Assoc. Prof. Dr. M.A.

Kadar Ma
CEO Malaysian Society of Quality in H
Introduction to Malaysia
Key Patient Safety Strategies
Patient Safety Initiatives In Malaysia
Recent Achievement
The Success Factors
Challenges
 Statistics
POPULATION (2013) 28.3 million
Life expectancy male (2010) 71.9
Life expectancy female (2010) 77
Annual population growth rate 1.3
( 2011)
Total expenditure on health 4.96%
per GDP (2009)
MOH Hospitals & Institutions 138
(2011)
Private hospital s (2011) 220
132 HOSPITAL 879 106 MOTHER & CHILD CLINIC
HEALTH CLINIC

1,864 87 1MALAYSIA CLINIC 1,774 DENTAL CLINIC

RURAL CLINIC

SPECIAL MEDICAL 6 SPECIAL INSTITUTIONS

6 INSTITUTIONS NATIONAL INSTITUTE 16
185 AMBULANCE 7 FLYING DOCTOR SERVICE
1MALAYSIA MOBILE CLINIC 12

MOBILE DENTAL
25 MOBILE DENTAL CLINIC MOBILE DENTAL TEAM
410 136 SCHOOL TEAM

1 1MALAYSIA BOAT CLINIC 1 1MALAYSIA DENTAL CLINIC

KEY PATIENT SAFETY STRATEGIES
Promotion &
Education

Research
Policies &
Guidelines
PATIENT
SAFETY

Specific Organisational
Programmes Structure

Monitoring
System
 KEY PATIENT SAFETY STRATEGIES
rganisational Structure Policies & Guidelines
Malaysian Society for • Healthcare standards
(Hospitals, Clinics,Chronic
Quality in Health (MSQH) dialysis, Dental Services…)
Patient Safety Council • Malaysian Patient Safety Goals
Malaysia (at MoH) • Clinical Governance
• Incident Reporting & RCA
Patient Safety Committee
• Safe Surgery Saves Lives
at health facility )
• Peri-operative Mortality
PATIENTS for Patient Notification & Review
Safety Malaysia • Independent Inquiry
• Transfusion Safety
• Clinical Practice Guidelines
Promotion & Educatio
• 1st National Patient Safety
Campaign 2013
• Specific patient safety area
• Safety Culture
• Malaysian Patient Safety
Goals
• Clinical Governance
• Incident Reporting, Root
cause analysis
• Patient for Patient Safety
Malaysia in 2014
 KEY PATIENT SAFETY STRATEGIES
Specific Research/Systematic
Monitoring System
Programmes Review
• “Clean Care is Safer Care” • PRIMARY STUDIES
Accreditation of • “Safe Surgery Saves Lives” • Medical Safety - Inpatient Care
Healthcare Facilities and • Tackling Antimicrobial Resistance • Medical safety – Primary care
• Medication Safety
Services. • Improve accuracy of patient
identification
• Blood Transfusion Safety
• Vaccine Safety
Malaysian Patient Safety • Transfusion Safety • Laboratory Safety
Goal •
•
Medication Safety
Critical value program
• Culture – the patient perception
• Handoff Communication
Hospital Indicator • Fall prevention • Dental Safety
Performance for • Healthcare- associated pressure ulcer
prevention
• Patient Falls
• Patient Safety Culture
Accountability (HPIA) • Catheter-Related Bloodstream
• SYSTEMATIC REVIEW
Clinical Indicators •
Infection Prevention
Ventilator Associated Pneumonia
• Culture
• Handoff Communication
Prevention
• Medication
• Incident Reporting and Learning • Patients unvoiced needs
System
PATIENT SAFETY COUNCIL MALAYSIA

• Formed following directive from Malaysian Cabinet on 29th January

2003.
• Functions:
› Advise the Honorable Health Minister on national patient safety
policies, strategies and action plans
› Enhance implementation of patient safety strategies
› Monitor and evaluate achievement of the Malaysian Patient Safety
Goals and take action at national level
› Promote and facilitate national, regional and international
collaboration in patient safety.
 Chairman
(Director General of
Health Malaysia)

Appointed Private Ministry of Ministry of Higher Education Patients for Secret

Members Sectors/NGOs Health Ministry of Patient
(3) – UMMC, UKMMC, (Quality in
Defense Safety
(3) (8) (19) HUSM Malaysia Care Sectio

ion Malaysian Academy Malaysian Academy of Malaysian Academy Malaysian

te Occupational & Dental
Medical of Society for Pharmaceutica of Family
al Environmental
ia Association Medicine Quality in Health Medicine Malaysia l Society Physician Association

Currently 36 members
PATIENT SAFETY COMMITTEE
(at facility level)
To lead patient safety initiatives
in the facility
To plan and establish
ways, work system and
programme to ensure patient
safety
To ensure implementation
Malaysian Patient Safety Goals
To monitor and assess status
of patient safety using “e-goals
patient safety”
To discuss incidents, complaints
and patient safety issues; take
appropriate actions and assess
its effectiveness
To plan and implement
promotional and educational
activities related to patient
safety
Others deem necessary
Consortium of Association Ministry of Health
of Medical Clinics Malaysia
MSQH Committee Members
 PATIENTS FOR PATIENT SAFETY MALAYSIA
 “PATIENTS For Patient Safety Country
Workshop” conducted by MSQH & Ministry
of Health in collaboration with WHO on
5th-6th Sept 2013.
 Following this, “PATIENTS For Patient
Safety Malaysia (PFPSM)”, voluntary
organization was established.
 PFPSM was launched by Honorary Minister
of Health on 29th April 2014
 PFPSM promotes partnership between
patients- healthcare providers -consumers in
enhancing patient safety.
 Patients engagement & empowerment to
improve patient safety
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MSQH Accreditation Standards
Malaysian Hospital
Accreditation Standards (1999)

Medical Clinic Accreditation

Programme (2012)

Chronic Dialysis Treatment

Standards (2013)

Dental Clinic Accreditation

Programme (2016)
 First edition (1999 )

Second edition (2004)

Third edition (2008)

Fourth edition (2013)

Fifth edition (2017)

 Current WHO Patient Safety Goals

1. Identify patient correctly

2. Improve effective communication
3. Improve the safety of high-alert medications
4. Ensure correct-site, correct-procedure, correct-patient surgery
5. Reduce the risk of healthcare associated infections.
6. Reduce the risk of patient harm resulting from fall

PATIENT SAFETY SOLUTIONS

1. Look-Alike, Sound-Alike Medication Names
2. Patient Identification.
3. Communication During Patient Hand-Overs.
4. Performance of Correct Procedure at Correct Body Site.
5. Control of Concentrated Electrolyte Solutions
6. Assuring Medication Accuracy at Transitions in Care.
7. Avoiding Catheter and Tubing Misconnections.
8. Single Use of Injection Devices.
 POLICY -D.G HEALTH CIRCULAR NO 2/2013
Establishment of Patient Safety Committee & Implementation
of Malaysian Patient Safety Goals

The Star Newspaper

Monday 20th May 2013

D.G Health Circular 2/2013

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*To implement Clinical Governance
To implement WHO’s 1st Global Patient
Safety Challenge: “Clean Care is Safer
Care”
To implement WHO’s 2nd Global Patient
Safety Challenge: “Safe Surgery Saves
Lives”
To implement WHO’s 3rd Global Patient
Safety Challenge: “Tackling Antimicrobial
Resistance”
To improve the accuracy of patient
dentification
To ensure the safety of transfusions of
blood and blood products
*To improve medication safety
8) To improve clinical communication by
implementing a critical value program
9)* To reduce patient fall
10)To reduce the incidence of healthcare- associa
pressure ulcer
11) To reduce Catheter-Related Bloodstream
Infection (CRBSI)
12) To reduce Ventilator Associated Pneumonia
(VAP)
13) *To implement the Patient Safety Incident
Reporting and Learning System
*Applicable for clinics
 e-goals patient safety
(online notification of MPSG performance)
(http://patientsafety.moh.gov.my/)

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 MALAYSIAN PATIENT SAFETY GOALS
NOTIFICATION 2013 VIA ‘e-goals patient safety’
(1st 6 months of implementation)

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 38 indicators
 e.g.: Percentage of issues raised in the meeting with the Board of
Visitors whereby response and action had been taken (Standard ≥70%
 270 indicators
 42 specialties and subspecialties
 e.g.: Percentage of Post Partum Haemorrhage (Standard ≤1%)
ists of Accredited Programme
Malaysian Hospital Accreditation Program is a
voluntary, independent programme conduct by Malaysian Society
or Quality in Health (MSQH); a member of the International
Society for Quality in Health (ISQua)
5th Edition Malaysian Hospital Accreditation Standards
Surveyor Training Programme
Guidelines produced by Ministry of Health Malaysia :
82 Clinical Practice Guidelines
1 NATIONAL PATIENT SAFETY CAMPAIGN
ST

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 1ST NATIONAL PATIENT SAFETY CAMPAIGN, SEMINAR
&
LAUNCHING OF MALAYSIAN PATIENT SAFETY GOALS 24TH JUNE 201

D.G of Health with stakeholders

Signing of Malaysian Patient Safety

Press Conference – 1st National
Goals Replica By D.G of Health 34
Patient Safety Campaign
CONFERENCES, CAMPAIGN AT FACILITY LEVEL &
EXHIBITION ON PATIENT SAFETY
MSQH-MOH Patient Safety
International Conference

Malaysian International
Healthcare Tourism Expo

Campaign & Seminar at Patient Safety Campaign in

UMMC Private Hospital
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MSQH Healthcare Summit 2016
5th Edition Hospital Accreditation Standards Training
ECRI Risk Management Training
International Forum on Quality & Safety in Healthcare organized
by BMJ
ISQua 2017 in London
ISQua 2018 in Kuala Lumpur Convention Centre, KLCC, Malaysia
 MSQH Healthcare Summit 2016

Risk Management Training

Programme by ECRI
International Forum on Quality & Safety
in Healthcare organized by BMJ
ISQua 2017 in London
ISQua 2018 in Kuala Lumpur Convention Centre,
KLCC, Malaysia
FIRST GLOBAL PATIENT SAFETY CHALLENGE
“CLEAN CARE IS SAFER CARE”

The Hon.Minister of Health, affirmed

Malaysia's commitment, 15th May 2006
witnessed by Professor Didier Pittet, leader of the
Global Patient Safety Challenge
INFECTION PREVENTION & CONTROL THROUGH INNOVATION
15th January 2014

Prof. Diedier Pittiet

Director, Infection Control Program, WHO Datuk Dr. Noor Hisham
Collaborating Centre on Patient Safety Abdullah
-Delivering lecture “Infection Control: From Director General of Health
Rubbing to Dancing Around The World” 43
-Delivering keynote address
 HAND HYGIENE COMPLIANCE VS
HEALTH CARE ASSOCIATED INFECTION
National Average of HHCR,
2008 - 2012
100
80
Percentage

60 82,8
40 56,6
20
0
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4

2008 2009 2010 2011 2012

National Average of HCAI, 2008 - 2012
3,5
3
3,15
Percentage

2,5 1,54
2
1,5
1
0,5
0
March Sept March Sept March Sept March Sept March Sept

2008 2009 2010 2011 2012

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SECOND GLOBAL PATIENT SAFETY CHALLENGE
“SAFE SURGERY SAVES LIVES”
THEME MINISTRY OF HEALTH MALAYSIA
“ S A F E R S U R G E RY PERIOPERATIVE CHECKLIST
THROUGH BETTER
COMMUNICATION”

Launching of Safety
Surgery Saves Lives
2009 45
IMPROVE PATIENT IDENTIFICATION

46
MEDICATION SAFETY

“tall man lettering” concept

for sound alike medication.

47
RCA workshop for state health
department, hospitals & health
clinics:
State Directors & officers
Hospital Directors
Doctors
Paramedics
have been conducted since 2005.
According to zone, states and
facilities.
3-2 days workshop
30-50 people, 6-10 per group
Content of Workshop:
Concept of Incident Reporting &
Learning System
Flow of reporting
Concept of RCA
How to do RCA
Examples of case presentation
Group discussion on how to conduct
RCA based on scenarios
Group presentation
Latest Training on Incident Reporting & Learning System and
RCA was conducted in MSQH, The National Cancer Institute
Malaysia and Kuala Lumpur State Health Dept.
LESSONS LEARNT FROM INCIDENT
Why Patient Safety Incident Happen?

Lack of /unclear “Refuse” to use “Assume” culture

“communication” check list

“Multi” Lack of
“OK” Culture “supervision
supervision”
tasking

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 RECENT ACHIEVEMENTS OF 2017
 Quality & patient safety now included in 11th Malaysia Plan (2016-2020)

 Patient Safety Council of Malaysia (13th January 2014) agreed to implement WHO Multi-
professional Patient Safety Curriculum Guide in:
Medical, Pharmacy, Dental, Allied Health and Nursing undergraduate programs
Housemanship training

 Chairperson of PATIENTS For Patient Safety Malaysia is now a member of Patient

Safety Council of Malaysia (patient representative) and MSQH Committee member.

 Malaysian Patient Safety Goals notification (June- Dec 2013) received for the first time

 Developments of Healthcare standards and Refinements and Upgrading of existing

standards.

 PFPS Malaysia activities (Pilot project with 13 public & private hospitals in 2016)
 SUCCESS FACTORS
Commitment of top leaders

Smart partnership and Good collaboration between Public, Private and

Profesional bodies.

Proactive and dedicated champions at national and facility level.

Internalization and institutionalization of patient safety mindset and

safety culture.

Top-down and bottom-up feedback system between policy

makers, implementers, providers and patients and families.

Integration of patient safety in Malaysian Healthcare Accreditation

Standards for facilities and services.
 CHALLENGES

Increase
workload

Staff
factors

Limited
resources

Patient &
family factors
 ACKNOWLEDGEMENT

WORLD HEALTH ORGANISATION Geneva and WPRO

MINISTRY OF HEALTH MALAYSIA
MALAYSIAN SOCIETY FOR QUALITY IN HEALTH
PATIENTS FOR PATIENT SAFETY MALAYSIA

Thank you

www.msqh.com.my
kadar@msqh.com.my
“Always remember to be safety conscious and
above all do no harm”
…

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