i EXECUTIVE SUMMARY There are total of 175 indicators from 44 clinical disciplines being monitored under KPI Clinical Services. It involves 93 Hospitals and Institutions under Ministry of Health Malaysia which is detailed as below: Table 1: Number of Hospitals That Monitored Clinical Services KPI Hospital Pulau Pinang has the highest number of KPI monitored with 126 indicators, followed by Hospital Tengku Ampuan Afzan (HTAA) with 116 indicators, and Hospital Sultanah Aminah with 115 indicators. Non-specialist hospitals and institutions have the lowest number of KPI monitored with 1 to 3 indicators per hospital/ institutions. Table 2 shows the average number of KPI monitored according to the type of hospital. Table 2: Average Number of Indicators Monitored by Type of Hospital PERFORMANCE The overall national performance index is 1.07. There are 18 indicators that did not achieve the standard or having Shortfall in Quality (SIQ) (Table 3). Most of the SIQ are indicators of waiting time to see doctor at specialist clinic (total of 14 indicators). Figure 1 shows the average of performance index by each state. All the states had achieved the standard (≥1). Type of hospital No. of hospitals that monitored Clinical Services KPI No. of hospitals which did not monitor Clinical Services KPI State 14 0 Major Specialist 27 1 (Hospital Cyberjaya -new hospital) Minor Specialist 18 2 (Hospital Pendang – new hospital & Hospital Tg Karang- move to a new building) Non-specialist 23 53 Institutions 11 0 Type of Hospital Average Number of KPI Monitored State Hospital 92 Major Specialist Hospital 54 Minor Specialist Hospital 30 Non-Specialist Hospital 21 Institution 15
ii Figure 1: Average Performance Index by State Table 3 shows the list of total indicators with SIQ. No. Indicator Discipline Performance Standard Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Specialist Outpatient Clinic 1. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Cardiology Outpatient Clinic Cardiology 56.2% ≥80% 2. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Gastroenterology & Hepatology Outpatient Clinic Gastroenterology & Hepatology 78.0% ≥80% 3. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Infectious Disease Outpatient Clinic Infectious Disease 73.3% ≥80% 4. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at General Medicine Outpatient Clinic General Medicine 79.0% ≥80% 5. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Nephrology Outpatient Clinic Nephrology 78.3% ≥80% 6. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Paediatric Cardiology Outpatient Clinic Pediatric Cardiology 72.4% ≥80% 7. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Breast & Endocrine Surgery Outpatient Clinic Breast & Endocrine Surgery 66.3% ≥80% 8. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at General Surgery Outpatient Clinic General Surgery 74.4% ≥80% 1.04 1.09 1.04 1.07 1.06 1.09 1.07 1.09 1.09 1.09 1.06 1.07 1.08 1.07 1.05 1.08 1.00 1.02 1.04 1.06 1.08 1.10 Performance Index Average Performance Index By State Table 3: Indicators with SIQ
iii INDICATOR OF WAITING TIME TO SEE DOCTOR AT SPECIALIST CLINIC There are 2 types of waiting time indicator to see doctor at the specialist clinic: 1. Percentage of Patients With Waiting Time ≤60 Minutes To See Doctor at Specialist Outpatient Clinic 2. Percentage of Patients With Waiting Time ≤90 Minutes To See Doctor at Specialist Outpatient Clinic 9. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Plastic & Reconstructive Surgery Outpatient Clinic Plastic & Reconstructive Surgery 79.3% ≥80% 10. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Urology Outpatient Clinic Urology 62.2% ≥80% 11. Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Radiotherapy & Oncology Outpatient Clinic Radiotherapy & Oncology 60.2% ≥80% Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Specialist Outpatient Clinic 12. Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Paediatric Cardiology Outpatient Clinic Paediatric Cardiology 85.3% ≥90% 13. Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Gastroenterology & Hepatology Outpatient Clinic Gastroenterology & Hepatology 87.8% ≥90% 14. Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Radiotherapy & Oncology Outpatient Clinic Radiotherapy & Oncology 81.2% ≥90% Other indicators 15. Percentage of Type 2 diabetes mellitus patients with HbA1c ≥8.5% (new indicator in 2023) Endocrinology 33.3% ≤20% 16. Percentage of Type 2 diabetes patients screened for chronic complications (new indicator in 2023) Endocrinology 72.9% ≥90% 17. Percentage of Severe Opioid Toxicity Requiring Reversal With Naloxone Palliative Medicine 0.01% 0% 18. Percentage of patients who underwent Coronary Artery Bypass Grafting (CABG) surgery within (≤) 9 months from the time decision made * This indicator was SIQ in 2020 performance Cardiothoracic Surgery 82.6% ≥90%
iv The indicator of Waiting Time ≤90 Minutes achieved better performance compared to the indicator of Waiting Time ≤60 Minutes. This is reflected on their performance indexes and percentage of SIQ (Table 3). There are more clinics with SIQ for the indicator of Waiting Time ≤60 Minutes, although the number of clinics which used this indicator were far lesser than the other indicator (Table 4, 5 and 6). It shows that the clinics were struggling to achieve the standards of waiting time ≤60 minutes compared to ≤90 minutes. Figure 2 shows the performance of indicator Waiting Time ≤60 Minutes To See Doctor by states. National performance was 82.8%. 2 states and 1 institute did not achieved the standard (≥80%); they are Kedah, WP Kuala Lumpur/Putrajaya and Institut Kanser Negara (IKN). Figure 3 shows the performance of indicator Waiting Time ≤90 Minutes To See Doctor by states. National performance was 94.5%. HKL and Kedah did not achieve the standard (≥90%). No. Indicator Performances Standard Performance Index 1. Percentage of Patients With Waiting Time ≤60 Minutes To See Doctor at Specialist Outpatient Clinic 82.8% ≥80% 1.038 2. Percentage of Patients With Waiting Time ≤90 Minutes To See Doctor at Specialist Outpatient Clinic 94.5% ≥90% 1.055 Type of Hospital No. of Clinics that used waiting time ≤90minutes No. of clinics with SIQ % of SIQ Institution 17 3 17.6% Major Hospital 146 3 2.1% Minor Hospital 59 4 6.8% Non specialist 132 2 1.5% State 253 19 7.5% Total 607 31 5.1% Type of Hospital No. of clinics that used waiting time ≤60minutes No. of clinics with SIQ % of SIQ Institution 16 4 25.0% Major Hospital 140 40 28.5% Minor Hospital 45 1 2.2% Non specialist 4 0 0% State 78 5 6.4% Total 283 50 17.7% Table 4: Overall Performances of 2 Type of Waiting Time Indicators Table 5: Percentage of SIQ for clinics that use indicator of waiting time ≤60 minutes according to the type of hospital Table 6: Percentage of SIQ for clinics that use indicator of waiting time ≤90 minutes according to the type of hospital
v RECOMMENDATION 1. We recommend expanding the KPI monitoring to all hospitals that deliver the services, no matter whether they have resident specialists on board or not. 2. Our future plan is to drop this indicator from the Clinical Services KPI, and let this KPI fall under the direct responsibility of the Hospital Director, as many of the factors involved are within the Hospital Director’s jurisdiction. 3. We will continue to monitor the performances of Clinical Services KPI and work closely with the Head of Services to ensure that chosen KPI are relevant 4. There will be annual meeting on achievement of Clinical Services KPI chaired by Deputy Director- General (Medical) where all SIQs will be addressed in the meeting. 5. Knowledge on SIQ still needs to be improved. We have developed a new guideline on SIQ specifically on KPI starting this year and hopefully, it is more user friendly and simple to use. 89.6 99.2 94.8 79.8 97.3 97.2 95.0 97.0 97.8 96.4 92.3 95.9 96.2 96.3 96.5 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Patients With Waiting Time ≤90 Minutes To See Doctor At Specialist Clinic, 94.5% 86.8 57.5 95.4 78.3 80.1 78.1 81.0 94.1 91.5 91.3 89.4 82.1 88.8 80.0 85.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Patients With Waiting Time ≤60 Minutes To See Doctor At Specialist Clinic, 82.8% Figure 2: Percentage of Patients With Waiting Time ≤60 Minutes to See Doctor By States Figure 3: Percentage of Patients With Waiting Time ≤90 Minutes to See Doctor By States
KPI CLINICAL SERVICE CARDIOLOGY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 2 National Performance: 56.2% Standard: ≥80% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 10 National Performance: 91.6% Standard: ≥90% 2020 Performance: 94.5% Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 90.1 51.0 0.0 20.0 40.0 60.0 80.0 100.0 Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Cardiology Outpatient Clinic, 56.2% 92.2 71.8 92.9 98.1 94.9 93.4 100 100 95.4 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Cardiology Outpatient Clinic, 91.6% 2
KPI CLINICAL SERVICE CARDIOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. Heart Failure Case Fatality Rate Number of Hospitals Involved: 10 National Performance: 4.5% Standard: ≤8% Number of Hospitals Involved: 10 National Performance: 3.2% Standard: ≤20% 4. Readmission Within 1 Month For Heart Failure 4.4 6.9 3.6 2.8 3.9 3.9 4.2 10.4 4.6 3.4 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Heart Failure Case Fatality Rate, 4.5% 0.0 3.8 0.8 5.5 3.9 0.4 4.7 6.7 1.4 7.1 0.0 1.0 2.0 3.0 4.0 5.0 6.0 7.0 8.0 Readmission within (≤) 1 month for Heart Failure, 3.2% 4
KPI CLINICAL SERVICE DERMATOLOGY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 10 National Performance: 89.7% Standard: ≥80% Number of Hospitals Involved: 22 National Performance: 97.2% Standard: ≥90% 2020 Performance: 95.3% 95.5 74.4 81.8 91.8 94.9 87.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0 JKWPKL/P Kedah N.Sembilan Pahang Selangor Terengganu Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Dermatology Outpatient Clinic, 89.7% 93.3 97.3 94.4 99.6 94.8 100 94.6 97.7 98.2 100 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Dermatology Outpatient Clinic, 97.2% 5
KPI CLINICAL SERVICE DERMATOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 22 National Performance: 93.7% Standard: ≥80% 2020 Performance: 93.0% 3. % of Psoriasis Patients Assessed For Quality of Life Number of Hospitals Involved: 22 National Performance: 0.1% Standard: ≤2% 2020 Performance: 0.1% 4. Infection Rate of Skin Biopsy Wound 88.5 99.0 96.3 100 100 88.9 100 100 100 100 100 88.4 100 91.1 100 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of new Psoriasis patients assessed for quality of life within (≤) 6 months of follow up, 93.7% 0.2 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.0 0.5 0.6 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 Infection rate of skin biopsy wound, 0.1% 6
KPI CLINICAL SERVICE GASTROENTEROLOGY & HEPATOLOGY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved:7 National Performance: 78.0% Standard: ≥80% Number of Hospitals Involved: 12 National Performance: 87.8% Standard: ≥90% 2020 Performance: 97.1% 94.9 88.1 94.0 72.1 0.0 20.0 40.0 60.0 80.0 100.0 Kedah N.Sembilan Pahang Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Gastroenterology and Hepatology Outpatient Clinic, 78.0% 63.8 94.5 76.9 97.1 98.1 89.3 100 100 95.0 95.3 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Gastroenterology and Hepatology Outpatient Clinic, 87.8% 7
KPI CLINICAL SERVICE GASTROENTEROLOGY & HEPATOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of OGDS Performed Within 24H in Patients With Upper Gastrointestinal Hemorrhage Number of Hospitals Involved: 11 National Performance: 98.5% Standard: ≥90% 2020 Performance: 99.8% Number of Hospitals Involved: 12 National Performance: 99.7% Standard: ≥90% 2020 Performance: 100% 4. % of Cirrhotic Patients Had Diagnostic Abdominal Paracentesis Within 48H 99.2 100 94.0 100 100 100 100 96.8 100 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of oesophagogastroduodenoscopy (OGDS) performed within (≤) 24 hours of admission, 98.5% 100 100 100 100 95.7 100 100 100 99.7 100 92 94 96 98 100 102 Percentage of cirrhotic patients with clinically apparent ascites had diagnostic abdominal paracentesis performed within (≤) 48 hours of admission to medical wards, 99.7% 9
KPI CLINICAL SERVICE GASTROENTEROLOGY & HEPATOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 5. % of Chronic Hepatitis C Patients Initiated on Anti-HCV within 8 months Number of Hospitals Involved: 14 National Performance: 98.5% Standard: ≥90% 2020 Performance: 97.6% 96.3 100 100 100 98.1 78.1 100 100 100 100 100 100 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Chronic Hepatitis C patients who are fully assessed and initiated on anti-HCV therapy within (≤) 8 months of first consultation, 98.5% 10
KPI CLINICAL SERVICE ENDOCRINOLOGY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 8 National Performance: 85.9% Standard: ≥80% Number of Hospitals Involved: 13 National Performance: 97.6% Standard: ≥90% 2020 Performance: 96.4% 72.5 90.1 98.6 92.9 92.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0 JKWPKL/P N.Sembilan Pahang Sabah Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Endocrine & Diabetes Outpatient Clinic, 85.9% 98.2 98.1 86.0 99.3 99.0 90.4 100 97.1 98.9 91.1 99.3 100 98.0 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Endocrine and Diabetes Outpatient Clinic, 97.6% 11
KPI CLINICAL SERVICE ENDOCRINOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Type 2 Diabetes Mellitus Patients With HbA1c ≥8.5% Number of Hospitals Involved: 20 National Performance: 33.3% Standard: ≤20% Number of Hospitals Involved: 19 National Performance: 72.9% Standard: ≥90% 4. % of Type 2 DM Patients Screened For Chronic Complications 37.5 32.5 46.3 52.3 47.2 45.1 39.4 18.6 22.5 36.0 37.9 16.5 40.3 24.0 0.0 10.0 20.0 30.0 40.0 50.0 60.0 Percentage of Type 2 diabetes mellitus patients with HbA1c > 8.5%, 33.3% 60.9 30.2 97.0 100.0 92.8 99.2 92.2 95.7 47.2 95.8 25.8 49.6 90.6 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Type 2 diabetes patients screened for chronic complications, 72.9% 12
KPI CLINICAL SERVICE GENERAL MEDICINE Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 24 National Performance: 79.0% Standard: ≥80% Number of Hospitals Involved: 55 National Performance: 94.3% Standard: ≥90% 2020 Performance: 94.5% 92.7 76.8 81.0 61.2 92.9 93.7 95.7 83.1 60.7 86.4 79.1 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at General Medicine Outpatient Clinic, 79.0% 82.5 92.0 88.9 95.9 98.0 98.0 98.3 98.3 95.6 78.1 94.1 96.6 99.5 93.9 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at General Medicine Outpatient Clinic, 94.3% 16
KPI CLINICAL SERVICE GENERAL MEDICINE Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. Non-ST Elevation Myocardial Infarction Case Fatality Rate Number of Hospitals Involved: 74 National Performance: 2.5% Standard: ≤10% 2020 Performance: 2.7% Number of Hospitals Involved: 73 National Performance: 0.08% Standard: ≤0.5% 4. % of Unplanned Readmission To Medical Ward 3.2 3.6 4.1 1.6 4.5 1.7 3.9 2.1 0.9 0.3 2.7 1.8 1.3 5.0 2.5 1.1 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Non ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate, 2.5% 0.30 0.15 0.10 0.13 0.08 0.02 0.05 0.08 0.09 0.15 0.01 0.06 0.07 0.03 0.09 0.00 0.05 0.10 0.15 0.20 0.25 0.30 0.35 Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge, 0.08% 18
KPI CLINICAL SERVICE GERIATRIC Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Healthcare Worker At Clinic Number of Hospitals Involved: 3 National Performance: 99.0% Standard: ≥80% 2. Waiting Time ≤90 Minutes To See Healthcare Worker At Clinic Number of Hospitals Involved: 14 National Performance: 99.7% Standard: ≥90% 2020 Performance: 99.5% 100 99.0 98 99 99 100 100 101 Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the healthcare worker at Geriatric Outpatient Clinic, 99.0% 100 100 95.7 100 100 100 100 100 100 100 98.8 93 94 95 96 97 98 99 100 101 Percentage of patients with waiting time of ≤ 90 minutes to see the healthcare worker at Geriatric Outpatient Clinic, 99.7% 19
KPI CLINICAL SERVICE GERIATRIC Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Post-Falls Assessment Done Within 1 Week Number of Hospitals Involved: 9 National Performance: 100% Standard: ≥90% 2020 Performance: 100% Number of Hospitals Involved: 12 National Performance: 99.1% Standard: ≥90% 2020 Performance: 99.0% 4. % of Patients Underwent Comprehensive Geriatric Assessment (CGA) 100 100 100 100 100 100 100 98.1 97.9 96 97 98 99 100 101 Percentage of patients undergoing Comprehensive Geriatric Assessment (CGA) within (≤) one week of admission to Geriatric ward, 99.1% 100 100 100 100 100 100 100 0 20 40 60 80 100 120 HKL Melaka P.Pinang Perak Sabah Sarawak Selangor Percentage of post-falls assessments done for patients within (≤) one week from incident of fall in Geriatric Ward, 100% 20
KPI CLINICAL SERVICE HAEMATOLOGY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 4 National Performance: 84.7% Standard: ≥80% Number of Hospitals Involved: 12 National Performance: 96.9% Standard: ≥90% 2020 Performance: 95.5% 89.2 91.9 82.0 75.0 80.0 85.0 90.0 95.0 N.Sembilan Pahang Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Haematology Outpatient Clinic, 84.7% 94.6 100 89.5 98.8 97.4 97.7 98.7 97.2 94.7 100 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Haematology Outpatient Clinic, 96.9% 21
KPI CLINICAL SERVICE HAEMATOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Induction Death From Chemotherapy Number of Hospitals Involved: 14 National Performance: 0.9% Standard: ≤10% 2020 Performance: 3.1% Number of Hospitals Involved: 14 National Performance: 0.01% Standard: ≤0.5% 4. Chemotherapy Extravasation Rate 0.5 1.7 0.0 0.1 0.0 0.0 3.2 1.3 0.8 2.2 4.6 0.0 1.0 2.0 3.0 4.0 5.0 Percentage of induction deaths from chemotherapy among newly diagnosed Acute Leukaemia/ Diffuse Large B-Cell Lymphoma (DLBL) patients, 0.9% 0.00 0.00 0.00 0.00 0.00 0.06 0.00 0.13 0.00 0.03 0.00 0.00 0.02 0.04 0.06 0.08 0.10 0.12 0.14 Chemotherapy Extravasation Rate, 0.01% 22
KPI CLINICAL SERVICE INFECTIOUS DISEASE Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 5 National Performance: 73.3% Standard: ≥80% Number of Hospitals Involved: 18 National Performance: 99.1% Standard: ≥90% 2020 Performance: 99.5% 95.2 94.9 96.3 64.3 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Kedah N.Sembilan Sabah Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Infectious Disease Outpatient Clinic,73.3% 92.9 100.0 97.2 99.9 98.1 93.6 99.2 100 100 98.7 100 100 100 100 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Infectious Disease Outpatient Clinic, 99.1% 23
KPI CLINICAL SERVICE INFECTIOUS DISEASE Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of HIV Patients Achieving Undetectable Viral Load Number of Hospitals Involved: 22 National Performance: 94.6% Standard: ≥85% 2020 Performance: 99.8% Number of Hospitals Involved: 20 National Performance: 94.3% Standard: ≥85% 2020 Performance: 89.8% 4. % of Patients On Carbapenem Have Documented Review Within 72H 90.0 100 95.0 95.9 89.5 100 83.7 97.4 95.8 100 96.6 95.3 94.5 100 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of HIV patients achieving undetectable HIV viral load within (≤) 6 months of commencement of anti-retroviral therapy, 94.6% 90.5 100 95.1 100 100 99.0 100 69.5 100 96.7 91.1 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of inpatients started on carbapenam in the Infectious Disease discipline who have a documented review within (≤) 72 hours of initiation, 94.3% 25
KPI CLINICAL SERVICE NEPHROLOGY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 10 National Performance: 78.3% Standard: ≥80% Number of Hospitals Involved: 34 National Performance: 95.2% Standard: ≥90% 2020 Performance: 97.3% 90.3 98.8 96.0 95.3 87.0 80.9 67.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0 JKWPKL/P Johor Kedah N.Sembilan Sabah Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at Nephrology Outpatient Clinic, 78.3% 93.7 98.9 82.6 98.1 99.6 92.1 92.7 97.0 97.0 99.7 92.9 95.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at Nephrology Outpatient Clinic, 95.2% 26
KPI CLINICAL SERVICE NEPHROLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Chronic Haemodialysis Patients With Delivered KT/V of ≥1.2 Number of Hospitals Involved: 59 National Performance: 93.1% Standard: ≥85% 2020 Performance: 94.6% Number of Hospitals Involved: 31 National Performance: 0.8/100 Patient-months Standard: ≤4/100 Patient-months 2020 Performance: 0.7/100 Patient-months 4. Incidence Rate of Peritonitis on Chronic Peritoneal Dialysis 91.6 89.3 95.3 94.1 90.9 89.5 94.2 93.3 95.4 93.5 91.8 93.6 92.2 91.8 86.0 88.0 90.0 92.0 94.0 96.0 Percentage of chronic haemodialysis patients with delivered KT/V of ≥ 1.2, 93.1% 2.2 2.6 1.8 2.9 3.2 0.7 0.1 2.8 2.7 0.1 3.5 2.0 2.2 2.5 0.0 0.5 1.0 1.5 2.0 2.5 3.0 3.5 4.0 Incidence rate of peritonitis in adult patients on chronic peritoneal dialysis, 0.8/100 patient-months 28
KPI CLINICAL SERVICE NEUROLOGY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 3 National Performance: 81.2% Standard: ≥80% Number of Hospitals Involved: 12 National Performance: 97.3% Standard: ≥90% 2020 Performance: 95.6% 86.1 99.7 60.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 N.Sembilan Pahang Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Neurology Outpatient Clinic, 81.2% 97.8 96.9 92.7 100 96.9 99.8 96.9 99.3 100 99.8 97.7 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Neurology Outpatient Clinic, 97.3% 29
KPI CLINICAL SERVICE NEUROLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Ischaemic Stroke Patients Receiving IV rt-PA Within 35 Minutes Number of Hospitals Involved: 12 National Performance: 80.5% Standard: ≥65% 2020 Performance: 88.4% Number of Hospitals Involved: 12 National Performance: 97.8% Standard: ≥85% 2020 Performance: 97.5% 4. % of Acute Ischaemic Stroke Patients Obtained Neurology Consultation Within 24H 73.5 100 100 75.0 83.3 84.6 100 83.3 56.3 91.1 56.3 90.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Ischaemic Stroke (IS) patients receiving IV recombinant tissue plasminogen activator (IV rt-PA) therapy within (≤) 35 minutes of CT brain initiation, 80.5% 100 100 100 100 100 100 100 100 100 100 86.8 80 85 90 95 100 105 Percentage of Acute Ischaemic Stroke (AIS) inpatients obtained Neurology consultation within (≤) 24 hours of referral, 97.8% 30
KPI CLINICAL SERVICE PAEDIATRIC Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 26 National Performance: 87.4% Standard: ≥80% Number of Hospitals Involved: 51 National Performance: 94.1% Standard: ≥90% 2020 Performance: 95.5% 90.4 100.0 73.0 98.1 59.6 90.9 88.6 98.3 89.0 87.5 95.8 86.9 84.6 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Paediatric Outpatient Clinic, 87.4% 93.7 67.7 94.4 99.9 97.7 98.9 94.8 100.0 97.4 97.1 95.2 94.3 90.1 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Paediatric Outpatient Clinic, 94.1% 31
KPI CLINICAL SERVICE PAEDIATRIC Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Survival of Inborn Livebirth With Birthweight 1000-1499g Number of Hospitals Involved: 50 National Performance: 95.4% Standard: ≥90% 2020 Performance: 94.6% Number of Hospitals Involved: 74 National Performance: 0.02% Standard: ≤0.5% 2020 Performance: 0.01% 4. Community Acquired Pneumonia Death Rate 94.4 92.9 97.4 92.9 94.9 94.0 94.5 97.5 97.1 97.8 93.1 100 95.7 95.7 96.3 96.9 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of survival of inborn livebirths with birthweight between 1000-1499g, 95.4% 0.00 0.00 0.00 0.02 0.03 0.04 0.00 0.00 0.00 0.00 0.00 0.00 0.17 0.00 0.01 0.00 0.00 0.05 0.10 0.15 0.20 Community Acquired Pneumonia (in previously healthy children between 1 month and 5 years) Case Fatality Rate, 0.02% 32
KPI CLINICAL SERVICE PAEDIATRIC Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 5. % of Paediatric Patients With Unplanned Readmission Number of Hospitals Involved: 75 National Performance: 0.05% Standard: ≤0.5% 2020 Performance: 0.04% 0.04 0.16 0.02 0.05 0.06 0.08 0.00 0.02 0.01 0.02 0.05 0.08 0.05 0.06 0.01 0.15 0.00 0.05 0.10 0.15 0.20 Percentage of paediatric patients with unplanned readmission to Paediatric Ward within (≤) 48 hours of discharge, 0.05% 33
KPI CLINICAL SERVICE PAEDIATRIC CARDIOLOGY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 4 National Performance: 72.4% Standard: ≥80% Number of Hospitals Involved: 4 National Performance: 85.3% Standard: ≥90% 2020 Performance: 83.1% 98.9 89.8 92.3 68.2 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Pahang Sabah Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Paediatric Cardiology Outpatient Clinic, 72.4% 77.3 77.3 99.8 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 HKL Johor P.Pinang Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Paediatric Cardiology Outpatient Clinic, 85.3% 34
KPI CLINICAL SERVICE PAEDIATRIC CARDIOLOGY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. Major Complication Associated With Patent Ductus Arteriosus Occlusion Number of Hospitals Involved: 6 National Performance: 0.7% Standard: ≤2.5% 2020 Performance: 0.0% Number of Hospitals Involved: 7 National Performance: 0.0% Standard: ≤1% 2020 Performance: 0.0% 4. % of Patients With Unplanned Readmission 0.0 0.0 0.0 0.0 3.7 0.0 0.0 1.0 2.0 3.0 4.0 Johor P.Pinang Pahang Sabah Sarawak Selangor Major complication associated with elective Patent Ductus Arteriosus (PDA) occlusion, 0.7% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.4 0.6 0.8 1.0 HKL Johor P.Pinang Pahang Sabah Sarawak Selangor Percentage of paediatric cardiology patients with unplanned readmission to Paediatric Ward within (≤) 48 hours of discharge, 0.0% 36
KPI CLINICAL SERVICE RESPIRATORY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 5 National Performance: 93.3% Standard: ≥80% Number of Hospitals Involved: 16 National Performance: 95.0% Standard: ≥90% 2020 Performance: 96.0% 97.7 84.7 99.1 93.4 92.2 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Kedah N.Sembilan Pahang Sabah Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Pulmonology Outpatient Clinic, 93.3% 91.7 95.7 83.9 97.7 98.7 96.6 95.9 95.7 100 99.9 94.1 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Pulmonology Outpatient Clinic, 95.0% 37
KPI CLINICAL SERVICE RESPIRATORY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Major Complication During Flexible Diagnostic Bronchoscopy Number of Hospitals Involved: 16 National Performance: 0.0% Standard: ≤1% 2020 Performance: 0.3% Number of Hospitals Involved: 18 National Performance: 98.4% Standard: ≥90% 4. % of Complicated TB Cases Seen Within 2 Weeks 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.4 0.0 0.1 0.2 0.3 0.4 0.5 Percentage of major complications during elective flexible diagnostic bronchoscopy, 0.0% 97.3 93.3 100 100 99.7 100 100 100 100 100 100 95.7 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of complicated Tuberculosis (TB) cases seen within (≤) 2 weeks in Pulmonology/ TB clinic, 98.4% 38
KPI CLINICAL SERVICE PSYCHIATRY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 16 National Performance: 87.1% Standard: ≥80% Number of Hospitals Involved: 63 National Performance: 96.5% Standard: ≥90% 2020 Performance: 98.1% 89.2 99.7 86.5 89.8 82.7 98.7 94.5 92.9 84.3 86.5 82.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Psychiatry Outpatient Clinic, 87.1% 97.0 91.7 91.1 100 96.0 99.5 99.3 98.7 99.5 99.9 99.4 96.5 98.4 97.2 86.0 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Psychiatry Outpatient Clinic, 96.5% 39
KPI CLINICAL SERVICE PSYCHIATRY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. Defaulter Rate Among Psychiatric Outpatients Number of Hospitals Involved: 75 National Performance: 6.0% Standard: ≤10% 2020 Performance: 5.8% Number of Hospitals Involved: 72 National Performance: 97.0% Standard: ≥90% 2020 Performance: 97.6% 4. % of New Patients Reviewed By Psychiatrist Within 30 Days 7.5 5.8 4.1 7.4 4.3 5.3 1.1 5.4 6.0 2.8 3.7 4.3 6.2 6.0 9.6 6.0 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Defaulter rate among Psychiatric outpatients, 6.0% 99.9 100 90.4 98.1 91.4 100 98.2 100 99.7 99.7 100 97.6 99.7 99.8 89.8 99.5 84.0 86.0 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of new patients reviewed by psychiatrist within (≤) 30 days at Psychiatry Outpatient Clinic, 97.0% 40
KPI CLINICAL SERVICE PALLIATIVE MEDICINE Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 2 National Performance: 98.6% Standard: ≥80% Number of Hospitals Involved: 9 National Performance: 99.2% Standard: ≥90% 2020 Performance: 98.5% 99.3 94.9 92.0 93.0 94.0 95.0 96.0 97.0 98.0 99.0 100.0 Perak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Palliative Medicine Outpatient Clinic, 98.6% 96.5 99.2 98.0 100 100 100 100 100 100 94.0 95.0 96.0 97.0 98.0 99.0 100.0 101.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Palliative Medicine Outpatient Clinic, 99.2% 41
KPI CLINICAL SERVICE PALLIATIVE MEDICINE Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Inpatients With Severe Cancer Pain Whose Pain Had Been Significantly Reduced Number of Hospitals Involved: 12 National Performance: 98.9% Standard: ≥90% 2020 Performance: 99.5% Number of Hospitals Involved: 10 National Performance: 0.01% Standard: 0% 2020 Performance: 0.02% 4. % of Severe Opioid Toxicity Requiring Reversal With Naloxone 98.6 100 98.8 98.8 100 100 100 100 100 96.6 94.0 96.0 98.0 100.0 102.0 Percentage of inpatients with severe cancer pain on initial encounter whose pain had been significantly reduced within (≤) 24 hours of therapy, 98.9% 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.25 0.00 0.00 0.05 0.10 0.15 0.20 0.25 0.30 Percentage of severe opioid toxicity requiring reversal with naloxone due to inappropriate opioid administration or prescription, 0.01% 42
KPI CLINICAL SERVICE RHEUMATOLOGY Jan – Dec 2022 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 8 National Performance: 81.4% Standard: ≥80% Number of Hospitals Involved: 13 National Performance: 93.5% Standard: ≥90% 2020 Performance: 92.3% 81.5 85.3 92.1 93.4 93.0 73.3 0.0 20.0 40.0 60.0 80.0 100.0 JKWPKL/P N.Sembilan Pahang Sabah Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Rheumatology Outpatient Clinic, 81.4% 87.9 96.3 83.0 100 99.5 93.3 91.2 98.7 92.3 100 99.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Rheumatology Outpatient Clinic, 93.5% 44
KPI CLINICAL SERVICE RHEUMATOLOGY Jan – June 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of SLE Patients Prescribed Hydroxychloroquine Number of Hospitals Involved: 19 National Performance: 99.9% Standard: ≥90% 2020 Performance: 99.7% Number of Hospitals Involved: 19 National Performance: 99.5% Standard: ≥90% 2020 Performance: 99.6% 4. % of Rheumatoid Arthritis Patients Screened For Viral Hepatitis 100 100 100 100 100 100 100 100 100 100 100 100 99.4 100 99 99 99 100 100 100 100 Percentage of newly presented SLE patients prescribed hydroxychloroquine (HCQ) in Rheumatology Outpatient Clinic, 99.9% 100 96.0 98.4 100 100 100 100 100 100 100 100 100 100 100 94 95 96 97 98 99 100 101 Percentage of Rheumatoid Arthritis patients screened for Viral Hepatitis prior to starting methotrexate, 99.5% 45
KPI CLINICAL SERVICE BREAST & ENDOCRINE SURGERY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 6 National Performance: 66.3% Standard: ≥80% Number of Hospitals Involved: 8 National Performance: 93.4% Standard: ≥90% 2020 Performance: 88.2% 55.9 75.6 93.2 100 42.4 82.3 0.0 20.0 40.0 60.0 80.0 100.0 120.0 JKWPKL/P Kelantan N.Sembilan Pahang Selangor Terengganu Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Breast & Endocrine Outpatient Clinic, 66.3% 91.7 92.4 100.0 99.5 99.3 72.7 91.1 95.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 HKL Johor Kelantan Melaka P.Pinang Perak Sabah Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Breast & Endocrine Outpatient Clinic, 93.4% 46
KPI CLINICAL SERVICE BREAST & ENDOCRINE SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Patients With Clear Surgical Margin in Breast Conserving Surgery Number of Hospitals Involved: 13 National Performance: 91.9% Standard: ≥85% 2020 Performance: 95.7% Number of Hospitals Involved: 13 National Performance: 2.2% Standard: ≤3% 2020 Performance: 2.6% 4. % of Recurrent Laryngeal Nerve Injury in Primary Benign Thyroid Operation 88.6 100 96.2 95.7 100 80.0 100 100 100 100 76.8 100 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with clear surgical margins in Breast Conserving Surgery (BCS), 91.9% 0.0 9.8 0.0 0.0 0.0 0.0 0.0 0.0 0.8 16.2 5.5 2.3 0.0 0.0 5.0 10.0 15.0 20.0 Percentage of recurrent laryngeal nerve (RLN) injury in primary benign thyroid operation, 2.2% 49
KPI CLINICAL SERVICE TRAUMA SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Turnaround Time For Crash Laparotomy Within 60 Minutes Number of Hospitals Involved: 2 National Performance: 100% Standard: ≥90% 2020 Performance: 100% 2. Survival Rate of Trauma Patients With ISS Score <16 Number of Hospitals Involved: 2 National Performance: 100% Standard: 100% 2020 Performance: 100% 100 100 0 50 100 150 Johor Selangor Turnaround time from booking OT for crash laparotomy to surgery within (≤) 60 minutes, 100% 100 100 0 20 40 60 80 100 120 Johor Selangor Survival rate of trauma patients with Injury Severity Score (ISS) less than (<) 16, 100% 50
KPI CLINICAL SERVICE TRAUMA SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Trauma Laparotomy Cases Performed Without Complication Number of Hospitals Involved: 2 National Performance: 100% Standard: ≥95% 2020 Performance: 100% 100 100 0 20 40 60 80 100 120 Johor Selangor Percentage of trauma laparotomy cases performed without complication, 100% 51
KPI CLINICAL SERVICE CARDIOTHORACIC SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 1. Elective Isolated CABG Surgery Mortality Rate (High Volume Centre) Number of Hospitals Involved: 2 National Performance: 0.7% Standard: ≤3% 2020 Performance: 1.9% Number of Hospitals Involved: 5 National Performance: 1.7% Standard: ≤7% 2020 Performance: 0.8% 2. Elective Isolated CABG Surgery Mortality Rate (Low Volume Centre) 0.0 1.2 0.0 0.5 1.0 1.5 P.Pinang Selangor Elective isolated Coronary Artery Bypass Grafting (CABG) surgery mortality rate (High volume centres), 0.7% 2.7 0.0 0.0 0.0 1.1 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Johor Kelantan Pahang Sabah Sarawak Elective isolated Coronary Artery Bypass Grafting (CABG) surgery mortality rate (Low volume centres), 1.7% 52
KPI CLINICAL SERVICE CARDIOTHORACIC SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. Incidence Rate of Pneumothorax Number of Hospitals Involved: 7 National Performance: 0.5% Standard: ≤5% 2020 Performance: 0.7% Number of Hospitals Involved: 7 National Performance: 82.6% Standard: ≥90% 2020 Performance: 47.9% 4. % of Patients Underwent CABG Within 9 Months 2.1 0.0 0.0 0.0 0.4 0.4 0.7 0.0 0.5 1.0 1.5 2.0 2.5 Johor Kelantan P.Pinang Pahang Sabah Sarawak Selangor Incidence rate of pneumothorax following removal of chest drains, 0.5% 74.0 100 100 100 100 46.9 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Johor Kelantan P.Pinang Pahang Sabah Sarawak Selangor Percentage of patients who underwent Coronary Artery Bypass Grafting (CABG) surgery within (≤) 9 months from the time decision made, 82.6% 53
KPI CLINICAL SERVICE COLORECTAL SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 16 National Performance: 97.7% Standard: ≥90% 2020 Performance: 97.3% 1. Waiting Time ≤6 Weeks For Colorectal Cancer Surgery 2. % of Patients With Unclear Surgical Margins In Rectal Cancer Surgery Number of Hospitals Involved: 16 National Performance: 1.8% Standard: ≤10% 2020 Performance: 1.0% 92.1 100 100 100 84.8 100 100 100 98.9 100 100 96.5 92.9 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of patients with waiting time of ≤ 6 weeks for Colorectal Cancer surgery, 97.7% 2.0 0.0 0.0 5.9 0.0 0.0 0.0 0.0 2.6 0.0 9.3 5.0 0.0 0.0 2.0 4.0 6.0 8.0 10.0 Percentage of patients with unclear surgical margins in Rectal Cancer surgery, 1.8% 55
KPI CLINICAL SERVICE COLORECTAL SURGERY Jan – June 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 16 National Performance: 0.6% Standard: ≤10% 3. Post Operative Mortality Rate For All Major Elective Colorectal Surgery 2.8 0.0 0.0 0.0 0.0 0.0 0.8 0.0 0.0 0.6 0.7 1.4 1.8 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Post-operative mortality rate for all major elective colorectal surgery, 0.6% 56
KPI CLINICAL SERVICE GENERAL SURGERY Jan – Dec 2022 1. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my Number of Hospitals Involved: 25 National Performance: 74.4% Standard: ≥80% Number of Hospitals Involved: 43 National Performance: 94.6% Standard: ≥90% 92.1 94.1 98.2 99.1 96.7 98.1 96.3 97.7 87.7 90.6 96.1 95.4 93.1 94.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the General Surgery Outpatient Clinic, 94.6% 67.9 99.8 61.5 33.7 79.7 82.0 86.0 85.6 86.2 97.9 73.0 75.7 73.7 82.1 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the General Surgery Outpatient Clinic, 74.4% 57
KPI CLINICAL SERVICE GENERAL SURGERY Jan – Dec 2022 Clinical Performance Surveillance Unit (CPSU) Medical Care Quality Section Medical Development Division Ministry of Health Malaysia Tel: 03-88831190/ 03-88906046 Email: cpsu.medicaldev@moh.gov.my 3. % of Patients With Postponement of Surgery For Urgent Cases Number of Hospitals Involved: 55 National Performance: 12.3% Standard: N/A 2020 Performance: 8.9% Number of Hospitals Involved: 54 National Performance: 96.4% Standard: ≥90% 4. % of POMR Cases Reported Using vPOMR Form 11.5 0.0 24.1 12.6 4.9 7.3 30.2 7.1 2.1 0.8 11.0 0.0 17.5 22.3 14.7 5.3 0.0 5.0 10.0 15.0 20.0 25.0 30.0 35.0 Percentage of patients with postponement of surgery for urgent cases, 12.3% 57.5 100 100 100 100 100 100 87.7 100 100 100 100 100 100 96.1 94.9 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Peri-operative Mortality Review (POMR) cases reported using vPOMR form, 96.4% 60