the relatives 6 ne0tBofB#in in a
manner that is clearly understood by them. 3ocumentation of this should be
recorded in the patient@s case notes.
1.7 Dis.%a"#'
C.F.1 Planned 3ischarge
i. The %edical Officer 6 Specialist in charge of the patient shall be responsible for
communicating information in relation to planned discharge not less than 8! hours
in advance.
ii. *dentification wristbands shall be removed at discharge e0cept for newborn and
paediatric.
iii. .ard nurse shall ensure only parents6guardians are allowed to ta#e discharged
children home. Only parents are allowed to ta#e home discharged
babies6newborns.
iv. On discharge (including $O: discharge)" patients shall be provided with relevant
documents related to their admission" follow up and further management e.g.
discharge notes" medical certificate" appointment card etc.
v. $ll patient deemed fit for discharge shall be provided with a prescription and
relevant information about their medication prior to discharge.
vi. $ll discharged patient must settle their bills in accordance with Gthe ,ees I%edicalJ
Order 1;<8 and the :evised -ircularsH 2No3 455 dlm3 KK 267/26 Jld3 89 Panduan
Perlak%anaan Perintah :i 4 Perubatan 9 Pindaan 2667 ; <aj Baru Bagi Pe%akit
)rang A%ing= and official receipt issued.-itizens (Patient) who are unable to settle
their bill due to financial reason will be referred to the%edical Social 3epartment 6
:evenue 4nit 6 hospital administration.
5.6.2 3ischarged $t Own :is# ($O:)
i. $ll patients re&uesting to be discharged against medical advised can do so after
obtaining ade&uate e0planation and clarification and from the medical officer in
charge.
ii. The $O: discharge form has to be completed by the medical officer in charge and
signed by the patient 6 relatives 6 guardian and witness.
C.F.9 $bsconded patient
i. Patient leaving the ward without permission shall be declared as Dabsconded@.
ii. *f a patient is found to be missing from the ward 6 bed" all efforts shall be made to
locate him 6 her. *f the patient remained missing after 8! hours" a police report shall
be made.
1.3 D'at%
C.>.1 3eath at Hospital
i. The attending doctor in the ward or the emergency department shall carry out
confirmation of death. Patients who die in the hospital shall be transferred to the
mortuary accompanied by hospital personnel after one hour of being pronounced
dead 6 confirmation of death.
ii. On confirming death" the ward6department staff shall verify the deceased status
as organ donor" notify the mortuary and the ne0tBofB#in and conduct the last office. *f
the ne0t of #in is not contactable" the police shall be notified.
iii. +urial permit shall be signed by the %edical officer in charge of the ward. House
Officers shall not be allowed to sign the burial permit.
iv. +ody of deceased must be tagged with a body tag bearing the identity of the
deceased" a white tag for cases not re&uiring autopsy and a red tag for cases
re&uiring autopsy.
v. $ll deaths in the hospital shall be registered at the mortuary. 3ead bodies shall be
released to the ne0t of #in or authorised person through the mortuary. $ll information
on body release shall be well documented.
vi. *n the case of referred patient" the hospital shall be responsible for the transfer
bac# of the dead body to the referring government hospital.
vii.4nclaimed bodies ( nonBmedicolegal cases) shall be notified to the police and
notices placed in newspaper after 9 days (%uslim) and 1! days (nonB%uslim). The
body shall be handed over to the respective religious body for burial or cremation if
no claim is made after the said days following notification.
viii. ,or unclaimed bodies of nonBcitizen" the respective embassies shall be
notified of the death.
i0. %anagement and handling of infectious dead bodies shall be in accordance to the
standard procedures to prevent cross infection. The Health *nspector in the 3istrict
Health Office shall be notified.
x. /0isting guidelines such as Poli%i dan Pro%edur Kawalan Jangkitan, Kementerian
Ke%ihatan ala+%ia and the 3isinfection and Sterilization Policy and Practice 8==8
shall be complied with.
C.>.8 Post %ortem
i. .hen the cause of death could not be determined" a clinical post mortem maybe
re&uested by the specialist in charge. -onsent from the ne0tBofB#in must be obtained
before a post mortem is performed.
ii. ,or medicolegal 6 police cases" the police shall be informed of the death. The
police may issue a post mortem re&uest.
iii. 3ead body brought to the hospital by the police for post mortem shall be sent
directly to the mortuary.

1.5 R'+'""al S2st')
C.<.1 General
i. Transfer of patients may occur routinely or as part of a regionalized plan to
provide optimal care for patients at more appropriate and6or specialized facilities.
ii. :eferral of patients between hospitals can occur from a lower to higher level
of care" higher to lower level of care and also at the same level of care depending on
the needs of the patients and 6 or the providers of care.
iii. Hospital to develop preBe0isting transfer arrangements between the facilities
and preBtransfer communication between appropriate responsible persons to facilitate
efficient flow of continuum of care to the patient
iv. /0isting guidelines such as GGuidelines ,or The :eferral $nd Transfer Of Patients
+etween %OH HospitalsH shall be complied with when referring patient.
C.<.8 *ntra ,acility Transfer
i. $ll unstable patients shall be accompanied by trained personnel during
transfer.
ii. $ll patients re&uiring assisted ventilation from /mergency 3epartment
may be admitted directly to critical care ward after consultation between the
specialist and anesthetistBinBcharge of the critical care ward.
C.<.9 *nter ,acility Transfer
i. The decision to transfer a patient shall be made upon consultation with the
specialist concerned.
ii. $ll patients shall be stabilized and deemed stable by medical officer in charge
before transfer.
iii. Patient@s ne0tBofB#in shall be informed about the process of transfer. *n the event
where the transfer is urgent and patient@s ne0tBofB#in are not contactable" the police
shall be informed to help in contacting them.
iv. The staff accompanying referred cases shall be decided by the specialist in
charge. ,or hospitals without specialist this will be decided by the medical officer in
charge after consultation with the receiving hospital.
v. $ll critical patients shall be accompanied by a team of paramedics trained in
resuscitation and headed by a medical officer. $ccompanying staff for other cases
shall be decided by the specialist 6 medical officer in charge based upon the clinical
condition of the patients.
vi. $ll documents pertaining to patient@s condition shall be made available to facilitate
the transfer. :eferral letter accompanying patient should include a detail history of
patient and reason for referral. $ll related radiological images ? report" blood results
should be included.
vii. %onitoring of patients shall be done base on the clinical condition of the patient
and recorded accordingly.
viii. *f patient@s clinical condition deteriorate during the transfer and resuscitation is
re&uired" the ambulance may en route to the nearest health facility.
ix. *f death occurs during transfer" it shall be certified by a medical officer and the
body shall be brought bac# to the referring hospital.
1.8 Do.-)'ntation O+ Clini.al Ca"'
i. -linical management of all patients shall be recorded and documented in
the out
patient card" case notes or computerised system and shall be updated upon
completion of e0amination by the attending authorised hospital personnel.
ii. $ll documents related to patient management including lab results" KB:ays"
nursing care plan" observation charts etc shall be compiled along with the case notes
and #ept current.
iii. 3ocumentation of clinical care shall be maintained by authorised hospital
personnel attending to the patient and each entry shall be dated" initialled and
stamped.
iv. $ll amendments made must be clearly cancelled" initialled and stamped by the
respective authorised hospital personnel. /ntries shall not be deleted by corrective
fluid.
v. Patient@s file shall be sent to the :ecord Office within >8 hours after discharge.
vi. %anagement of Patient %edical :ecord shall be in accordance to Pe#eliling
Aetua Pengarah Aesihatan 1>68=1=
1.16 Cons'nt
i. $s a general guide" the following types of procedure shall re&uire a signed
consent form:
surgical procedure
general anaesthesia
regional anaesthesia
invasive radiology procedure
blood transfusion
other high ris# and or invasive treatment
ii. -onsent shall be obtained from the patient or ne0tBofB#in prior to carrying out any
clinical procedures. *n cases of emergency" where all efforts to trace relatives and
ne0tBofB#in have failed" the Hospital 3irector and one or two specialists can give
consent for the procedure to be carried out. $ll efforts made to trace the relatives6
ne0tBofB#in shall be documented in the case notes.
iii. $ll consent must be ta#en by a medical officer using the appropriate form. The
information provided includes:
patient@s condition
proposed treatment
potential benefits and ris#s
possible alternatives
li#elihood of success
possible problems related to recovery
possible results of non treatment
iv. -onsent shall be obtained from the patient if he 6 she is at least 1< years old and
of sound mind.
v. ,or patients below the age of 1< or patient of unsound mind consent shall be
obtained from the legal guardian.
1.11 P"o.',-"' an, s-"#'"2
i. /ach patient@s procedure or surgery is planned and documented in the patient@s
case notes.
ii. The ris#s" benefits and alternatives are discussed with patient and family and
should be documented in the patient@s case notes.
iii. $ll consent must be ta#en by a medical officer using the appropriate form.
iv. /fforts shall be made to ensure that the procedure is carried out on:
The right patient
The right site
The right procedure
v. 4pon arrival at the OT the OT nurse shall verify with the relative 6 patient
regarding the following based on a chec#list:
Patient@s details
-onsent
Type of operation
Site of operation
vi. The surgery performed is recorded using a pre prepared format and attached to
the patient@s case notes. 3ocumentation should include the post operative diagnosis"
a description of the surgical procedure" findings and any surgical specimen sent and
the name of the surgeon and assistant.
vii. /ach patient@s haemodynamic status is continuously monitored during and
immediately after surgery and written in the patient@s case notes
viii. Patient care after surgery is planned and documented.
5.12 D"-# an, M',i.ation
C.18.1 4sage
i. Hospital drug formulary shall be maintained and used as a guide for drug
prescription.
ii. Prescription and supply of drugs not listed in the Hospital drug formulary but
available in the %inistry drug formulary (blue boo#) shall re&uire the specialist or
head of department@s approval.

iii. Prescription and supply of drugs not listed in the %inistry drug formulary (blue
boo#) shall re&uire the %inistry@s approval. The respective head of the department
shall be responsible for the ustifications of the drug usage and cost implication.
iv. :e&uest for approval shall be made using the specified format and submitted
through the director@s office.
C.18.8 Prescription
i. 3octors shall prescribe drugs only to registered patients.
ii. Prescription referred by the pharmacy department from other %inistry of Health
hospitals and clinics shall be accepted. Prescription from *L7 shall be endorsed by
the hospital specialist before prescription is filled" subect to availability of drugs.
iii. Prescription from the private sector shall not be accepted.
iv. Term prescription (more than 1 month) shall be filled in at specified intervals.
Patient shall be re&uired to collect their medicines within one wee# of the date of
prescription.
C.18.9 3ispensing
i. 3rugs shall be dispensed at the specified pharmacy counter. 3ispensing of drugs
to patients shall be done during office hours e0cept for patients in the emergency
department.
ii. 3rug counselling shall be provided to individual patients based on needs.
iii. +edside dispensing shall be carried out for discharged patients.
iv. 4rgent needs for inpatients shall be met by the pharmacy personnel on call.
C.18.! %onitoring
i. 4sage of drugs" prescriptions and drug reaction shall be monitored by the
pharmacy department.
ii. 3rug committee shall be established to coordinate" monitor and manage all issues
relating to drugs and drug usage.
1.1 St'"ili$ation an, Disin+'.tion
i. The Sterile Supply 4nit shall be overall responsible for the sterilization and
disinfection services in the hospital.
ii. Sterilization and disinfections of e&uipment and surgical items shall be carried out
using the appropriate and accepted techni&ue or method.
iii. Staff involved in the sterilization process shall follow the standard procedures to
ensure the sterility of the product.
iv. Staff shall wear proper attire for safety protection against infection and other
hazards
v. ,or highBris# patient" such as #nown case of H*E6$*3S and Hepatitis +"
disposable sets shall be used.
vi. Sterilisation of delicate e&uipment shall be carried out by trained staff using
appropriate techni&ue. Soft dressing shall be preBpac#ed and sterilized centrally.
1.1* In+'.tion Cont"ol
The Hospital shall establish the Hospital *nfection -ontrol and $ntibiotic 4sage
-ommittee who has an advisory" planning" coordinative and supervisory role which
include" mainly:
i. ,ormulation and review policies and procedures regarding hospital
ac&uired infection and proper usage of antimicrobial therapy.
ii. 3isseminate #nowledge" improve s#ills and inculcate desired values in
health care wor#ers about the subect through education and training.
iii. 3isseminate and ensure compliance with the policies and procedures
among health care wor#ers and (where applicable) patients" relatives and visitors.
iv. Plan out hospitalBwide infection control programmes and activities yearly.
This function is incorporated in the day to day activities of personnel" patients and
visitors.
1.11 Mana#')'nt o+ M',i.al R'.o",s an, R'po"ts
C.1C.1 %edical :ecords
i. /very patient receiving care in the hospital shall have his6her own medical record.
ii. -are given and procedures done on a patient shall be documented in the patient@s
medical record. The attending doctor shall be responsible for proper
documentation and legibility of the notes in the record.
iii. Hospital using the manual system shall implement an integrated case note where
all care providers write their notes on the same continuing sheet and in
chronological order.
iv. $ll case notes and treatment records of a patient shall be compiled as one
medical record and #ept in a single folder.
v. :eferral letter and other documents relating to the care shall be #ept together with
the patient@s medical record.
vi. %anagement of medical records shall be under the responsibility of the %edical
:ecord 4nit. The records shall be managed to ensure safety" confidentiality and
fast retrieval.

vii. $ medical record committee shall be established to coordinate all issues
pertaining to medical record services.
viii. $ll personnel involved in the handling of medical records shall be responsible for
maintaining the confidentiality and safety of the records.
C.1C.8 %edical :eport
i. %edical report shall be prepared on receiving written re&uest from the patient or
authorized person.
ii. %edical report shall be prepared by a doctor or if re&uested" by the specialist in
the respective discipline involved in the care. The report shall be prepared within a
specified time i.e. ! wee#s for state hospitals and 8 wee#s for specialist and nonB
specialists hospitals.

iii. %edical report of medicoBlegal or potential medicoBlegal cases shall be prepared
or verified by the head of the department before release.
iv. %edical report shall be charged in accordance to the ,ees $ct 1;<8 6 its
amendment or in accordance to the %inistries circulars. The charge is based on
the comple0ity of report and range between :%!= ' :%1===.
C.1C.9 %edical Statistics
i. 3ata and statistics to be collected shall be as specified by the %inistry or the
%edical :ecord -ommittee of the hospital.
ii. The respective department and unit shall submit data to the medical record unit
within the specified time.
iii. :elease of medical data and statistics of the hospital shall be done through the
medical record unit and subect to the Hospital 3irector@s approval.
1.17 H'alt% E,-.ation
i. The hospital shall provide effective health education services in support of inpatient
and outpatient care in the hospital.
ii. The Health /ducation 3epartment 6 4nit shall plan" coordinate" implement"
monitor and evaluate all activity related to health education programs in line with
current %OH policies.
iii. The Health /ducation 3epartment 6 4nit shall organized training for staff on
patient@s education techni&ue on the use of Health /ducation hardware and
software.
1.17 Et%i.s an, La(.
The hospital shall abide by the laws of the -ountry" Policies and Guidelines of the %inistry
of Health" medical ethics and relevant Policies and Guidelines of other %inistries. $cts"
policies and guidelines may be amended by the relevant authorities as and when necessary.
7. MEDICAL FACILITIES
7.1 Sp'.ialist Clini.s
i. The clinics shall be used to provide specialist outpatient care.The consultation ?
e0amination rooms shall be commonly shared between the various department 6 unit as
and when necessary.Patient@s privacy must be maintained throughout the consultation.
ii. $ll specialist clinics shall operationalise
under the supervision of the specialist inBcharge and shall remain operational during
office hours based on a predetermine clinic schedule.
iii. $ll specialist clinic services are provided
on an appointment basis which is based on an appointment and scheduling system
determine by the respective hospital6department 6 unit (manual or computerized).
iv. $ll appointment are given based on the
availability of resources. ,or urgent appointment" the referring doctor shall be
re&uired to consult the specialist6medical officer of the respective discipline before
referring the patient.
v. :escheduling" cancellation and deferral of
appointments shall be approved in accordance to the policy of the department 6 units.
vi. $ll clients re&uiring services in the clinic
must be furnished with the relevant document to facilitate appointment scheduling and
registration e.g. referral letter" appointment card" guarantee letter (e-./) etc.
vii. The necessary fees related to the services
provided shall be paid by the client according to the ,ees %edical Order $ct 1;<8 6
:evised -irculars and receipt issued.
viii. $ll clinics shall display their client charter
which must be consistent with the daily services rendered. $ll clinics must ensure that the
duration to obtain an appointment for all new patients is within a reasonable period.
These must be monitored on a regular basis by the clinic for continuous improvement.
i0. 3etails of the clinic consultation shall be
documented in the medical record. $t the end of clinic session" patient may be either
discharged" given another clinic appointment" referred elsewhere or admitted in 3ay
-are6.ards for investigations6procedures.
7.2 E)'"#'n.2 D'pa"t)'nt
i. The emergency department shall be used to provide emergency care to patients
brought in or referred to the hospital.
ii. The department shall have designated areas or zones for management of
patients according to the severity of illness.
iii. $ll patients shall be triaged according to zones6colour5 red for the critically ill"
yellow for semicritical and green for nonBcritical patient.
iv. .aiting time for the green zones shall be displayed at the /mergency
3epartment.
7. Da2 Ca"'
The day care unit shall be commonly shared6utilized by all clinical disciplines for
medical treatment" endoscope procedures and minor surgeries. Hospitals shall
have a list of procedures performed as day care.
i. 3aycare services shall be provided %onday to ,riday (wor#ing days) from
3.66 a) to 1.66p).
ii. Patients selected to undergo day care procedure are lowBris# patient.
These patients for shall be admitted and discharged within the same day.

iii. $ll patients scheduled for daycare services shall be furnished with all
relevant documents to facilitate their registration and admission.
iv. -onsent shall be obtained by the medical officer in charge for all
daycare procedures after ade&uate e0planation to the patient6relatives.
v. Patient shall be certified fit by a medical officer before discharge5 if
they are deemed unfit they shall be admitted to the respective wards for further
management.
vi. -onfirmation of patient undergoing daycare procedures must be
made 8! to !< hours prior to the procedure.
vii. +illing for these patients shall be in accordance with the ,ees
I%edicalJ Order 1;<8 and the :evised -ircularsH 2No3 455 dlm3 KK 267/26 Jld3 89
Panduan Perlak%anaan Perintah :i 4 Perubatan 9 Pindaan 2667 ; <aj Baru Bagi
Pe%akit )rang A%ing= and official receipt issued.
6.4 Op'"ation T%'at"'
i. The Hospital management shall be responsible for providing OT facilities
to cater for elective as well as emergency procedures involving general
anesthesia" regional anesthesia and local anesthesia.
ii. $ll elective surgeries shall be carried out between =<==B1F== hours on
normal wor#ing days according to schedule by respective department base on the
allocated OT days. $dditional elective OT may be carried out on wee#end or
public holidays in order to reduce waiting time depending on the need and
availability of resources.
iii. /mergency OT shall be operational 8! hours a day5 where applicable a
second /mergency OT may be open based on the need and availability of
resources.
iv. $ll patients undergoing elective and emergency surgery shall be assessed
by the anesthetic %edical Officer or Specialist.
v. $ll procedures carried out in the OT shall comply with all e0isting
guidelines and policies (e.g. GGuidelines on *nfection -ontrol of Hospital $c&uired
*nfections and the 3isinfections and Sterilization Policy and PracticeH" %OH"
8==8).
7.1 Int'nsi&' Ca"' / C"iti.al Ca"' 0
i. Patients admitted to *ntensive -are shall be cared for by the intensive care
team from the department of anesthesia along with the primary department 6 unit.
ii. The admission and discharge of all patients to and from *-4 shall be
determined by the $nesthetistBinBcharge in consultation with the respective
specialist from the referring department 6 unit.
iii. Priority for admission shall be based on the urgency of patient@s need for
intensive care. 4nscheduled" emergency admission shall ta#e precedence over
scheduled elective surgical admission. Triaging of admissions to the unit shall be
done by the anesthetist.
iv. .hen continuing intensive care is deemed medically futile (brain death)"
consideration shall be given to withholding or withdrawal of life support. This
decision shall be discussed with the patient@s family and with other team members
as appropriate.
v. :elatives 6 ne0tBofB#in re&uesting termination of treatment and $O:
discharge for ill ventilated patients shall discuss with the specialist of the primary
department 6 unit. $de&uate e0planation and the ris#s shall be given prior to
approval for discharge.
vi. Patients on $O: discharged shall be accompanied home by a nurse.
/0tubation of the patient shall be carried out by the nurse at home.
vii. :elatives 6 ne0tBofB#in re&uesting $O: discharge for ill ventilated patients to
be transferred to other medical facilities shall discuss with the specialist of the
primary department 6 unit. $de&uate e0planation and the ris#s involved shall be
given prior to approval for $O: discharge. PreBtransfer communication between
the specialists of the referring and receiving unit6facility shall be done.
viii. ,or referral to a private facility" the arrangement for the transport
and care during the transfer shall be the responsibility of relatives 6 ne0tBofB#in
which may be facilitated by the *-4 personnel.

ix. The clinical management of patients in intensive care unit shall be guided by
management protocols in intensive care (%OH 8==F) and other guidelines 6
protocol occupational and safety health $ssurance (OSH$).
x. Specific infection control measures shall be adhered to (Guidelines on
*nfection -ontrol of Hospital $c&uired *nfections and the 3isinfections and
Sterilization Policy and PracticeH" %OH" 8==8).
xi. The *deal 7ursing 7orm of nurse to patient ratio /1910 according to the level
of *ntensive -are shall be adhered to during all shifts.
xii. The number of intensive care unit beds shall be at least 9BCM of the total
acute hospital beds in maor hospitals. ($nesthesia ? *ntensive -are Services
%OH6P6 1!8.=> (+P)" ,ebruary 8==< )
7. :;ALITY MANA!EMENT
3.1 Stan,a", & In,i.ato"s
i. The national indicators shall be used to monitor the hospital performance in
&uality care.
ii. $ll cases of shortfall in &uality (S*N) shall be investigated to find out the cause and
to carry out remedial action.
iii. The hospital shall establish its own specific indicators for monitoring &uality within
the department and unit.

3.2 :-alit2 I)p"o&')'nt A.ti&iti's
i. The department and unit shall be responsible for the provision of &uality service.
ii. The department and unit shall establish their own standards and indicators for
monitoring &uality.
iii. The hospital shall establish a Nuality %anagement -ommittee to oversee and
coordinate all activities on &uality. -oordinators shall be appointed for the different
activities.
iv. The following &uality activities shall be implemented"
Nuality assurance studies
Nuality -ontrol -ircle (A%A)
*ncident reporting
Patient satisfaction survey
-lients -harter
*SO ;=== certification
Hospital $ccreditation certification
5. TRAININ!
5.1 Esta4lis%)'nt o+ a Contin-o-s P"o+'ssional D'&'lop)'nt /CPD0 P"o#"a))'
i. /ach hospital shall establish a structural organization to provide the direction and
governance for the -P3 programme.
ii. To maintain staff competency" which include technical" soft s#ill and
communication s#ill" each personnel (both administrative and clinical) will be given the
opportunity to attend training programmes in areas relevant to their functions.
iii. Sufficient funding and other resources which may include library" auditorium"
seminar room" s#ill lab" computer lab etc. will be established in each hospital.
iv. /ach hospital is encouraged to establish formal and informal lin#ages and
collaborations with local and international healthBrelated organizations to facilitate
training activities.
v. 3atabases of inBhouse and e0ternal training programmes organized and6or
attended by each personnel must be maintained and updated
8.2 -redentialing ? Privileging
i. /ach hospital shall establish a structural organization and mechanism for
purposes of credentialing and6or privileging of clinical personnel relevant to type of
services being offered. :efer to Guidelines: Sistem O-redentialingO dan OPrivileging di
Aementerian Aesihatan %alaysia +il =168==1
ii. $ll nonBgovernment medical practitioners practicing in a government facility as
university lecturers" locum or on sessional basis shall be re&uired to obtain a written
approval to practice in a government facility" from the 3irector General of Health in
accordance to Section 9!- of the %edical $ct 1;>1.
8.3 Fo")ali$', p"o#"a))'s +o" Ho-s' O++i.'"s an, ot%'" post<4asi.=#"a,-at' t"ainin#
i. $ hospital that has been designated as a training centre for undergraduates 6
House Officers and6or other postB basic6graduate programmes is re&uired to establish
a formalized training and assessment structure relevant to the type of training being
provided
ii. /ach hospital with post graduate activities shall establish an undergraduate and
postgraduate committees to coordinate and monitor the activities.
8. RESEARCH
i. /ach hospital is to establish a structural organization and mechanism to provide
guidance and governance for research activities.
ii. /ach hospital shall provide a conducive environment that will actively facilitate and
support research activities. The hospital is encouraged to establish a clinical research
centre 6 unit 6 facility to coordinate and provide technical support. Sufficient funding and
other related resources shall be allocated
iii. $ny research proposed to be underta#en within the hospital by hospital personnel or
in collaboration with other agencies or by e0ternal agencies themselves (such as
universities) must first see# the approval of the Hospital 3irector of Heath prior to
submission to the %alaysian :esearch and /thics -ommittee (%:/-).
iv. $ll principle investigators and collaborators wishing to underta#e clinical trial research
must ac&uire a Good -linical Practice certificate (G-P) before being given permission to
conduct trials

16.S;PPLIES AND ASSETS
16.1 P"o.-"')'nt
i. Procurement shall be carried out in accordance to the government financial
procedure or Treasury *nstruction.
ii. Procurement of all medical items such as drugs" consumables" chemical reagents
shall be coordinated by the medical store.
iii. Procurement of office stationeries and other nonBmedical items shall be
coordinated by the general administration unit and *T consumables by the
*nformation Technology unit.
iv. Purchasing of food items shall be coordinated by the catering department 6 unit.

16.2 E>-ip)'nt an, P%a")a.'-ti.al S-ppli's
1=.8.1 :e&uirement ? Specification
i. :e&uirement of medical e&uipment" consumables" drugs and pharmaceutical
supplies shall be decided by the individual department6unit and coordinated by the
Pharmacy 3epartment.
ii. The respective head of the department shall be responsible for preparing the
technical specifications.
1=.8.8 3elivery ? Supply
i. Standard items shall be stored for ! months supply and nonB standard item shall
be made available only on re&uest.
ii. $ll pharmaceutical supplies shall be delivered to the medical store e0cept for
chemical reagent" which shall be sent directly to Pathology department. The
supply of consumables shall be collected direct from medical store and the supply
of drugs shall be collected from the ward supply pharmacy.
iii. +ul#y e&uipments shall be delivered directly to the respective end user. The /nd
4ser and the %edical Store personnel shall be present to verify the delivery.
iv. Head of department or representative shall be responsible to verify the contents"
ensure compliance to the specifications and carry out testing and commissioning
before signing the acceptance forms.
v. 3angerous and Psychotropic 3rugs shall be stored" transported" and managed
only by authorised staff.
vi. *tems re&uiring refrigeration (temperature 8B<
=
-) and inflammable 6 e0plosive
materials shall be #ept in individual storage area.

1=.8.9 /&uipment 6 *nventory 2ist
i. The hospital shall maintain an upBtoBdate e&uipment6inventory list. The
department and unit shall also maintain its own e&uipment6 inventory list and the
planned preventive maintenance schedule.
ii. /&uipment shall not be moved or transferred to another department or another
hospital without prior approval of the Hospital 3irector. $ny movement of
e&uipment shall be documented.
1=.8.! 3isposal
i. Head of department shall be responsible to submit a list of e&uipment to be
disposed 6 condemned to the ,inance and $ccount 4nit.
ii. /&uipment which has been given the certificate of Dbeyond economic repair@ may
be disposed accordingly.
11. COMM;NICATION SYSTEM
11.1 T'l'p%on's
i. D$@ line shall be made available to the Hospital 3irector as head of organization.
ii. Heads of -linical 3epartments may be provided with a type D+@ P$+K line. Specific
areas shall also be provided a type D+@ line. $ll other telephone lines within the
hospital shall be of type D-@
iii. Telephones shall be for official use only. 4sage of telephone will be monitored by
the operators.
iv. Hand phones maybe be provided to certain category of staff as follows:
Hospital 3irector
Heads of disciplines
3esignated personnel on active calls
;;; personnel on active duties
medical team6medical response team on duty
*n compliance with the government directives
v. %obile phones should not be used in critical areas such as *-4 and 7*-4 in
accordance to %OH guidelines.
vi. $ twoBway radio communication system shall be used between the
ambulance and the station in response to an emergency call.
11.1 N-"s' Call S2st')
i. $ nurse call system shall be provided to all beds for patient to use when
assistance is re&uired. The system may be e0tended to patient areas such as
washrooms and toilets.
ii. 7urses shall attend to the patient immediately when the nurse call system is
activated.
11.2 P-4li. A,,"'ss S2st').
i. The Public $ddress (P$) system may be used for ma#ing announcements" alert
and providing information
ii. The P$ system may also be used for emergency situations using specific codes
as follows:
:ed alert
Pellow alert
Stand down
-ode blue
12. HOSPITAL AMENITIES
12.1 Ca" Pa"?
i. -ar par# shall be made available for staff and public. Only cars with
hospital stic#ers shall be allowed to enter the staff par#ing area. $ few designated
car par#s for 3octor onBcall and disabled patients shall be made available with
easy access to clinical areas. $ccess to public car par#s maybe charged.
ii. The Hospital shall not be responsible for the safety of the vehicles.
Signage shall be put up to inform the public that vehicles are par#ed at their own
ris#.
12.2 Sta++ Fa.iliti's
i. Staff facilities shall either be allocated to individuals (e.g. office room and
rooms in nurse hostel) or commonly shared by all staff (e.g. rest room and staff
changing room).
ii. The common areas shall be either under the responsibility of the General
$dministration or the specific department where it is located.
iii. -all rooms shall be provided for 3octors onBcall
iv. $ccommodations or &uarters shall be provided to some staff based on
availability" eligibility and service needs.

12. P-4li. Fa.iliti's
i. Public facilities shall be under the responsibility of the General $dministration
4nit. The following are some of the facilities available for public use:
Balai 'elawat
Prayer rooms
+reast feeding room
-afeteria
.ash room and toilet
Shops6#ios#
Telephone #ios#
-yber cafQ
$utoBteller machines6ban#ing facilities
Post office
Police base etc.
ii. Eisitor@s lounge (Balai Pelawat) shall be opened 8! hours as a rest place for
patient@s relatives. Those who use the lounge shall be subected to the rules and
regulation of the hospital.
iii.Prayer rooms shall be opened for 8! hours to the public and staff.
1. PRIVATISED SERVICES
1.1 S'.-"it2 S'"&i.'s
i. The security services in hospitals maybe be privatized. Scope of service shall be
based on the agreed contract.
ii. This service shall be operated by an appointed licensed security agency and shall
be managed6coordinated by the hospital General $dministration 4nit.
iii. To ensure the safety of government and public properties" the security
services in the hospital shall encompasses the scope set below
-ontrol the movement of patients" clients and staff in the hospital
area where only authorize person are allowed
/nsure safety of hospital asset and properties. /nsuring smooth
movement of vehicle traffic in accordance to traffic law.
/nsuring physical safety of staff" patient and clients including
appropriate response in the event of ris# 6 hazard 6 disaster
iv. The security plan shall include standard operation procedure including schedule
patrol" outlet chec#" visitors chec#" staff chec# and 8! hour security location. The
8! hour security presence shall be determine by hospital but generally covers
these minimum areas stated below
/mergency department
%ain entrance
2abor room
%aternity ward
Pediatric ward including 7eonatal unit
High dependency area such as *-4" H3. and --4.
$dmission counter
%edical Store
$ppropriate technologies can be used such as electronic access card" security camera
and automatic par#ing gates.
v. The security system shall also include operation procedure in the event of special
circumstances such as mass casualty" dignitaries@ visits" evacuation" outbrea#s
and fire. This plan should cover the following items
Safety of site of evacuation
Safety of building left unattended
:edirection of vehicle traffic
-ontrol of crowd" press and victims and their belongings
/nsuring of access of authorized personnel to location
These areas shall be demarcated by the securities personnel.
vi. $ll security personnel shall be vetted by the police to ensure there are no security
personnel with criminal records. Security personnel should undergo medical
e0amination to ensure they are fit to perform their duties
vii. The security personnel must develop a structure and mechanisms to wor# closely
with the police and fire brigade and other related agencies.
1.2 O-tso-".', Cat'"in# S'"&i.'s
i. Production and supply of diet shall be carried out by the appointed
outsourced food service company. *t shall be accountable to the 3ietetic and
-atering 3epartment of the respective hospital.
ii. ,oods shall be prepared according to the Privatised ,ood Service
-ontract Specification prepared by %inistry of Health.
iii. Serving of patients@ diet shall be done on a fully centralized plating system.
iv. $ll #itchen facilities and e&uipment are government@s asset and rented to
the outsourced Health food service company. %aintenance of e&uipment shall be
done by the hospital concession company. Payment for the utilities used by the
company shall be made to the hospital.
v. The hospital -atering and 3ietetic department shall ensure:
that raw food material received are of accepted
standard and stored properly to prevent contamination and rapid
deterioration.
Scheduled samplings of raw and coo#ed foods shall
be collected at regular intervals and send to the ,ood 2abs for analysis.
that food handlers are vaccinated and trained to
ensure &uality of food provided.
food preparation are in compliance with the %OH
guidelines (H$--P).
1. Hospital S-ppo"t S'"&i.'
19.9.1 General
i. The following C support services shall be privatized in accordance to the
specifications in the contract prepared by the %inistry"
-leansing
2inen
.aste management
+iomedical engineering
,acility engineering
ii. The administration unit shall be responsible for the overall coordination of the C
services. $ 2iaison Officer for each service shall be appointed to monitor and
coordinate all the activities and to ensure compliance to the Technical
:e&uirement and Performance *ndicators (T:P*)" the %aster $greed Procedures
(%$P) and the Hospital Specific *mplementation Plan (HS*P).
iii. The overall coordinator shall have regular meetings with the liaison officers to
discuss issues and remedial action to be ta#en to improve the services.
iv. There shall be a committee to discuss and decide on deductions for nonB
conformance.
19.9.8 -leansing
i. -leansing shall be carried out in accordance to the schedule as agreed in the Hospital Specific
*mplementation Procedure (HS*P).
ii. -leansing shall be carried out according to the correct techni&ue" e&uipment and using of
appropriate detergent.
19.9.9 2inen Services
i. $ll linen shall be delivered in a manner" which provides full protection from
contamination during handling and transportation.
ii. -lean linen already chec#ed and folded to an agreed pattern shall be supplied
according to schedule. 2inen shall be transported in designated clean or soiled
linen carts.
iii. Supply of clean linen shall be on a topBup basis and comply with par level of each
ward6 unit6 department6 OT as agreed in the HS*P.
iv. Soiled linen from wards" OT and other departments shall be placed in colorBcoded
bags (:ed B infected" Green B OT linen and .hite B soiled) provided by the
concessionaire and collected at the respective areas by the concessionaire as per
agreed schedule.
19.9.! .aste management
i. .aste shall be handled in accordance with standard precaution and infection
control measures.
ii. The transportation of clinical and general waste shall follow a designated route
as agreed by Hospital Privatization -ommittee.
iii. The chemical waste shall be handled appropriately in accordance to the
re&uirement of G/nvironmental $ct 1;>!@ and /nvironmental Nuality (Scheduled
.aste) :egulations 1;<;.
iv. GGuidelines on the 3isposal of -hemical .astes from 2aboratories" 8=== by
3epartment of /nvironment" %inistry of Science" and Technology ? /nvironment"
%alaysiaH shall be referred to for detailed procedures in handling of chemical
waste.
1..1 ,acility ? +iomedical /ngineering
i. The concession company shall be responsible for carrying out planned preventive
maintenance according to the schedule recommended by the manufacturers of
e&uipment.
ii. The regular maintenance service of mechanical" electrical" civil and bioBmedical
e&uipment within the warranty period shall be underta#en by the vendors through
Hospital Support Service.
iii. The Hospital Support Service shall rectify any brea#down within the shortest
possible time as specified in the T:P*.
iv. $ny improvement6alteration wor# and reimbursable wor# re&uired shall be
referred to the Hospital 3irector for approval.
1*. DISASTER MANA!EMENT
1*.1 Disast'"s Plan
i. There shall be an /mergency %anagement -ommittee headed by the
Hospital 3irector. The members of the committee shall include the clinicians"
representatives from the relevant department6unit and representative from the
privatized support services.
ii. The committee shall be responsible for the preparation of the 3isaster
%anagement Plan" Hospital -ontingency Plan and its implementation. %eetings
shall be held regularly to discuss issues and remedial measures.
iii. *n the event of disaster" the Hospital 3irector shall declare red alert and
activate the disaster management plan.
iv. The 3isaster %anagement Plan shall include the followings"
The emergency alert system
2ist of posts and responsibilities
%edical teams
%anagement of the victims
3ocumentation and statistics
v. $ll staff shall be briefed on the 3isaster %anagement Plan and their roles and
responsibilities. $ppropriate training shall be carried out.
vi. $ disaster drill shall be organized regularly at least once a year.
vii. 3epartment and unit head shall be responsible for the disaster plan of their
own department6unit.
1*.2 Hospital '&a.-ation
i. The hospital shall have a plan for evacuation of building.
ii. Staff shall be briefed on the evacuation plan" e0it routes and the gathering
site.
iii. $n e0it route plan shall be displayed at strategic location in every
department6 unit6 ward.
iv. $n evacuation drill shall be carried out at least once a year.
1*. Sp'.i+i. .ontin#'n.2 plans
i $ specific contingency plan shall be made available for the following
situation"
Power failure
*T system brea#down
2ift brea#down
-ut in water supply
Gas lea#age
,lood
3isease outbrea#
$ir condition failure
+uilding infestation
ii The plan shall include notifications" allocation of responsibilities "
immediate actions" alternative solutions and follow up measures.
iii $ll staff shall be briefed on the plan and appropriate training shall be
carried out.
11. INFORMATION AND COMM;NICATION TECHNOLO!Y /ICT0
*-T services shall be maintained by the appointed company. *t shall be accountable to
*-T 3epartment of the respective hospital. Operation and support of *-T service shall be
carried out by appointed company accountable to *-T 3epartment.
.ill wor# on thisR

17. PLANNIN! AND DEVELOPMENT

i. /very clinical head of department shall plan e0isting clinical development
that includes short term and long term plan.
ii. Hospital should have master plan that describes the future needs of the
service based on situational analysis done at inception 6 current status which
shall includes service" physical and financial re&uirement.
iii. $ short term of planning and development should be developed yearly (1 '
C years) to address current needs of services and possible e0pansion. This shall
include 3asar +aru" DOneBOffs@ and +P F.
-ontributors:
3ato 3r. Ghazali Hasni H %d. Hassan
Pengarah Hospital :aa Perempuan Sainab 11" Aota+aru
3r. Saidah Hussain
%antan Pengarah Hospital :aa Perempuan +ainun" *poh
3r. Laafar -he@ %at
Pengarah Hospital Tuan#u Laafar" Seremban
3r. Siti Saleha %ohd. Salleh
Pengarah Hospital Selayang
3ato 3r. +ahari 3ato To# %uda H $wang 7gah
Pengarah Hospital Sultan $hmad Shah" Temerloh
3r. $zman $bu +a#ar
Pengarah Hospital Serdang
3r. %ohd. Shah 3ato *dris
Pengarah Hospital Tuan#u $mpuan 7aihah" Auala Pilah
3r 7or $#ma Pusuf
3r 2aili %urni %o#htar
3r %uhammad bin %ohd Shariff