1. STRENGTHENING THE TRAINING OF HOs & MOs IN EFFORT TO PRODUCE MORE SPECIALISTS FOR THE COUNTRY: ROLE OF HOSPITAL DIRECTORS 1

2. 2 MANPOWER PLANNING: CONTINUUM House Officers

3. HOUSE-OFFICERS: MAIN ISSUES 3  Intake of HOs: Medical Grads Production vs. Vacancy of Posts  Redefining Training Norm: Redistribution of HO Posts  New HOs Hospital Level Orientation  Flexi Working System  New Disciplines Introduced: Psychiatry & Primary Care

4. MEDICAL GRADUATES 4  Medical graduates:  Local & abroad  378 universities worldwide (in 35 countries)  Variation in quality related to:  Curriculum, training/clinical exposure  Exposure to diseases, especially tropical diseases  Different languages spoken/local cultures  Increasing number of medical graduates especially since 2008

5. 5 NUMBER OF NEW HOUSE OFFICERS APPOINTED (1998 – 2013) Year Year1998199920002001200220032004200520062007200820092010201120122013 Local Universities Local Universities3603724775198308509079459931,1041,4491,7261,8641,9642,1802,588 Overseas Universities Overseas Universities619433345241167109129104661868771,3321,3881,6001,5632,403 Total Total9798058227609979591,0361,0491,0591,2902,3263,0583,2523,5643,7434,991

6.  Continuous intake by SPA throughout the year  HO posts: Total = 10,803 posts (10,360 in MOH)  HO posts filled:9,789 (90.6%) – as of 31.1.2014  HO vacancies:1,014 (9.4%)  New Medical graduate interviewed by SPA (Feb 2014)  About 1,000 waiting to be appointed.  Expected number of local medical graduates…  Continuous intake by SPA throughout the year  HO posts: Total = 10,803 posts (10,360 in MOH)  HO posts filled:9,789 (90.6%) – as of 31.1.2014  HO vacancies:1,014 (9.4%)  New Medical graduate interviewed by SPA (Feb 2014)  About 1,000 waiting to be appointed.  Expected number of local medical graduates… 6 STATUS OF HO POSTS (UD41): 31.1.2014 STATUS OF HO POSTS (UD41): 31.1.2014Year Public Local Medical Schools (IPTA) Private Local Medical Schools (IPTS) Total Number of Students (IPTA + IPTS) 20171,6982,2833,981 20161,4711,7073,178 20151,3751,5312,906

7. PRELIMINARY DATA…  About 50% (45-60%) of HO started housemanship in Jan/Feb/Mac 2012 able to complete training within 2 years in 2014  (Note: Preliminary data/not accurate as only cover 2 months)  The others 50%, take more than 2 years for various reason:  Leave taken in excess e.g. maternity leave, getting married, etc.  MIA  Extended to complete log book  Requested transfer causing disruption of training  Extended due to incompetency CLOGGING THE UD41 POSTS BACKLOG! CLOGGING THE UD41 POSTS BACKLOG! ….IHM IS CONDUCTING A DETAIL STUDY 7 HO COMPLETING TRAINING HO COMPLETING TRAINING

8.  Facilitate to vacant the UD41 post for HO as soon as they finish training:  Facilitate promotion process from UD41 to UD44 once HO completed Housemanship  Or sandarkan to UD44 post while waiting for urusan kenaikan pangkat – so new HO can fill in UD41 post  Submit Full Registration to MMC quickly  Continuous monitoring of HO’s attendance/disciplinary issues – action to be taken by Unit Sumber Manusia/TP Hospital (Pengurusan)  Proper documentation on problematic HOs pertaining to their assessment/competency/disciplinary etc.  Facilitate to vacant the UD41 post for HO as soon as they finish training:  Facilitate promotion process from UD41 to UD44 once HO completed Housemanship  Or sandarkan to UD44 post while waiting for urusan kenaikan pangkat – so new HO can fill in UD41 post  Submit Full Registration to MMC quickly  Continuous monitoring of HO’s attendance/disciplinary issues – action to be taken by Unit Sumber Manusia/TP Hospital (Pengurusan)  Proper documentation on problematic HOs pertaining to their assessment/competency/disciplinary etc. 8 ROLE OF HOSPITAL DIRECTORS

9.  Current Training Norm for HO based on acute beds (minus ENT, Ophthalmology, Subspecialty wards, etc.)  Number of Acute Beds: total = 35,664 beds (in MOH: 32,665)  Number of HO posts: total = 10,803 posts (in MOH: 10,360)  Ratio = 1 : 3.3  Redefine HO training norm:  Include other factors e.g. training received in OT, Day Care, Out Patient Clinic, Procedure Room, etc.  Stage 1: create Correction Factor (discipline specific, to calculate virtual bed for more accurate training norm)  Stage 2: calculate Virtual Bed & number of HOs according to 1 : 4 ratio for each discipline  Stage 3: redistribution of post to all training hospitals  Current Training Norm for HO based on acute beds (minus ENT, Ophthalmology, Subspecialty wards, etc.)  Number of Acute Beds: total = 35,664 beds (in MOH: 32,665)  Number of HO posts: total = 10,803 posts (in MOH: 10,360)  Ratio = 1 : 3.3  Redefine HO training norm:  Include other factors e.g. training received in OT, Day Care, Out Patient Clinic, Procedure Room, etc.  Stage 1: create Correction Factor (discipline specific, to calculate virtual bed for more accurate training norm)  Stage 2: calculate Virtual Bed & number of HOs according to 1 : 4 ratio for each discipline  Stage 3: redistribution of post to all training hospitals 9 REDEFINING TRAINING NORM: REDISTRIBUTION OF HO POST Acute Bed Ratio Number of HO 35,664 1 : 3.3 10,803 35,664 1 : 3.5 10,190 35,664 1 : 3.8 9,385 35,664 1 : 4.0 8,916 Cannot be done abruptly as currently 9,789 HOs occupying the post

10. REDISTRIBUTION OF UD41 POST BETWEEN MOH TRAINING HOSPITALS: EXAMPLE NoTraining Number of NumberNumberExistingRedistributionDifference HospitalsOfficialofofApproved of Post According to Between A & B Beds Virtual Beds HOs Required Posts Ratio of Existing Post Ratio 1 : 4 (A) (A) to Virtual Bed (B) i.e. post required 1 HTF, Kangar 404705176189181-8 2 HSB,Alor Star 8561315329390337-53 3 HSAH, Sg Petani 55093223320623933 4 H. Kulim 31063715910116362 5 H. Pulau Pinang 11071444361510370-140 6 H. Seberang Jaya 314637159245163-82 7 H. Taiping 60889222318822941 8 HRPB, Ipoh 9901475369408378-30 9 H. Teluk Intan 54884821215921859 10 H. Sri Manjung 270570142203146-57 11HKL21152519630745646-99 12 H. Putrajaya 310567142171145-26 13 HTAR, Klang 8931559390465400-65 14 H. Selayang 88012393103183180 15 H. Serdang 55593023221323926 16 H. Kajang 326615154159158 17 H. Sungai Buloh 62298724722425329 18 H. Ampang 44478719718020222 19 HTJ, Seremban 8501236309408317-91 20 HTAN, Kuala Pilah 314543136184139-45 21 H. Melaka 10411604401414412-2 22 HPSF, Muar 550797199220205-15 23HSAJB989165541433642589 10

11.  Efficient posting & rotation of HOs between departments  After redistribution exercise:  Some hospitals will get more UD41 posts  Some will have their UD41 post reduced  But, service delivery still by MO/Specialist  HOs undergo training (not extra pair of hand)  Maximizes training in areas other than main wards e.g. training received in OT, Day Care, Out Patient Clinic, Procedure Room, etc.  Efficient posting & rotation of HOs between departments  After redistribution exercise:  Some hospitals will get more UD41 posts  Some will have their UD41 post reduced  But, service delivery still by MO/Specialist  HOs undergo training (not extra pair of hand)  Maximizes training in areas other than main wards e.g. training received in OT, Day Care, Out Patient Clinic, Procedure Room, etc. 11 ROLE OF HOSPITAL DIRECTOR

12. HOSPITAL LEVEL ORIENTATION COURSE  HO report duty: 2 nd & 4 th week of each month after induction course  To undergo 5 days of hospital level orientation  Uses generic framework for orientation (next slide)  To include Basic Life Support (BLS) course  At respective hospital  Can combine with other hospital’s health workers to maximise each time the course is done

13. GENERIC FRAMEWORK-1: ORIENTATION COURSE TIMETABLE 8AM 9AM 10AM 11AM 12PM 1PM 2PM 3PM 4PM 5PM 6PM 7PM 8PM 9PM 10PM MONINTRO HOSPITAL DIRECTOR LUNCH HEALTH & SAFETY TUE MEET HOD IT/DOCUMENTATION OF MEDICAL NOTE LUNCH RADIOLOGY DEPT TAGGING WED PATHOLOGY DEPT LUNCHPHARMACYTAGGING THUR BASIC LIFE SUPPORT LUNCH + CLINICAL SKILL TRAINING e.g. blood taking, etc. TAGGING FRI BLOOD TRANSFUSION RECORD OFFICE LUNCH HR DEPT TAGGING SATTAGGING SUN OFF DAY OR

14. GENERIC FRAMEWORK-2: ORIENTATION COURSE CONTENT Introduction - Organisational chart - Map/location of various departments - Services - Introduction by HR Department – various forms to be filled Hospital Director - Welcome speech -Housemanship training overall structure -Expectation etc. - Laporan Nilaian Prestasi Tahunan (LNPT) Health & Safety Health & Safety - Immunisation (Hepatitis B, H1N1 etc.) - Fitness to practice (physical & psychiatric illness) - Occupational hazards & safety precautions - Needle stick injury & sharp bin - Waste (clinical, non-clinical) -Infection Control, etc IT & Medical Notes Documentation -Intro to IT system in IT based hospitals -Guide on proper documentation, writing medical notes (by physician / paediatrician) -Medicolegal implication, etc

15. Radiology -Requesting imaging – indication, appropriate imaging, urgency etc -Forms – type of forms, information required, etc -Tracing imaging report, etc Patology -Requesting investigations – indication, appropriateness, urgency etc -Forms – type of forms, information required, etc -Tracing investigation report, etc Pharmacy Pharmacy -Prescribing, prescribing error -Class of drugs (A,B,C) -Antibiotic protocol -DDA Blood transfusion -Group Cross Match, Group & Save -Requesting blood product -Blood transfusion protocol & DIVC regime -Transfusion error & its management, etc GENERIC FRAMEWORK-3: ORIENTATION COURSE CONTENT

16. GENERIC FRAMEWORK-4: ORIENTATION COURSE CONTENT Others Others -Clinical skills e.g. blood taking, urinary catheterisation, Ryles Tube, IV cannulation, etc. -Soft skills/Communication skills -Medical ethics e.g. patient’s right, confidentiality, autonomy, beneficence, consent, cultural concern, negligence, chaperone, etc. -Right attitude for doctors Record Office -Admission, discharge, discharge summary -Coding / ICD-10 -Death certifícate, burial permit, birth form -Related protocol/SOP HR Department -Leaves, pay roll, attendance, punch card, confirmation in service, full registration, disciplinary actions, etc. Basic Life Support -Need to train more instructor -Instructor can include paramedics, staff nurses, etc. -Can be combined with other staff to maximise the course, more worthwhile

17.  Organises hospital orientation  Engage relevant Depts to enrich the Orientation Course  Regular dialog with new Hos  Deliver expectation of MOH & Hospital Director  As a Civil Servant: follow General Order (rules & regulation)  HO training programme: need to complete training – to be competent & safe doctors  Organises hospital orientation  Engage relevant Depts to enrich the Orientation Course  Regular dialog with new Hos  Deliver expectation of MOH & Hospital Director  As a Civil Servant: follow General Order (rules & regulation)  HO training programme: need to complete training – to be competent & safe doctors 17 ROLE OF HOSPITAL DIRECTORS

18. INPUTS RECEIVED Housemanship Training Hospital House Officers Other Stake Holders IHSR Research MOH Head of Services for 7 Basic Disciplines AnaesthesiaAnaesthesia Emergency Medicine INPUTS FOR ENHANCEMENT OF FLEXI SYSTEM Phone calls/letters from HOs,parents & spouses of HOs Various top MOH Officers-HO meetings e.g. HospTawau 10.5.2013 Various top MOH Officers-HO meetings e.g. HospTawau 10.5.2013 HOs,parents & spouses of HOs come in person to MOH HQ/JKN Hospital Directors Housemanship Programme Coordinators HODs & Senior Clinicians MedicineMedicine SurgerySurgery PaediatricPaediatric OrthopaedicOrthopaedic O&GO&G Articles written by HOs to Newspapers

19. Various continuous inputs from all stake holders including HO INPUTS FOR ENHANCEMENT OF FLEXI SYSTEM 19 Meeting with HKL Medical Dept @ 23.5.2013 Meeting with States Health Deputy Director (Medical) & Director of HKL @ 8.7.2013 Meeting with Head of Services, selected Hospital Directors & Senior Consultants @ 10.7.2013 Meeting with Head of Services, selected Hospital Directors & Senior Consultants @ 1.8.2013 – formulation of generic Framework of Flexi System Specialist Conference at Avillion Legacy Hotel, Melaka on 20-22.9.2013 Meeting with States Health Deputy Director (Medical) & Director of HKL @ 7-8.10.2013 Meeting with States Health Deputy Director (Medical) & Director of HKL @ 7-8.10.2013 Meeting with TPKN(P), Head of Services, all 42 Housemanship Training Hospitals’ Directors, Specialists & HO Training Coordinator @ IKN 23.10.2013 Briefing to Health Minister in Melaka–MOH Way Forward 18.10.2013 MMA InternationalSeminar on HO Training / Minister’s Speech - 16.11.2013 Briefing Sessions to House Officers: –Southern Region @ Hosp Muar 19.11.2013 –Central Region @ Hosp Sg Buloh 2.12.2013 –Northern Region @ Seberang Jaya 16.12.2013 –East Coast Region @ HSNZ 23.12.2013 –Sabah State @ HQE –Sarawak State @ HUS – Mesy Khas KPK @ Johor – Mesy TPKN(P) & TP HKL with TKPK(P) & PPP @ Langkawi Briefing Sessions to House Officers: –Southern Region @ Hosp Muar 19.11.2013 –Central Region @ Hosp Sg Buloh 2.12.2013 –Northern Region @ Seberang Jaya 16.12.2013 –East Coast Region @ HSNZ 23.12.2013 –Sabah State @ HQE –Sarawak State @ HUS – Mesy Khas KPK @ Johor – Mesy TPKN(P) & TP HKL with TKPK(P) & PPP @ Langkawi

20.  Existing Flexi System to be further strengthened!  Not to reintroduce on-call system (90-120 Hrs)  There is no specific model/specific timetable that fit all Hospitals / Disciplines  The need to establish a generic framework which is flexible to meet all basic principle/requirement of Flexi System  Emphasis on more accountability in patient care & more time spent during office hours for training 20 FEEDBACK & CONCENSUS

21. SUMMARY: GENERIC FLEXI SYSTEM FRAMEWORK 21 * Each discipline/hospital is given flexibility to modify the flexi system accordingly to suit its own local environment as long as it conforms with generic framework above  Duration: average of 65-75 hours per week for 4 months posting  To implement Modified Flexi System  For ward based discipline – may implement 3 sessions as per example in the next slide (1 normal working hours + 2 flexi hours)  For non ward based discipline – implement existing system as in ED Dept. May also be applicable for Anaesthesia.  Shall not work continuously for more than 16 hours per session (without breaks)  All days are considered as working days inclusive of Public Holidays (PHs) & weekends (as HOs are undergoing training)  Entitled for replacement day off if working on PH  HO shall be given 1 full day off per week – can fall on any day  Protected Post-night duty off (afternoon off)  Protected time for CME must be provided & HO expected to attend at least 75% of department’s CME sessions  Emphasis on more accountability in patient care & more time spent for training during office hours

22. 7am-12pm12pm-4pm4pm-10pm10pm-7am 5 hrs 3 hrs (-1 hr lunch) 6 hrs 9 hrs Table HO 1 Table HO 1hrs/day MON MF2 (NORMAL + EVENING) 14 TUEMF1 8 WED 14 THUMF3 MF3 (NIGHT) 17 FRI Post-night duty till 12pm OFF 5 SATOFF 0 SUNMF3 MF3 (NIGHT) 14 Cumulative hours for week Cumulative hours for week 72 EXAMPLE OF MODIFIED FLEXI SYSTEM - MEDICAL DEPT, HKL 22 Refined schedule to enable more time to be spent during day time/office hours – to maximise attendance to ward rounds, OT, Day Care/OPD, procedures, CMEs, hand-over, etc. - - - - -

23. MODIFIED FLEXI WORKING HOURS 7am-12pm12pm-4pm4pm-10pm10pm-7am 5 hrs 3 hrs (-1 hr lunch) 6 hrs 9 hrs Table HO 1 Table HO 1hrs/day mon MF2 (NORMAL + EVENING) 14 tue MF1 8 wed 14 thu MF3 MF 3 (NIGHT) 17 fri Post-night duty till 12pm OFF 5 sat OFF 0 sun MF 3 MF 3 (NIGHT) 14 Cumulative hours for week 72 Table HO 2 Table HO 2 mon Post-night duty till 12pm OFF 5 tue MF2 (NORMAL + EVENING) 14 wed MF3 MF3 (NIGHT) 17 thu Post-night duty till 12pm OFF 5 fri MF2 (NORMAL + EVENING) 14 sat MF3 MF3 NIGHT) 14 sun OFF 0 Cumulative hours for week 69 Table HO 3 Table HO 3 mon MF 1 8 tue MF3 MF3 (NIGHT) 17 wed Post-night duty till 12pm OFF 5 thu MF2(NORMAL + EVENING) 14 fri MF3 MF3 (NIGHT) 17 sat OFF OFF 0 sun MF2 (NORMAL + EVENING) 14 Cumulative hours for week 75 Table HO 4 Table HO 4 mon MF3 MF3 (NIGHT) 17 tue Post-night duty till 12pm OFF 5 wed MF1 8 thu MF1 8 fri MF1 8 sat MF2 (NORMAL + EVENING) 14 sun OFF 0 Cumulative hours for week 60 23

24.  Ensure compliance of respective Depts  Allow flexibility according to the Framework  Gather input from various stake-holders within hospital for suggestion on further improvement  Medical Development Division will gather feedback in May/June 2014  Resolve relevant HO issues at hospital level  Liaises with JKN/BPP for more complicated issues  Ensure compliance of respective Depts  Allow flexibility according to the Framework  Gather input from various stake-holders within hospital for suggestion on further improvement  Medical Development Division will gather feedback in May/June 2014  Resolve relevant HO issues at hospital level  Liaises with JKN/BPP for more complicated issues 24 ROLE OF HOSPITAL DIRECTORS

25. NEW DISCIPLINES INTRODUCED  Since 2008 - Cabinet has decided to extend the Housemanship Training to 2 years  6 posting (5 compulsory, 1 obligatory)  Emergency Medicine introduced as Alternative posting  2010 - Anaesthesia introduced as another Alternative posting to Emergency Medicine  2014 - 2 more Alternative posting introduced:  Psychiatry Posting  Primary Health 25

26.  To include Psychiatry HOD and FMS into the Jawatankuasa Latihan PPS at Hospital level  Only for hospitals offering these postings  Efficient posting of HOs to these 4 alternative postings  Give attention to relevant administrative aspects  To include Psychiatry HOD and FMS into the Jawatankuasa Latihan PPS at Hospital level  Only for hospitals offering these postings  Efficient posting of HOs to these 4 alternative postings  Give attention to relevant administrative aspects 26 ROLE OF HOSPITAL DIRECTORS

27. 27 MANPOWER PLANNING: CONTINUUM Medical Officer

28.  Country requires more specialist & subspecialists in various fields  Current Master Programme not able to produce enough specialists to cater needs  IPTA only manage to train about 500 to 600 doctors into experts in a year  Brain drain – MOH trained specialists goes to private sector & universities  Country requires more specialist & subspecialists in various fields  Current Master Programme not able to produce enough specialists to cater needs  IPTA only manage to train about 500 to 600 doctors into experts in a year  Brain drain – MOH trained specialists goes to private sector & universities ISSUES & CHALLENGES

29.  Limited trained capacities in local universities  Inadequate trained Health Human Resources  Lack of monitoring of trainees in Master program  On average 38% Master trainees graduated on time  Parallel Pathways not well coordinate  Dichotomy of Post grad training  Promotion & Placement  Bottle neck promotion for specialist grade UD54  Placement of specialists to hospitals without adequate equipments  Limited trained capacities in local universities  Inadequate trained Health Human Resources  Lack of monitoring of trainees in Master program  On average 38% Master trainees graduated on time  Parallel Pathways not well coordinate  Dichotomy of Post grad training  Promotion & Placement  Bottle neck promotion for specialist grade UD54  Placement of specialists to hospitals without adequate equipments ISSUES & CHALLENGES

30.  Maldistribution of Health Human Resources  Geographical (Urban vs. Rural)  Logistic constrains  Lack of financial incentives  Attrition  Brain drain of MOH specialists  need attractive retaining package  High attrition of specialist at UD54 ISSUES & CHALLENGES

31. BIDANG∑ PAKAR (2010)∑ PAKAR (2013)KEPERLUAN (2020) O&G2542881149 ANAESTHESIA3263841755 PEDIATRIK2783691016 PERUBATAN DALAMAN5537521984 PSIKIATRI115154642 RADIOLOGI183243931 PEMBEDAHAN AM276285576 OFTALMOLOGI179217920 ORTOPEDIK219249566 OTORINOLARINGOLOGI113142406 PATOLOGI182258319 NUMBER OF SPECIALISTS in 2010 & 2013 vs. PROJECTED COUNTRY’S NEEDS IN 2020

32. NUMBER OF SPECIALISTS PASSED FOR YEAR 2009-2013 Master Programme and Parallel Pathway SPECIALTYQUALIFICATION 20132012201120102009 INTERNAL MEDICINE MRCP4476675530 MMED2425312734 PAEDIATRIC MRCPCH2327251310 MMED2621151412 O&G MRCOG55533 MMED3719232615 ONCOLOGY FRCR21101 MMED34341 SURGERY FRCS00000 MMED3339211723 ANESTHESIA FANZCA00000 MMED4643404737 TOTAL 243260231206166

33. STRENGTHENING MO’s TRAINING:  Strengthening & facilitate parallel pathway (Membership Programme) in producing more specialist, e.g. in:  MRCP  MRCPCH  MRCOG  FANZCA  FRCS  Etc.  Establishment of Post Graduate Medical Education, Specialists & Subspecialists Unit under Medical Development Division of MOH

34. 34 ROLE OF HOSPITAL DIRECTORS ROLE OF HOSPITAL DIRECTORS  Encouraged to take Part I / equivalent  Those who passed Part I / equivalent :  Identify & Register them with hospital and Bahagian Perkembangan Perubatan - parallel pathways registration form  Must be posted to related department (e.g. those with MRCP part I/II to Medical department)  Facilitate M.O to complete their rotational posting:  MRCOG  Antenatal ward, Labour room, Feto-maternal medicine, Uro-gynaecology, etc  MRCP  Respiratory, Haematology, Endocrinology, Gastroenterology, Cardiology, etc  Register to Medical Development Division those who passed Part 2/PACES completely  For gazettement and posting

35. BENEFIT OF REGISTRATION  Quality management, review & evaluation  Equality, diversity & opportunity  Delivery of appropriate curriculum & assessment  Support & development of trainees  Management of education, training & rotational posting  Early gazettement

37. PARALLEL PATHWAYS REGISTRATION FORM

38. 38 MANPOWER PLANNING: CONTINUUM Specialist: Master & Parallel Pathway

39.  Need adequate number of generalist  Subspecialist training  Merit for generalist who had served the periphery  Requirement of rotation posting  Subspecialist encouraged to provide basic specialty services  Except for specialized centers 39 SPECIALIST VS SUBSPECIALIST SPECIALIST VS SUBSPECIALIST

40. 40 MANPOWER PLANNING - CONCLUSION

41. 41