HOSPITAL ACCREDITATION IN MALAYSIA

 

HOSPITAL ACCREDITATION IN MALAYSIA

 

History

The rapid expansion and development of the healthcare industry brought to light the wide variation in the standard of care provision among healthcare workers. Increasing trends in litigation further focused on the accountability of healthcare providers.  The need for standards for processes, systems and facilities for the provision of care became a priority for the medical fraternity.

 

Australia was among nations that formalized such standards through consensus, based on models of good care. The Australian Council for Healthcare Standards (ACHS) was established to develop standards and put in place a system for the assessment of the quality and safety in healthcare organizations through compliance to the standards.

 

image002In Malaysia similar sentiments led to the establishment of the Malaysian Society for Quality in Health (MSQH) through consensus by the Ministry of Health (MOH), The Association of Private Hospitals of Malaysia (APHM) and the Malaysian Medical Association (MMA). MSQH is the national accrediting body for healthcare facilities and services in Malaysia.  On 1st October 1999, a Memorandum of Understanding (MoU)) was signed by MOH, MMA, APHM and MSQH for the development of the Malaysian Healthcare Accreditation Program . The objective of accreditation was to ensure provision of patient care  in a safe environment in line with professional and ethical practice.

 

Accreditation Standards

The quality dimensions addressed in accreditation include accessibility of care, safety, appropriateness and effectiveness of care, patient centered activities, efficiency, and competency of the healthcare provider. Based on these dimensions, standards were developed by the signatories of the MoU andimage004

 

 

 

 

 

 

 

 

 

 

 

universities with the aid of a WHO consultant. The focus of the standards was on organization and management, human resource management, policies and procedures, facilities and equipment as well as quality improvement efforts.

Accreditation Standards have been developed for the following services:

  • Governing Body & Management
  • Emergency Service
  • Medical / Surgical Services
  • Critical Care
  • Operating Suite
  • Day Surgery
  • Anesthetic Service
  • Allied Health
  • Radiology
  • Pathology
  • Medical Records
  • Nursing Service
  • Central Sterilizing Service
  • Pharmacy Service
  • Food Service
  • Housekeeping Service
  • Linen Service
  • Environmental Service
  • Engineering Service
  • General
 
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  Private Healthcare Facilities and Services Act 1998

The accreditation standards address the requirements of the Private Healthcare Facilities Act (1998) Part XII Clause 64-74 in relation to

  • Standards and Safety Aspects in Healthcare
  • Quality Assurance and CQI
  • National Mortality Assessment Committee
  • Incident Reporting

 

 

 

 
Private Healthcare Facilities and Services Regulations 2006

The standards also meet requirements of the Private Healthcare Facilities and Services Regulations 2006 in relation to

  • Organization and ownership,
  • Facility design, electrical, ventilation, plumbing, water supply, lighting, maintenance, communication, transport
  • Policy requirements
  • Standards for specific services: surgical, anesthesia, pediatric, obstetrical and gynecological care, critical care, emergency care, pharmaceutical services etc.

 

 

 

 

 Surveyor Training

A system for the assessment of hospitals for compliance to standards has been established through accreditation surveys. Surveyors consist of healthcare personnel of good standing related to inpatient care. A potential surveyor will be invited to participate in surveyor training by MSQH. Based on performance during the training, a surveyor trainee could then be invited to participate as ‘observer' at an accreditation survey prior to being appointed as surveyor. Prof. Madya Hasnan Jaafar,  and Prof Madya Nik Abdullah Nik Mohamad of PPSP, USM are trained accreditation surveyors.

 

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Risk Management

The hospital accreditation process is a risk reduction activity based on the assumption that when the hospital meets or surpasses the required accreditation standards, then errors and adverse events are less likely to occur - thus ensuring safe care and appropriate outcomes.  Incident Reporting which is built into the standards allows for proactive preventive action. Formal Credentialing and Privileging of staff fosters greater confidence among staff and patients. Improved documentation facilitates effective medical defense.


Accreditation Process

The accreditation process begins with training. The training is conducted by MSQH . The standards are handed over to the hospital at the training session as part of the package. The process begins with understanding the standards. This is followed by Gap Analysis, namely assessing ‘what is' and comparing it with ‘what should be'. Action is then taken to bridge the gap. Once confident of substantial compliance to standards, the hospital does a self assessment based on the criteria set. The hospital then makes a formal request for a survey from MSQH. The survey is planned and implemented by MSQH.

 Accreditation Survey

The accreditation survey begins with the opening meeting of the survey team with the management and members of the staff. This meeting consists of a briefing on the hospital by the hospital management followed by the introduction of the Survey Team and a briefing on the conduct of the survey by the chief surveyor.  The survey is conducted across the hospital and is inclusive of night visits. A closing meeting ends the survey. At this meeting, surveyors brief the hospital on their findings and Hospital staff are encouraged to clarify any points raised.

 Accreditation Award

Following the closing meeting, the surveyors meet and discuss the accreditation award to the hospital based on the hospital's performance. A recommendation will then be made to the MSQH Council accompanied by a detailed report of the survey. The MSQH Council then decides on the Accreditation Award which could be one of the following:

 

  • Three Years Accreditation if the hospital has substantially complied with standards.
  • One Year Accreditation if the hospital has generally complied with standards but there were certain areas with issues which required to be addressed. In this instance a Focus Survey could be conducted within the year to determine if the areas of concern have been addressed appropriately. If found to be compliant, the hospital would then be awarded an additional two years of accreditation. If found to be still non-compliant, then accreditation would be withdrawn.
  • No Accreditation if the hospital has generally not complied with the standards.

 

 

 

 

 

 

Accredited Hospitals

Hospital Accreditation has been in place since 1999. As of 31st December 2006, 156 hospitals have undergone training for Accreditation. Of these, 88 hospitals (68 Ministry of Health hospitals, 1 Ministry of Defense hospital, and 19 Private Hospitals) have been accredited. Of the accredited hospitals, 34 have been accredited for a second cycle and 4 hospitals for a third cycle. Among University Hospitals, UKM has begun the exercise for accreditation.

 Health Tourism

Only Accredited Hospitals are listed and promoted by the Malaysian Government for Health Tourism.

 

Dr. Mary Abraham

Quality Coordinator for Health Campus, USM