Page 238 - ANUAL REPORT MOH 2017

Quality Initiatives And Monitoring Year 2015 Year 2016 Year 2017
Modified Balanced Scorecard Indices of Hospital Director’s KPI (HPIA – Hospital
Performance Indicator for Accountability 2015 to 2017
6. Environmental Support 1.102 1.092 1.108
** Index value of >1 = above target; <1 = below target; equal to 1 = on target
Clinical Disciplines Directorate KPI Performances 2015 to 2017
1. Medical Based Disciplines 1.578 1.639 1.675
2. Surgical Based Disciplines 1.116 1.125 1.124
3. Diagnostic & Clinical Support Based 1.107 1.136 1.134
Disciplines
** Index value of >1 = above target; <1 = below target; equal to 1 = on target
Occupational Safety and Health Unit
1. Number of MOH Hospital and - 34 88
Institution with established
Occupational Safety & Health Unit
2. Number of MOH Hospital and - 93 115
Institution conducted safety audit
Infection Control Unit
1. Establishment of Antimicrobial - 45 61
Stewardship (AMS) Team in MOH (implementation (Target : 14) (Target : 29)
Hospitals (number) started in 2016)
2. Establishment of Wound Care Team - 70 99
in MOH Hospitals (number) (implementation (Target : 14) (Target : 29)
started in 2016)
3. Prevalence of Healthcare Associated 1.68% 1.38% 1.77%
Infection (HCAI) (Target : ≤5%) (Target : ≤5%) (Target : ≤5%)
4. Percentage of Hand Hygiene 79.8% 79.6% 79.7%
Compliance (Target : ≥75%) (Target :≥75%) (Target :≥75%)
5. Prevalence of Healthcare Associated 0.20% 0.23% 0.24%
Blood Stream Infection (HA-BSI) (Target : ≤0.3%) (Target : ≤0.3%) (Target : ≤0.3%)
6. Incidence of Methicillin Resistant 0.17% 0.15% 0.14%
Staphylococcus Aureus (MRSA) (Target : ≤0.3%) (Target : ≤0.3%) (Target : ≤0.3%)
7. Incidence of Carbapenem Resistant 0.05% 0.05% 0.06%
Enterobacteriaceae (CRE) (Target : ≤0.1%) (Target : ≤0.1%) (Target : ≤0.1%)
8. Incidence of Extended Spectrum 0.22% 0.21% 0.19%
Beta Lactamase (ESBL) producing (Target : ≤0.3%) (Target : ≤0.3%) (Target : ≤0.3%)
Klebsiella pneumoniae
9. Incidence of Extended Spectrum Beta 0.16% 0.12% 0.11%
Lactamase (ESBL) producing E.Coli (Target : ≤0.2%) (Target : ≤0.2%) (Target : ≤0.2%)
Patient Safety Unit
1. Percentage of Government 80.2% 84.1% 83.6%
Healthcare Facilities Reporting (Target : 80%) (Target : 80%) (Target : 80%)
Malaysian Patient Safety Goals
Performance
2. Total Patient Safety Incidents - 2,769 5,689
Reported from Ministry of Health
Malaysia Hospitals & Institutions

MINISTRY OF HEALTH MALAYSIA ANNUAL REPORT 2017 237