1. ACCREDITATION Marcus Stephen Hospital Keningau Sabah Sandakan - 16 March 2016

2. ACCREDITATION OF HEALTHCARE ORGANIZATIONS “ Accreditation refers to the procedure by which MSQH offers formal recognition to healthcare organizations (facility and services providers) found to meet substantial level of compliance and competence as outline in the relevant standards”

3. “Accreditation is a self-assessment and external peer review process use by healthcare organizations to accurately assess their level of performance in relation to established standards and implement ways to continuously improve the healthcare system.” ISQua: Federation of Operating Rules 1998 WORKING DEFINITION OF ACCREDITATION

4. HOSPITAL ACCREDITATION STANDARDS Definition: –A standard is a level of requirements or conformance to widely-accepted practice / established model as determined by the expertise –They serve as an accepted measure for comparison.

5. OBJECTIVES To promote hospitals in providing excellent services through Teamwork Innovative projects Best practice

6.  Safety  Effectiveness  Appropriateness  Efficiency  Responsiveness  Patient Centered – consideration for human dignity, privacy, confidentiality, comfort etc… Standard impact the quality of Healthcare

7. FOCUS OF STANDARDS What things are available STRUCTURE PROCESS What do you do with these things What is the result of what you do with these things that you have FUTURE EMPHASIS OUTCOME

8. INCREASING MEDICO-LEGAL CASES * Increasing Focus on Accountability –Accountability: The obligation to answer for responsibility that has been conferred

9. To provide the best possible care to the patient (Achieving optimum results from available resources):  Safe care in a safe environment.  Adherence to professional and ethical practice.  Appropriate management and treatment.  Value for money service. National system for assessing quality and safety in healthcare organization. ACCREDITATION - TOOL to demonstrate Accountability WHY ACCREDITATION?

10. Private Healthcare Facilities & Services Act 1998 Part Xll & Xlll Clause 64 -76 * Standards and Safety Aspect in Healthcare * Quality Assurance * National Mortality Assessment Committee * Incident Reporting.

11. Focus on Patient’s Safety Although the accreditation process mainly focuses on structure, process and continuous quality improvement as its core, It is a Risk Reduction Activity The underling principle is that when healthcare organization meet or surpass the required accreditation standards, then errors and adverse events are less likely to occur. Ensuring Safer Care & Safer Outcome

12. Quality QUALITY STANDARD Excellence

13. QUALITY IN HEALTHCARE Identify and minimize medical errors Emphasis on prevention of errors Incident reporting is vital in risk management Safe facilities

14. HOSPITAL- WIDE APPROACH  Individuals Outsourced Services Offsite Organizations System (Governing Body) Departments or Units Outsourced Services On site 

15. Focuses in Accreditation MEDICAL STAFF FOCUS ON PATIENT FOCUS ON PROCESS QUALITY SAFETY COMPETENCY EFFECTIVENESS APPROPRIATENESS EFFICIENCY ACCESSIBILITY CONTINUOUS QUALITY IMPROVEMENT BETTER QUALITY OF LIFE PATIENT CENTRED LEADERSHIP ORGANISATIONAL STRUCTURE

16. MALAYSIAN HOSPITAL ACCREDITATION STANDARDS

17. Organizational - Wide Service COVERAGE :24 SERVICES 1. GOVERNANCE, LEADERSHIP AND DIRECTION 2. ENVIRONMENTAL AND SAFETY SERVICES 3. FACILITY AND BIOMEDICAL EQUIPMENT MANGEMENT AND SAFETY 4. NURSING SERVICES 5. PREVENTION AND CONTROL OF INFECTION 6. PATIENT AND FAMILY RIGHTS 7. HEALTH INFORMATION MANAGEMENT SYSTEM (HIMS)

18. SERVICE STANDARD 8. EMERGENCY SERVICES 9. CLINICAL SERVICES (GENERIC) 9A. CLINICAL SERVICES - CARDIOLOGY SERVICES 9B. CLINICAL SERVICES - ONCOLOGY SERVICES 10. ANAESTHETIC SERVICES 11. OPERATING SUITE SERVICES 12. AMBULATORY CARE SERVICES 13. CRITICAL CARE SERVICES (GENERIC) 13. CRITICAL CARE - RECOMMENDED CHECKLIST LEVELS OF CARE OF ICUs FOR REFERENCING 13A. CRITICAL CARE SERVICES - LABOUR / DELIVERY SERVICES 14. RADIOLOGY/DIAGNOSTIC IMAGING SERVICES 15. PATHOLOGY SERVICES

19. 16. BLOOD TRANSFUSION SERVICES 17. REHABILITATION MEDICINE SERVICES 17A. ALLIED HEALTH PROFESSIONAL SERVICES - PHYSIOTHERAPY 17B. ALLIED HEALTH PROFESSIONAL SERVICES - OCCUPATIONAL THERAPY 17C. ALLIED HEALTH PROFESSIONAL SERVICES - DIETETICS 17D. ALLIED HEALTH PROFESSIONAL SERVICES - SPEECH & LANGUAGE PATHOLOGY 17E. ALLIED HEALTH PROFESSIONAL SERVICES - AUDIOLOGY SERVICE STANDARD

20. 17F. ALLIED HEALTH PROFESSIONAL SERVICES - OPTOMETRY 17G. ALLIED HEALTH PROFESSIONAL SERVICES - HEALTH EDUCATION 17H. ALLIED HEALTH PROFESSIONAL SERVICES - MEDICAL SOCIAL 17I. ALLIED HEALTH PROFESSIONAL SERVICES - PSYCHOLOGY COUNSELLING 17J. ALLIED HEALTH PROFESSIONAL SERVICES - CLINICAL PSYCHOLOGY SERVICE STANDARD

21. 18. PHARMACY SERVICES 19. CENTRAL STERILE SUPPLY SERVICES 20. HOUSEKEEPING SERVICES 21. LINEN SERVICES 22. FOOD AND DIETARY SERVICES 23. FORENSIC MEDICINE SERVICES 23A. MORTUARY SERVICES 24. STANDARDS FOR GENERAL APPLICATIONS

22. Six Major Areas of Concerned Organisation and Management Human Resource Development and Management Policies and Procedures Facilities and Equipment Quality Improvement Activities Safety and Special Requirements

23. Standards developed by leading experts in the healthcare field. Standards provide guidelines for quality patient’s care. Standards are educational in nature Standards are not “prescriptive” The focus is shifted from “us” to the patient Assessment is done by peers VALUE OF ACCREDITATION

24. The True Value is the – improved patient outcomes and – improved employee morale that comes from increased knowledge, ownership and teamwork. THE TRUE VALUE IS NOT ACCREDITATION ITSELF

25. Special requirements The safety aspects that are not compromised. An organization that does not meet the safety requirements of the standards will not be accredited although it has met the rest of the standards. These standards provide the basis for organizational assessment of the delivery of quality patient care and services, and the utilization of available resources.

26. Special requirements These standards are applicable to all types of hospitals - public and private, large and small, urban and rural. Today, many people are concerned about finding the best ways to meet their health care needs. When you use a facility accredited by the MSQH, you know its meets our rigorous standards.

27. What Health Facilities That May Be Accredited Any healthcare facility or service as defined by The Private Healthcare Facilities And Services Act 1998, Healthcare services include: Medical, dental, nursing, midwifery, allied health, pharmacy, and ambulance services and any other services provided by a healthcare professional;

28. What Health Facilities That May Be Accredited Any service for the screening, diagnosis, or treatment of persons suffering from any disease, injury or disability of mind or body; Any service for preventive or promotive health care purposes; Any service provided by any healthcare Para-professional; Any service for curing or alleviating any abnormal condition of the human body by the application of any kind of medical technology; Any health-related services.

29. MSQH Hospital Accreditation Provides Recognition  For Your Customers  For Your Organisation  For The People Working In Your Organisation  For The People Who Fund Your Organisation

30. External Peer Review Consist of senior Practicing Medical Directors, Nursing Directors, clinicians, engineers SC - Substantial Compliance PC - Partial Compliance NC - Non Compliance NA – Not Applicable

31. One-year Accreditation A one-year Accreditation is awarded to facility which have met the requirements of most of the standards. A facility awarded a one-year accreditation is offered the opportunity to undergo a Focus Survey within the next twelve (12) months.

32. Focus Survey During the focus survey, only those areas of deficiency noted in the initial survey are visited. However, this does not exclude visits to other areas deemed relevant by the surveyors. The facility should have taken action on the recommendations which were recorded by the surveyors at the initial survey, and should achieve substantial compliance to MSQH standards in order to qualify for the award of an additional three (3) years.

33. Non-Accreditation Accreditation cannot be awarded to a facility in which the surveyors have observed and reported that a significant number of standards are not complied with. Facilities who are not accredited are encouraged to implement the recommendations made in the Survey Report and to re-apply for survey. It is recommended that a minimum of twelve (12) months should elapse, to allow time for remedial actions and rectification works, before the next survey is undertaken.

34. Final Award The final award decision and the recommendations are forwarded by MSQH Chief Executive Officer (CEO), to the Chief Executive Officer, the owner, or the chair of the governing body of the surveyed facility. Release of any confidential information pertaining to the facility will be subject to written consent from the CEO, the owner or the chair of the governing body.

35. FULL ACCREDITATION 4 YEARS 1 YEAR ACCREDITATION FOCUS SURVEY + 3 YEARS AWARD NON-ACCREDITATION Major Aspect Safety - compromised

36. “DO WHAT IS BEST FOR THE PATIENT” PROBABLY YOU ARE THAT PATIENT ONE DAY