Clinical Governance in KPJ Healthcare Berhad 1
SEVEN PILLARS OF CLINICAL GOVERNANCE Definition: Clinical Governance is a framework through which organisations are accountable for continuously improving the quality of their services and safeguarding high standards of care by creating an environment in which excellence in clinical care can flourish. Clinical Governance in KPJ
• Vision: Be the preferred healthcare provider • Mission: Deliver Quality Healthcare Services • Provides resources and management support • Clinical leadership through appointment of senior, experienced consultants in leadership positions • Does not compromise on safety and quality • Good Clinical Governance is good for business and is part of Good Corporate Governance KPJ’s Commitment to Clinical Governance
1. Conduct Quarterly Clinical Governance Meeting 2. Clinical Service – compiles info, /data & prepare reports for circulation & prepare slides for the meeting KPJ BOARD HOSPITAL BOARD HOSPITAL BOARD OF MANAGEMENT HOSPITAL MEDICAL (DENTAL) ADVISORY COMMITTEE Person in Charge /Medical Directors’ Council (Quarterly) 1. Central Credentialing Committee (CCC) 2. Professional Development Committee (PDC) 3. Transformation and Quality Innovation Committee (TQIC) 4. Clinical Safety and Risk Management Committee (CSRMC) 5. Education and Research Committee (ERC) 6. Clinical and Research Ethics Committee (CREC) 1. Credentialing & Privileging, 2. Hospital Infection & Antibiotic Control 3. Health Information Management 4. Mortality & Morbidity Review 5. Pharmacy & Therapeutics 6. Surgical & Medical Intervention 7. Risk, Quality & Safety 8. Hospital Transfusion Committee 9. Hospital Clinical Ethics 10. Ad – Hoc Peer Review 11. Education & Audit 1. Patient Complaints & Resolution 2. ConsultantManagement Meeting Clinical Committees Hospital Committees GROUP MEDICAL ADVISORY AND CLINICAL GOVERNANCE COMMITTEE (GMACGC) Pathway of Group Clinical Governance Committees 7
The Chairman of Group Medical Advisory and Clinical Governance Committee is a Senior Medical Professional and a KPJ Board Member, nominated and approved by KPJ Healthcare Berhad. Members of The Group Medical Advisory and Clinical Governance Committee consist of: a. President and Managing Director of KPJ Healthcare Berhad, b. Chairman of all the Group Clinical Governance Committees and Chairman of KPJ Medical Directors. c. Medical Professionals approved by the KPJ Healthcare Berhad. d. Group Head of KPJ Business Operations. e. Group Head of Clinical Medical Services. Group Medical Advisory and Clinical Governance Committee
FUNCTIONS OF SUBCOMMITTEES OF GMACGC COMMITTEES FUNCTIONS Medical Directors’ Council 1. Work closely with GMACGC to improve clinical governance at hospital levels Transformation and Quality InnovationCommittee 1. Drive transformation initiatives in providing care 2. Implement innovations in quality and safety 3. Drive culture change 4. Develop service clusters and Centres of Excellence Clinical Safety and Risk ManagementCommittee 1. Monitor, analyse and report scientifically safety incidents safety goals and clinical indicators. 2. Develop quality and safety dashboards using SPCC 3. Analyse and report mortality and morbidity incidents and incidence. ProfessionalDevelopment Committee 1. Review and update current clinical policies 2. Develop and introduce professional enhancementfor doctors and all healthcare professionals. 3. Develop and implement clinical audits
FUNCTIONS OF SUBCOMMITTEES OF GMACGC COMMITTEES FUNCTIONS Education and Research Committee 1. Integrate KPJ University and Hospitals into a singleplatform to train and educate healthcare professionals of all levels 2. Enhance research activities in hospitals 3. Elevate major hospitals into academic healthcentres Clinical and Research Ethics Committee 1. Monitor ethical issues involving clinical care 2. Provide advice on ethical questions as they arise 3. Review and decide on ethical appropriateness ofresearch proposals Central Credentialing Committee 1. Act as oversight body to credentialing approvals ofhospital credentialing committees
Clinical Governance policies and guidelines related to good clinical practice
KPJ GOVERNING POLICIES 1. Accident & Emergency 2. Anaesthesia 3. Cardiology 4. Charges 5. Consultant 6. Committee 7. Credentialing & Privileging 8. Diagnostic Imaging 9. Dietetic 10. Dialysis 11. Hospital Wide 12. Intensive Care Unit 13. Infection Control 14. Incident Reporting 15. Laboratory 16. Medical Record 17. Mortality 18. Obstetrics & Gynaecology 19. Oncology 20. Operation Theatre 21. Paediatrics 22. Pharmacy 23. Surgery
1.Medical Professional By-laws (Part 1) 2.Rules & Regulations 2016/2017
Examples of some Clinical Indicators in use in KPJ CLINICAL INDICATORS STANDARDS 1. Rate of LSCS International Standard : 25% - 30% 2. % Number of complication (deaths) related to procedures done in Cath Lab MSQH standard: < 1% 3. Myocardial Infarction case fatality rate KKM Standard : ≤ 10% 4. (%) Number of STEMI cases via A&E receiving thrombolyti c within 30 minutes MSQH Standard: >90% 5. (%) Number of post-operative cataract complications KKM: <0.2% (2 cases out of 1000 patients) 6. (%) Number of 3rd and 4 th degree vaginal tears from instrumental and vaginal deliveries MSQH Standards: <10% (with Specialist facility)
Statistical Process Control Chart (SPCC) : Actual Error in Inpatient and Outpatient ▪ Actual Error incident rate is fluctuated within the control limits in general, except for Outpatient in January 2023. 0.015 0.007 0.019 0.006 0.012 0.000 0.007 0.021 0.007 0.025 0.007 0.000 Rate / 1000 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Prescriptions SPCC OP AE APRIL 2022 - MARCH 2023 Rates by month UCL CL LCL 0.177 0.071 0.084 0.080 0.042 0.216 0.168 0.222 0.105 0.100 0.126 0.140 0.121 0.052 -0.118 Apr-22 May-22 Jun-22 Jul-22 Aug-22 Sep-22 Oct-22 Nov-22 Dec-22 Jan-23 Feb-23 Mar-23 Rate / IInpatient Days SPCC IP AE APRIL 2022 - MARCH 2023 Rates by month UCL CL LCL 107 Medication Error
13 Top 5 DCBP Scheduled surgery delayed > 30 min due to surgeon's absence Incomplete consent form Absence of Paediatrician during Caesarean Section One Anaesthetist managing 2 cases simultaneously Consent obtained in OT for scheduled cases Samples of DCBP ( Departures from Clinical Best Practices (OT) Departure from Clinical Best Practices (DCBP) Operation Theatre as at March 20223 to March 2022 Type of Incident 2023 2022 Variances (%) No. of DCBP Per 1,000 Surger ies No. of DCBP Per 1,000 Surger ies No. of DCBP Per 1000 Surger ies Total number of Surgeries 26,198 21,456 DCBP 17 0.6 14 0.7 3 0.1 • DCBP - shows a increasing trend. • DCBP – 0.6 per 1,000 surgeries
HOSPITAL ACCREDITATION Malaysian Society for Quality in Health (MSQH) for Dental 1 KPJ KL Dental Specialist Centre 1 st No. KPJ Hospitals MSQH Cycle 1 KPJ Ampang Puteri 7th 2 KPJ Ipoh 6th 3 KPJ Damansara 6th 4 KPJ Johor 5th 5 KPJ Selangor 5th 6 KPJ Tawakkal 4th 7 KPJ Seremban 4th 8 KPJ Perdana 4th 9 KPJ Penang 4th 10 KPJ Kajang 4th 11 Kedah Medical Centre 4th 12 KPJ Sentosa KL 3rd 13 KPJ Pahang 3rd 14 KPJ Puteri 2nd 15 KPJ Pasir Gudang 2nd 16 KPJ Sabah 2nd 17 KPJ Rawang 2nd 18 KPJ Maharani 2nd 19 KPJ Klang 2nd 20 KPJ Perlis 1st Awards and Accreditation
➢Strive for consistently good, quality care ➢ Be willing to have your performance measured, audited ➢ You cannot do it alone – work as a team ➢ Create value in your work. Cost is not necessarily the main concern of your patient ➢ Be part of the hospital clinical governance system Managing the Challenges
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The first KPJ Healthcare Conference was held in 2001. Since then, KPJ Healthcare Berhad has organised yearly, 13 Conferences and 8 KPJ Healthcare Workshops. This year we will be organising the 14th KPJ Healthcare Conference
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