Page 239 - ANUAL REPORT MOH 2017

Quality Initiatives And Monitoring Year 2015 Year 2016 Year 2017
3. House Officers Undergone Mandatory - - 4,936
Patient Safety Awareness Course for (implementation (implementation
House Officers started in 2017) started in 2017)
Clinical Audit Unit
1. Pain Free Hospital 8 12 13
2. POMR Bulletin 2 2 2
Medical Staff Values and Ethics Unit
1. Complaints on non-medicolegal 720 769 1486
services (number)
2. Feedback received by MOH hospital 434 777 915
(application, award, inquiry)
Standards and Accreditation Unit
1. Number of MOH hospitals with 30 15 20
accreditation certification
2. Number of MOH hospitals / 21 19 54
institutions with MS ISO 9001
certification
3. Number of MOH hospitals /institution 5 7 16
with EKSA ( MAMPU ) certification
4. Numbers of MOH hospitals with 9 10 10
National Innovation Awards
Source:The Medical Care Quality Section, Medical Development Division, MoH

HIGHLIGHTS OF 2017

POLICIES AND PROCEDURES
1. Terma Pengukuhan Penyelaras Kualiti Negeri dan Hospital bagi AKtiviti Survelan Pencapaian
Klinikal (Arahan Ketua Pengarah Kesihatan 15 April 2015 (rujukan: KKM87/P3/12/6/3 Jld.14 (21)
2. Pelaksanaan HPIA (Hospital Performance Indicator for Accountability) versi 5.0 (KPI Pengarah
Hospital) - Arahan Ketua Pengarah Kesihatan ruj: KKM.600-28/2/8 Jld. 3 (26) dated 11 January
2017
3. Director General of Health Malaysia Directive Letter on the Implementation of Patient Safety
Awareness Course for House Officer; 6 January 2017
4. Director General of Health Malaysia Circular on the Implementation of Incident Reporting &
Learning System 2.0 for MoH Malaysia Hospitals & Institutions; 5 December 2017
5. Disinfectant Manual
6. Multidrug Resistant Organism (MDRO)& Methicillin Resistant Staphylococcus Aureus (MRSA)
Bacteremia Manual, 2 Edition
nd
7. Guidelines on the Implementation of Patient Safety Awareness Course for House Officer; 6
January 2017
8. Guidelines on the Implementation of Incident Reporting & Learning System 2.0 for MoH Malaysia
Hospitals & Institutions; 16 October 2017

238 ANNUAL REPORT 2017 MINISTRY OF HEALTH MALAYSIA