11

COUNTRY PROFILE COUNTRY PROFILE ON:ON:

PATIENT SAFETY PATIENT SAFETY ISSUES ISSUES AND EFFORTSAND EFFORTS: : MALAYSIAMALAYSIA

presentedpresented by:by:

Dr. Dr. KalsomKalsom btbt. . MaskonMaskonDeputyDeputy--DirectorDirector

Medical Development Division Medical Development Division Ministry of Health MalaysiaMinistry of Health Malaysia

22

A. A BRIEF DESCRIPTION OF

THE MALAYSIAN HEALTHCARE SYSTEM

33

By:By:Dr. Dr. KalsomKalsom MaskonMaskon

Deputy Director Deputy Director Section on Quality in HealthcareSection on Quality in HealthcareMedical Development DivisionMedical Development Division

MOH, Malaysia MOH, Malaysia

The Malaysian health The Malaysian health care systemcare system

MINISTRY OF HEALTH MALAYSIAMINISTRY OF HEALTH MALAYSIA

44

MALAYSIA

MalaysiaMalaysia

55

M A L A Y S I A

S A R A W A K

S A B A H

I N D O N E S I AI N D O N E S I A

SOUTH CHINA SEA

BRUNEI

KEDAH

PERLIS

PERAK

P.PINANG

KELANTAN TERENGGANU

PAHANG

SELANGOR

N.SEMBILAN

MELAKA JOHOR

SINGAPORE

THAILAND

W.P.LABUAN

W.P. KUALALUMPUR

66

Country ProfileCountry Profile

* * Malaysia occupies a central positionwithin Southeast Asia including two land masses separated by the South China Sea

* Multi - ethnic population(Malay, Chinese, Indian, Others)

•Estimated population :25million (2003):32 mill (2020)

* Relatively young population

* Population average growth rate 2.5%

77

SocioSocio--Economic Indicators Economic Indicators (2003)(2003)

Per capita income : RM 14,098 (3710 USD)Economic growth : 5.5%Inflation rate : 2.0% Unemployment rate : 3.1%Dependency ratio : 58.5% Urban population : 62%* Population served with : 87% (rural)

safe water supply 98% (urban) * Population with : 98.4% (rural)

adequate sanitary latrines: 100%(urban)* 1999 data

88

Population trend by age groupPopulation trend by age group

0

5

10

15

20

25

0-14 6.75 7.89 8.9315-64 10.56 13.77 20.8765+ 0.67 0.99 2.19

1990 2000 2020

MILLION 6.8%

4.3%

3.7%

99

Health Care ProvisionHealth Care Provision

PUBLIC SECTOR *Ministry of Health (MOH) : Major provider

*Ministry of Education

*Ministry of Defense

*Ministry of Housing and Local Government

*Ministry of Home Affairs

*Ministry of Human Resource

PRIVATE SECTOR

TRADITIONAL/COMPLEMENTARY MEDICINE

NON-GOVERNMENTAL ORGANIZATIONS.

1010

National Referral System, MOH, MalaysiaNational Referral System, MOH, Malaysia

NationalReferralCentres

RegionalHospital/State Hospital

Hospitals with Specialistsin Districts

Hospitals without Specialistsin Districts

Health Clinics1 : 20,000 population

Rural/Community Clinics1 : 4,000 population

INSTITUTIONALCARE

PRIMARYHEALTHCARE

Ambulatory Care Centres

1111

RURAL PRIMARY EALTHCARERURAL PRIMARY EALTHCARE

Health ClinicHealth Clinic

Community Clinic

Community Clinic

Community Clinic

Community ClinicCoverage : 15,000 - 20,000 population

(2,000 - 4,000)

1212

Health facilities MOH Health facilities MOH &Private&Private

MOH FACILITIES MOH FACILITIES

Public HealthPublic HealthHealth ClinicsHealth Clinics 845845Community Clinic Community Clinic 1,9241,924Mobile Teams Mobile Teams 204 204

MOH HOSPITALSMOH HOSPITALSHospitals 118Hospitals 118(Acute Beds)(Acute Beds) (34,089)(34,089)Medical Institutions 6 Medical Institutions 6 ( Chronic Beds)( Chronic Beds) 5,456)5,456)

PRIVATE FACILITIES PRIVATE FACILITIES

Private clinics : > 5,000 Private clinics : > 5,000

PRIVATE HOSPITALPRIVATE HOSPITALHospitals : 219 Hospitals : 219 Beds :10,405 Beds :10,405

1313

B. PRINCIPAL PROBLEMS RELATED TO PATIENT SAFETY IN

MALAYSIA

presentedpresented by:by:

Dr. PAA Mohamed Dr. PAA Mohamed NazirNazir bin Abdul bin Abdul RahmanRahmanPrincipal Assistant DirectorPrincipal Assistant Director

Section on Quality in HealthcareSection on Quality in HealthcareMedical Development Division Medical Development Division

Ministry of Health MalaysiaMinistry of Health Malaysia

1414

MalaysiaMalaysia’’s Experiences Experience

So far, So far, no major studiesno major studies of the of the magnitude and methodological magnitude and methodological finesse of :finesse of :

The Harvard Study of Medical PracticeThe Harvard Study of Medical Practiceor or

The Quality in Australian HealthcareThe Quality in Australian HealthcareStudyStudy

1515

MalaysiaMalaysia’’s Experiences Experience

Problems concerning safety in: Problems concerning safety in:

Public Sector hospitals:Public Sector hospitals:addressed by various Quality addressed by various Quality

Improvement activities in MOH Improvement activities in MOH

Private sector:Private sector:Individual hospitalIndividual hospital’’s interest,s interest,““Benchmarking studyBenchmarking study”” conducted in 19 conducted in 19

hospitals in private sector in 2002hospitals in private sector in 2002

1616

MalaysiaMalaysia’’s Experiences Experience

Public sector problems related to patient Public sector problems related to patient safety involve :safety involve :

surgicalsurgical--related disciplinesrelated disciplines

certaincertain““incidentsincidents”” e.g. preventable e.g. preventable adverse eventadverse eventss

hospitalhospital--acquired infection acquired infection

1717

MalaysiaMalaysia’’s Experiences Experience

Data on specific problems related to Data on specific problems related to patient safety:patient safety:

will be presented together with a will be presented together with a description of the various Quality description of the various Quality Improvement activities that target Improvement activities that target patient safetypatient safety

…………. in the next section. in the next section

1818

C. Patient safety initiativesC. Patient safety initiatives

QUALITY ASSURANCE PROGRAMMEQUALITY ASSURANCE PROGRAMME

Started in 1985 Started in 1985 –– indicator approachindicator approach

Presently 20 Quality Improvement Presently 20 Quality Improvement activities covering a number of activities covering a number of approachesapproaches

QUALITY ASSURANCE PROGRAMME QUALITY ASSURANCE PROGRAMME IN MINISTRY OF HEALTHIN MINISTRY OF HEALTH

•• Launched in 1985Launched in 1985 (with implementation of(with implementation ofPatient Care Services QA Programme)Patient Care Services QA Programme)

•• QAP expanded toQAP expanded toPublic Health ServicesPublic Health Services (1990)(1990)Pharmaceutical ServicesPharmaceutical Services (1990)(1990)Dental ServicesDental Services (1992)(1992)Engineering ServicesEngineering Services (1992)(1992)Laboratory ServicesLaboratory Services (1992)(1992)Training & Manpower Training & Manpower

ServicesServices (1996)(1996)Planning DivisionPlanning Division (1998)(1998)

2020

QAP ORGANISATIONAL QAP ORGANISATIONAL STRUCTURESTRUCTURE

2121

The MOH Steering Committee

Programme Level QAP Committee

State QAP Steering Committee

State QAP technical sub-committee

Hospital / District QAP Committee

The MOH Steering Committee

Programme Level QAP Committee

State QAP Steering Committee

State QAP technical sub-committee

Hospital / District QAP Committee

2222

MEDICAL PROGRAMME QAPMEDICAL PROGRAMME QAP::QI Activities That Target Patient SafetyQI Activities That Target Patient Safety

2323

MOH Operational Definition of MOH Operational Definition of QUALITY (2001)QUALITY (2001)

Facilities and services are of high quality Facilities and services are of high quality if they are:if they are:

1.1. SAFESAFE2.2. Effective Effective 3.3. AppropriateAppropriate4.4. Equitably accessedEquitably accessed5.5. EfficientEfficient6.6. PatientPatient--centredcentred and consumerand consumer--friendlyfriendly

2424

QI ACTIVITIES QI ACTIVITIES IN THE MEDICAL CARE IN THE MEDICAL CARE

PROGRAMMEPROGRAMME ……....

They deal with hospital They deal with hospital performance in performance in ………………

(a)(a) Technical aspect of QTechnical aspect of Q(b)(b) InterInter--personal (Caring) personal (Caring)

aspect of Qaspect of Q

2525

Technical QualityTechnical QualityIndicator ApproachIndicator Approach(i)(i) National Indicator Approach (NIA)National Indicator Approach (NIA)(ii)(ii) Hospital Specific Approach (HSA) Hospital Specific Approach (HSA)

(iii)(iii) Patient Safety Council of MalaysiaPatient Safety Council of Malaysia(iv)(iv) Incident ReportingIncident Reporting(v)(v) Hospital Infection ControlHospital Infection Control

2626

Clinical AuditClinical Audit (Internal Peer (Internal Peer Review)Review)

(vii)(vii) PerioperativePerioperative Mortality Mortality ReviewReview (POMR)(POMR)

(viii)(viii) Intensive Care Unit audit Intensive Care Unit audit (ix) (ix) Nursing auditNursing audit

2727

External Peer ReviewExternal Peer Review

(x)(x) Hospital Accreditation Hospital Accreditation ProgrammeProgramme

Explicit Process MeasurementExplicit Process Measurement

(xi) Clinical Care Pathways for mgt. of:(xi) Clinical Care Pathways for mgt. of:

Acute Myocardial Infarct, Acute Myocardial Infarct, Asthma, Asthma, Head Injury, Head Injury, EclampsiaEclampsia (in various stages of development)(in various stages of development)

MATERNAL MORTALITY REVIEW/MATERNAL MORTALITY REVIEW/PERINATAL MORTALITY REVIEWPERINATAL MORTALITY REVIEW

CLINICAL PRACTICE GUIDELINES (CPG)CLINICAL PRACTICE GUIDELINES (CPG)INNOVATIONSINNOVATIONS

CREDENTIALING OF MEDICAL STAFFCREDENTIALING OF MEDICAL STAFFHEALTH TECHNOLOGY ASSESSMENT (HTA)HEALTH TECHNOLOGY ASSESSMENT (HTA)

OTHER QUALITY IMPROVEMENT OTHER QUALITY IMPROVEMENT ACTIVITIES IN THE MOH MALAYSIA ACTIVITIES IN THE MOH MALAYSIA TARGETING PATIENT SAFETYTARGETING PATIENT SAFETY

2929

PATIENT SAFETY PATIENT SAFETY IN MALAYSIAIN MALAYSIA

3030

Making Patient Safety a National Making Patient Safety a National AgendaAgenda

The Hon. Health Minister tabled a The Hon. Health Minister tabled a Cabinet Note on Patient Safety to Cabinet Note on Patient Safety to Malaysian CabinetMalaysian Cabinet

Recommended formation of the Recommended formation of the Patient Safety Council of MalaysiaPatient Safety Council of Malaysia

Approved by Malaysian Cabinet : Approved by Malaysian Cabinet : 2929th th January 2003January 2003

3131

Patient Safety Council : CompositionPatient Safety Council : Composition

CChaired byhaired by : Director: Director-- General of Health General of Health Malaysia Malaysia

SecretariatSecretariat : Section on Q in Healthcare, Med. : Section on Q in Healthcare, Med. Development Div. MOHDevelopment Div. MOH

Representatives Representatives ––public and private sectorpublic and private sector

-- UniversitiesUniversities--professional bodiesprofessional bodies--consumer groupsconsumer groups

3232

PSCoMPSCoM : Terms of reference: Terms of reference

Advise Hon. Health Minister on :Advise Hon. Health Minister on :

national priority areas and strategiesnational priority areas and strategies for for patient safety and quality improvement in patient safety and quality improvement in

healthcarehealthcare

Gives importance to Gives importance to Clinical Risk Clinical Risk ManagementManagement

3333

6 Sub6 Sub--committeescommittees

Data and InformationData and InformationConsumer Education and EmpowermentConsumer Education and Empowerment

Continuing EducationContinuing EducationMedication SafetyMedication SafetyTransfusion SafetyTransfusion SafetySafe Staffing and Quality of Work LifeSafe Staffing and Quality of Work Life

3434

NATIONAL INDICATOR NATIONAL INDICATOR APPROACH (NIA)APPROACH (NIA)

3535

Common indicators & standards toCommon indicators & standards tomeasure quality in the various areas ofmeasure quality in the various areas ofconcernconcern

INDICATORS : monitored nationally INDICATORS : monitored nationally investigated locallyinvestigated locally to to identify shortfalls in Q identify shortfalls in Q

ActionAction taken for correction. taken for correction. Knowledge gained used to design betterKnowledge gained used to design bettersystems of care provisionsystems of care provision

National Indicator Approach (NIA):

3636

NATIONAL INDICATORSNATIONAL INDICATORS

TARGETING SAFETYTARGETING SAFETY

MEDICAL PROGRAMMEMEDICAL PROGRAMME

3737

HOSPITALHOSPITAL--WIDE INDICATORSWIDE INDICATORS1. Delay in surgery for : very urgent 1. Delay in surgery for : very urgent

casescases2. Unplanned return to operating 2. Unplanned return to operating

theatretheatre3. Unplanned re3. Unplanned re--admissions within 48 admissions within 48

hours of discharge.hours of discharge.4. 4. Incidence of pressure sores in nonIncidence of pressure sores in non--

ambulatory patientsambulatory patients5. Trauma patients returning to the 5. Trauma patients returning to the

Emergency department within 24 Emergency department within 24 hours of first consultation.hours of first consultation.

3838

SURGICAL INDICATORSSURGICAL INDICATORS

66.. Incidence of Plaster of Paris cast Incidence of Plaster of Paris cast complication. complication.

77. . Incidence of complications following Incidence of complications following ritual circumcisionritual circumcision

3939

ANESTHESIAANESTHESIA INDICATORSINDICATORS

8.8. Occurrence of adverse events Occurrence of adverse events during during recovery period.recovery period.

9.9. Unplanned admission to ICU Unplanned admission to ICU within 24 within 24 hours of surgery.hours of surgery.

4040

UROLOGY UROLOGY INDICATORSINDICATORS

10.10. Morbidity from Morbidity from PercutaneousPercutaneousNephrolithotripsyNephrolithotripsy (PCNL)(PCNL)

11.11. Morbidity from TransMorbidity from Trans--urethral Resection of Prostate(TURP).urethral Resection of Prostate(TURP).

4141

DIAGNOSTIC & IMAGING DIAGNOSTIC & IMAGING INDICATORSINDICATORS

12. Morbidity associated with 12. Morbidity associated with PercutaneousPercutaneous needle aspiration needle aspiration

cytology/Biopsy of chest and cytology/Biopsy of chest and abdomen abdomen

––pneumothoraxpneumothorax

13. 13. Morbidity associated with Morbidity associated with PercutaneousPercutaneous needle aspiration needle aspiration

cytology/Biopsy of chest and cytology/Biopsy of chest and abdomen abdomen

-- hemorrhagehemorrhage

4242

PHYSIOTHERAPY PHYSIOTHERAPY INDICATORSINDICATORS

14. Burns during delivery of 14. Burns during delivery of electroelectro--therapeutic modalities and thermal therapeutic modalities and thermal agents.agents.

4343

DIETARY INDICATORSDIETARY INDICATORS

15. Incidence of physical food 15. Incidence of physical food contamination.contamination.

4444

NURSING INDICATORSNURSING INDICATORS

16. 16. Incidence of Incidence of ThrombophlebitisThrombophlebitis in in patients receiving intravenous patients receiving intravenous therapy.therapy.

4545

NOSOCOMIALNOSOCOMIAL / / HOSPITAL INFECTION HOSPITAL INFECTION

CONTROLCONTROL

4646

Achievements:Achievements:'Point Prevalence Survey'Point Prevalence Survey‘‘

undertaken nationally since undertaken nationally since 20032003

-- Collection of data on HospitalCollection of data on Hospital--acquired infections : acquired infections : MRSAMRSA data data -- 14 14 State State hospitals hospitals

startingstarting 1 July 20021 July 2002

ESBLESBL data since August 2003data since August 2003

4747

Results of monitoring (MRSA)Results of monitoring (MRSA)

(Jan. (Jan. -- December 2003)December 2003) 14 hospitals 14 hospitals

Total MRSA Total MRSA = 3 132= 3 132

Total InTotal In--patient Admissions = 87,9116patient Admissions = 87,9116

Average National Rate Average National Rate = 0.35 %= 0.35 %

4848

TwiceTwice--yearly Point Prevalence Surveys : yearly Point Prevalence Surveys : Indicators for Monitoring of Indicators for Monitoring of NosocomialNosocomial

infectionsinfections

55 types oftypes of NosocomialNosocomial infections infections surveyed (March, September surveyed (March, September yearly)yearly)

(i)(i) UTIUTI -- symptomatic & asymptomaticsymptomatic & asymptomatic(ii)(ii) Surgical site infectionsSurgical site infections

-- superficialsuperficial-- deep deep incisionalincisional-- organ / spaceorgan / space

4949

NosocomialNosocomial infections infections ……continuedcontinued

(iii)(iii) PneumoniaPneumonia(iv)(iv) Blood Stream infectionsBlood Stream infections(v)(v) Clinical sepsisClinical sepsis

5050

Point PrevalencePoint Prevalence Survey in 14 hospitalsSurvey in 14 hospitals

6.1%6.1%7.7%7.7%PercentagePercentage

9 5599 5599 4079 407Total PatientsTotal Patients

583583731731Total Total NosocomialNosocomialcasescases

Sept. Sept. ‘‘0303March March ‘‘0303

5151

Prevalence SurveyPrevalence Survey

Pneumonia (Pneumonia (24.524.5% & 26.6%) % & 26.6%) SSI (SSI (21.921.9% & 21.6%)% & 21.6%)

””Targeted surveillanceTargeted surveillance”” for Ventilatorfor Ventilator--associated Pneumonia (VAP) dan SSI associated Pneumonia (VAP) dan SSI : in 2004 : in 2004

Concentrating on ICUs in 14 State Concentrating on ICUs in 14 State hospitals hospitals

5252

Determining:Determining:-- Norms for Infection Control Nurse Norms for Infection Control Nurse in MOH hospitalsin MOH hospitals

( 1 : 250 occcupied beds)( 1 : 250 occcupied beds)

-- every ward to train a every ward to train a 'link 'link nurse'nurse'

5353

Training & Continuing Education:Training & Continuing Education:-- Development of Development of ““PostPost--BasicBasic”” courses courses

in Infection Control in Infection Control

-- ““APSICAPSIC”” course conducted by course conducted by Malaysian Infection Control Society Malaysian Infection Control Society 2 weeks2 weeks durationduration

Awareness Programme & Awareness Programme & ””Hand Hand HygieneHygiene”” dandan ““Standard Standard PrecautionsPrecautions””

1,500 persons trained in all States 1,500 persons trained in all States except except PerakPerak & & PulauPulau PinangPinang

5454

PERI-OPERATIVE MORTALITY REVIEW

5555

PerioperativePerioperative Mortality Review:Mortality Review:

A national level study to identify:A national level study to identify:

remediable factors leading to mortality remediable factors leading to mortality

within the length of hospital stay ofwithin the length of hospital stay of

Patients who had undergone surgeryPatients who had undergone surgery

In order to improve the quality of patient careIn order to improve the quality of patient care

5656

Definition of perioperative Definition of perioperative mortality:mortality:

A death occurring within the A death occurring within the length of hospital staylength of hospital stay of a of a surgical or gynaecological surgical or gynaecological

procedure done procedure done under general or under general or regional regional anaesthesiaanaesthesia

5757

Prepares Reports/Case summaries & Recommendations

POMR REPORTING SYSTEM

Death Occurs in Wards

Surgical HeadReview Case

Ward Sister- Document biodata & inform doctor

POMR Coordinator(Hospital Matron)

Surgical Doctor

POMR Secretariat

For Assessment by POMR Committee

Anaesthetic Doctor

Head of Anaesthesiareview Case

5858

POMR FindingsPOMR Findings

Inadequate preInadequate pre--operative preparation, operative preparation, assessment and lack of consultation identified assessment and lack of consultation identified as major contributing factors as major contributing factors

Executive SummaryPOMR Reports 2nd & 3rd

5959

POMR DeathsPOMR Deaths

85% of deaths occurred during 85% of deaths occurred during emergency proceduresemergency procedures33% of these deaths were in patients 33% of these deaths were in patients > 60 years old> 60 years old62% of patients were ASA 62% of patients were ASA -- IV &V IV &V 43% of patients had associated 43% of patients had associated medical illness medical illness

6060

RECOMMENDATIONS OF THE POMR RECOMMENDATIONS OF THE POMR COMMITTEECOMMITTEE

Reorganising the Operating Theatre services to Reorganising the Operating Theatre services to give priority to Emergency casesgive priority to Emergency cases

Developing protocols and guidelines to manage Developing protocols and guidelines to manage ill patients ill patients

Ensuring appropriate preEnsuring appropriate pre--operative consultation operative consultation and optimisation of patients. and optimisation of patients.

--adequate assessment and preparation of adequate assessment and preparation of patients for surgery. patients for surgery.

Ensuring greater specialist participation in Ensuring greater specialist participation in treating ill casestreating ill cases

6161

RECOMMENDATIONS OF THE POMR RECOMMENDATIONS OF THE POMR COMMITTEECOMMITTEE

Ensuring the Ensuring the adequate matching of surgical adequate matching of surgical and anaestheticand anaesthetic skills in carrying out operations skills in carrying out operations

Increasing the number of Increasing the number of anaesthetic anaesthetic specialistsspecialists in the hospitalsin the hospitals

ProperlyProperly--equipped and staffed equipped and staffed trauma centrestrauma centresand and burns unitsburns units to manage the growing to manage the growing number of major trauma and burns cases. number of major trauma and burns cases.

6262

RECOMMENDATIONS OF THE POMR COMMITTEERECOMMENDATIONS OF THE POMR COMMITTEE

Increasing the number of Increasing the number of Intensive CareIntensive CareUnit bedsUnit beds and creating stepand creating step--down down facilities such as High Dependency facilities such as High Dependency Wards (HDW) Wards (HDW)

Ensuring the effective and appropriate Ensuring the effective and appropriate utilisation of these bedsutilisation of these beds

6363

RECOMMENDATIONS OF THE POMR COMMITTEERECOMMENDATIONS OF THE POMR COMMITTEE

Complex surgeryComplex surgery should only be should only be undertaken if adequate critical care undertaken if adequate critical care facilities are availablefacilities are available

Forming Forming retrieval teams to transfer ill retrieval teams to transfer ill and unstable patientsand unstable patients from smaller from smaller centres to higher levels of carecentres to higher levels of care

Conducting Conducting regular Morbidity and regular Morbidity and Mortality meetingsMortality meetings at the hospitals at the hospitals

6464

Products of POMRProducts of POMRPOMR ReportPOMR Report--biennialbiennialPOMR Assessors ManualPOMR Assessors ManualPOMR BulletinPOMR Bulletin-- 2020thth

COTDSCOTDS--computerisedcomputerised OT OT documentation systemdocumentation systemGuidelines for emergency casesGuidelines for emergency casesTAC TAC ––technical advisory committeetechnical advisory committee•• ICU/HDU beds, burns unit in major ICU/HDU beds, burns unit in major

hospitalshospitals

Opening of two Opening of two OTsOTs for emergency for emergency cases cases

6565

ACHIEVEMENTS :1. Developments of policies and guidelines.

2. Improvement in OT, ICU and HDU services.

3. Improvement in Training and Supervision.

4. Computerised OT Documentation System.5. Provide inputs for future development of

Surgical, Anaesthetic and Trauma Services,facility development and Human Resourceplanning for the 8th and 9th Malaysia Plan.

6666

PerioperativePerioperative Mortality Review Mortality Review (POMR)(POMR)

Actions taken as a result of reports)Actions taken as a result of reports)

1.1. POLICY : POLICY : PediatricPediatric ““major major surgerysurgery”” can only be performed by can only be performed by Paediatric SurgeonsPaediatric Surgeons

2. Special ambulance system to 2. Special ambulance system to transport neonatal patientstransport neonatal patients

6767

Policies and recommendationsPolicies and recommendations

EstablishedEstablished Paediatric ICUPaediatric ICU in each in each State or RegionallyState or Regionally

Public patients needing care not Public patients needing care not available in Government hospitals available in Government hospitals can have the care outsourced from can have the care outsourced from private hospitals private hospitals (out(out--sourcing of a sourcing of a service) when service) when referred by a referred by a Government doctorGovernment doctor

6868

National Audit on Adult Intensive National Audit on Adult Intensive Care Units Care Units

(NAICU)(NAICU)

6969

National Adult ICU AuditNational Adult ICU Audit

Objectives:Objectives:

To identify remediable factors in the To identify remediable factors in the provision of ICU services in Malaysia provision of ICU services in Malaysia and hence improve the quality of and hence improve the quality of ICU servicesICU services

7070

National Adult ICU AuditNational Adult ICU Audit

14 Hospitals involved:14 Hospitals involved:

all State hospitals (all State hospitals (>>4 ICU beds)4 ICU beds)

-- data collection using a standard data collection using a standard format format –– ““SYNAPSE SOFTWARESYNAPSE SOFTWARE””

AnalisisAnalisis of ICU dataof ICU data

7171

Findings

7272

ICU beds by sector ICU beds by sector (as on August 2003)(as on August 2003)

6.16.1509 509 (100)(100)8484TotalTotal

5.85.8233 233 (45.8)(45.8)4040Private hospitalsPrivate hospitals

10.810.854 54 (10.6)(10.6)55University / Military hospitalsUniversity / Military hospitals

3.33.380 80 (15.7)(15.7)2424MOH district hospitalsMOH district hospitals

9.59.5142 142 (27.9)(27.9)1515MOH state hospitalsMOH state hospitals

Average Average No. BedNo. Bed

No. ICU No. ICU Beds (%)Beds (%)

No. ICUNo. ICU

Definition of ICU bed = hemodynamic monitoring plus mechanical ventilation

Government ICU beds = 276 (54.2%) ICU beds = 1.1% of total hospital beds

7373

Referrals for ICU admission

0

200

400

600

800

1000

1200

1400

1600

A B C D E F G H I J K L M N

Admitted Not Admitted

Total referrals 8615

4911 (57%) denied admission

7474

FindingsFindings

Severe shortage of ICU bedsSevere shortage of ICU bedsPerformance of ICU comparable with Performance of ICU comparable with overseas overseas centrescentresHigh percentage of admissions from High percentage of admissions from operativeoperative--emergency patientsemergency patientsDisproportionately high mortality in Disproportionately high mortality in operative elective patientsoperative elective patients

7575

RecommendationsRecommendations

InIn--depth audit of outcome for major depth audit of outcome for major elective surgeries elective surgeries

Urgent need to increase intensive Urgent need to increase intensive care facilitiescare facilities

INCIDENT REPORTING

INCIDENT REPORTINGINCIDENT REPORTING

a system of reporting any unintended a system of reporting any unintended occurrences which could have occurrences which could have ((““nearnear--missmiss””))

or caused harm or caused harm ((““adverse eventsadverse events””)) to the to the patientpatient

31 31 ““incidentsincidents”” monitored nationallymonitored nationally

Root Cause Analysis / Problem analysis conducted at Root Cause Analysis / Problem analysis conducted at local levellocal level

7878

INCIDENTS MONITORED INCIDENTS MONITORED FOR ALL FOR ALL LOCATIONSLOCATIONS

::1. Medication Error1. Medication Error

2. Adverse Drug Reaction2. Adverse Drug Reaction

3. Adverse Transfusion Reaction3. Adverse Transfusion Reaction

4. Transfusion Error4. Transfusion Error

5. Adverse Outcome of Procedure5. Adverse Outcome of Procedure

6. AOR Discharges6. AOR Discharges

7. Equipment7. Equipment-- related Incidentsrelated Incidents

8. Patient Falls in Ward8. Patient Falls in Ward

9. Staff falls in Ward9. Staff falls in Ward

10. 10. Needle Stick InjuryNeedle Stick Injury

11. Complaints by Patients and / or Relatives11. Complaints by Patients and / or Relatives

7979

OPERATING THEATRE INCIDENTSOPERATING THEATRE INCIDENTS

1. 1. Cardiac / respiratory ArrestCardiac / respiratory Arrest2. Wrong Procedure Performed2. Wrong Procedure Performed3. Prolonged Stay in Recovery Room for 3. Prolonged Stay in Recovery Room for more than 2 hoursmore than 2 hours4. Operative Consent Error4. Operative Consent Error5. Incorrect Instrument or Swab Count5. Incorrect Instrument or Swab Count6. Elective Surgery Cancelled in OT6. Elective Surgery Cancelled in OT7. 7. ReintubationReintubation

8080

ICU INCIDENTSICU INCIDENTSAccidental Accidental ExtubationExtubationReadmission to ICU within 24 hours of Readmission to ICU within 24 hours of Discharge to WardDischarge to WardUnexpected DeathUnexpected DeathComplications during Stay in ICUComplications during Stay in ICU

LABOUR ROOM INCIDENTSLABOUR ROOM INCIDENTSDeath of Fetus Weighing > 800grams or > Death of Fetus Weighing > 800grams or > 28 weeks of gestation28 weeks of gestationPoor Poor ApgarApgar ScoreScoreInjury to Neonate during DeliveryInjury to Neonate during Delivery

8181

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 19981998

-- Section 37 REPORTABLE INCIDENTSSection 37 REPORTABLE INCIDENTS

::Unexplained DeathsUnexplained Deaths of patientsof patients

InjuriesInjuries to patients involving:to patients involving:•• brain or spinal cordbrain or spinal cord injuriesinjuries•• falls resulting in fractures, dislocations, concussions or falls resulting in fractures, dislocations, concussions or

lacerations extending beyond the epidermis into deep tissue or lacerations extending beyond the epidermis into deep tissue or which threaten vital structureswhich threaten vital structures

•• lifelife--threatening (or potentially fatal) threatening (or potentially fatal) complications of complications of anesthesiaanesthesia

•• lifelife--threatening (or potentially fatal) threatening (or potentially fatal) transfusion errors or transfusion errors or reactionsreactions

•• 2nd or 3rd degree burns2nd or 3rd degree burns involving > 20 % surface area (adult) involving > 20 % surface area (adult) or 15 % (child)or 15 % (child)

8282

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998-- REPORTABLE INCIDENTSREPORTABLE INCIDENTS

::FiresFires resulting in death or personal resulting in death or personal injuryinjury

Assault or batteryAssault or battery of patients by of patients by employees or other personsemployees or other persons

Malfunction or intentional or accidental Malfunction or intentional or accidental misuse of patient care equipmentmisuse of patient care equipment that that would have significantly adversely would have significantly adversely affected a patient or employees of the affected a patient or employees of the healthcare premiseshealthcare premises

8383

PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998PRIVATE HEALTHCARE FACILITIES & SERVICES ACT 1998-- REPORTABLE INCIDENTSREPORTABLE INCIDENTS

::Utility system failureUtility system failure that resulted in or that resulted in or contributed significantly to an contributed significantly to an ““incidentincident””SuicideSuicide of a patientof a patientInfant abductionInfant abduction or discharge to the wrong or discharge to the wrong familyfamilyRapeRapeSurgery on the wrong patientSurgery on the wrong patient or wrong or wrong body partbody part

Medication errorMedication error resulting in harm to the resulting in harm to the patientpatient

8484

HOSPITAL HOSPITAL ACCREDITATION ACCREDITATION

PROGRAMMEPROGRAMME

8585

DEFINITION OF ACCREDITATIONDEFINITION OF ACCREDITATION““a selfa self--assessment and external peer review process assessment and external peer review process

to accurately assess level of performance in relation to to accurately assess level of performance in relation to established standards and established standards and

to implement ways to continuously improve the to implement ways to continuously improve the healthcare systemhealthcare system””

ISQuaISQua definition : Federation definition : Federation Operating Rules 1998Operating Rules 1998

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MALAYSIAN HOSPITAL ACCREDITATION STANDARDS

Emergency Emergency Allied Health Pro.Allied Health Pro.AnaestheticAnaestheticCritical Care ServicesCritical Care ServicesCSSUCSSUDay Only SurgeryDay Only SurgeryEngineering & BuildingEngineering & BuildingEnvironmentalEnvironmentalFoodFoodGoverning Body/MgmtGoverning Body/Mgmt..

HousekeepingHousekeepingPathologyPathologyLinenLinenRadiologyRadiologyMedical RecordsMedical RecordsMedicalMedical--SurgicalSurgicalNursingNursingOperating SuiteOperating SuitePharmacyPharmacyGeneralGeneral

AREAS OF PRIORITY

Organization and Management.Human Resource Development and Management.Policies and ProceduresFacilities and Equipment.Quality Improvement ActivitiesSAFETY

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VOLUNTARY REQUEST

PREPARATION & STANDARDS INTERPRETATION

SELF-EVALUATION BY HOSPITALS

SURVEYORS’IDENTIFICATION/APPOINTMENT/CONCENSUS

SURVEY COORDINATION

PRE-SURVEY ASSESSMENT

SURVEYSURVEY

AGREEMENT ON SURVEY DATES

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FULL ACCREDITATION 3 YEARS

1 YEAR ACCREDITATION

FOCUS SURVEY

NON-ACCREDITATION

+ 2 YEARS AWARD

QUALITY IMPROVEMENT IS AQUALITY IMPROVEMENT IS ANEVERNEVER--ENDING JOURNEY,ENDING JOURNEY,

AND NOT A DESTINATIONAND NOT A DESTINATION

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THANK YOU, FOR YOUR ATTENTION

THANK YOU, THANK YOU, FOR YOUR FOR YOUR ATTENTIONATTENTION