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 5. Incidence Rate of Colonic Perforation Following Colonoscopy Number of Hospitals Involved: 53 National Performance: 0.1% Standard: ≤0.5% 2020 Performance: 0.1% 0.2 0.0 0.0 0.1 0.0 0.0 0.0 0.1 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.1 0.1 0.0 0.1 0.1 0.2 0.2 Incidence rate of colonic perforation following colonoscopy, 0.1% 61
KPI CLINICAL SERVICE HEPATOBILIARY 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: 6 National Performance: 94.5% Standard: ≥75% 2020 Performance: 70.1% 1. % of Non-life-threatening Referral That Are Given Appointment Within 1 Month 2. % of New ERCP Case From Index Referral That Are Given Appointment Within 14 Days Number of Hospitals Involved: 6 National Performance: 98.1% Standard: ≥90% 2020 Performance: 89.3% 80.2 99.5 100 98.0 82.6 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Johor Kedah Melaka Sabah Sarawak Selangor Percentage of non-life threatening referral that are given appointment for first consultation within (≤) 1 month, 94.5% 90.6 100 100 95.4 100 100 85.0 90.0 95.0 100.0 105.0 Johor Kedah Melaka Sabah Sarawak Selangor Percentage of new Endoscopic Retrograde Cholangiopancreatography (ERCP) case from index referral that are given appointment within (≤) 14 days, 98.1% 62
KPI CLINICAL SERVICE HEPATOBILIARY 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: 6 National Performance: 2.6% Standard: ≤10% 2020 Performance: 3.9% 3. Post Operative Mortality Rate For All Major Elective Hepatobiliary Surgery 1.8 4.8 5.3 1.5 5.1 0.5 0.0 1.0 2.0 3.0 4.0 5.0 6.0 Johor Kedah Melaka Sabah Sarawak Selangor Post-operative mortality rate for all major elective Hepatobiliary Surgery, 2.6% 63
KPI CLINICAL SERVICE NEUROSURGERY 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: 9 National Performance: 85.9% Standard: ≥80% Number of Hospitals Involved: 7 National Performance: 95.8% Standard: ≥90 % 2020 Performance: 97.6% 66.8 84.9 95.6 88.2 100 84.5 89.0 95.6 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 Neurosurgery Outpatient Clinic, 85.9% 93.1 94.0 100 99.2 100 95.7 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 HKL Johor P.Pinang Perak Sabah Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Neurosurgery Outpatient Clinic, 95.8% 64
KPI CLINICAL SERVICE NEUROSURGERY 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. Mild Traumatic Brain Injury Case Fatality Rate Number of Hospitals Involved: 16 National Performance: 0.03% Standard: ≤2% 2020 Performance: 0.1% Number of Hospitals Involved: 14 National Performance: 0.03% Standard: ≤5 % 2020 Performance: 0.9% 4. % of Patients With Surgical Site Infection 0 0 0.24 0 0 0 0 0 0 0 0 0 0 0.05 0.1 0.15 0.2 0.25 Mild Traumatic Brain Injury (TBI) Case Fatality Rate, 0.03% 1.74 5.30 0.00 0.00 0.65 0.71 0.00 0.76 0.00 0.00 0.00 1.00 2.00 3.00 4.00 5.00 6.00 Percentage of patients with surgical site infection following clean elective neurosurgical surgery, 1.06% 65
KPI CLINICAL SERVICE OBSTETRIC & GYNAECOLOGY 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: 26 National Performance: 89.0% Standard: ≥80% Number of Hospitals Involved: 48 National Performance: 95.4% Standard: ≥90% 2020 Performance: 94.7% 84.0 89.7 81.3 89.4 99.0 95.5 92.6 88.8 88.2 92.2 81.1 91.4 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 Obstetrics and Gynaecology Outpatient Clinic, 89.0% 87.4 95.7 93.7 98.0 95.9 97.4 97.9 93.6 95.7 93.2 95.4 96.8 96.0 93.0 80.0 85.0 90.0 95.0 100.0 Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Obstetrics and Gynaecology Outpatient Clinic, 95.4% 66
KPI CLINICAL SERVICE OBSTETRIC & GYNAECOLOGY 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: 75 National Performance: 0.42% Standard: ≤0.5% 2020 Performance: 0.53% 4. % of Massive Primary Postpartum Haemorrhage Incidence 3. % of Patients With Eclampsia Administered Magnesium Sulphate Number of Hospitals Involved: 52 National Performance: 100% Standard: ≥90% 2020 Performance: 100% 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 100 0 20 40 60 80 100 120 Percentage of patients with Eclampsia administered magnesium sulphate (MgSO4), 100% 0.34 0.07 0.67 0.31 0.28 0.55 0.24 0.28 0.17 0.42 0.46 0.46 0.77 0.28 0.47 0.40 0.00 0.20 0.40 0.60 0.80 1.00 Percentage of massive primary Postpartum Haemorrhage (PPH) incidence in cases delivered in the hospital, 0.42% 67
KPI CLINICAL SERVICE OBSTETRIC & GYNAECOLOGY 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 Unrecognized Intraoperative Ureteric Injury Number of Hospitals Involved: 54 National Performance: 0.16% Standard: ≤1.5% 2020 Performance: 0.2% 0.00 0.00 0.00 0.24 0.00 0.00 0.00 0.00 0.00 0.00 0.00 0.39 0.32 0.25 0.79 0.00 0.10 0.20 0.30 0.40 0.50 0.60 0.70 0.80 0.90 Percentage of patients with unrecognised intraoperative ureteric injury during benign gynaecological surgery, 0.16% 68
KPI CLINICAL SERVICE OPHTHALMOLOGY 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: 20 National Performance: 84.4% Standard: ≥80% Number of Hospitals Involved: 37 5National Performance: 90.7% Standard: ≥90 % 2020 Performance: 95.1% 2. Waiting Time ≤90 Minutes To See Healthcare Worker At Clinic 92.5 92.1 85.4 82.8 94.0 86.9 80.7 86.3 86.1 82.9 81.9 70.0 75.0 80.0 85.0 90.0 95.0 Percentage of patients with waiting time of ≤ 60 minutes to see the healthcare worker at Ophthalmology Outpatient Clinic, 84.4% 90.2 94.0 47.0 96.6 94.2 89.6 89.3 99.8 99.2 95.9 93.0 95.3 99.2 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 healthcare worker at Ophthalmology Outpatient Clinic, 90.7% 69
KPI CLINICAL SERVICE OPHTHALMOLOGY 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 Obtained Visual Acuity of 6/12 or Better Following Cataract Surgery Number of Hospitals Involved: 47 National Performance: 95.9% Standard: ≥90 % 2020 Performance: 94.8% Number of Hospitals Involved: 50 National Performance: 0.04% Standard: ≤0.2 % 2020 Performance: 0.04% 4. % of Patients Developed Infectious Endophthalmitis Following Cataract Surgery 92.9 97.2 95.2 97.4 96.2 94.9 95.6 95.9 97.0 94.6 98.2 94.6 98.7 97.2 94.0 95.5 90.0 92.0 94.0 96.0 98.0 100.0 Percentage of patients without pre-existing ocular co-morbidity obtained visual acuity of 6/12 or better within (≤) 3 months following cataract surgery, 95.9% 0.00 0.00 0.00 0.03 0.00 0.00 0.00 0.05 0.00 0.06 0.04 0.00 0.06 0.02 0.10 0.06 0.00 0.02 0.04 0.06 0.08 0.10 0.12 Percentage of patients developed Infectious Endophthalmitis following cataract surgery, 0.04% 70
KPI CLINICAL SERVICE ORTHOPAEDIC 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 ≤75 Minutes To See Doctor At Clinic Number of Hospitals Involved: 66 National Performance: 91.3% Standard: ≥90% 2020 Performance: 94.9% 2. % of Patients With Surgical Site Infection Following Orthopaedic Surgery Number of Hospitals Involved: 55 National Performance: 0.4% Standard: ≤2% 2020 Performance: 0.5% 91.7 98.9 93.3 86.0 87.2 98.0 100 93.9 96.7 97.4 90.2 86.2 93.7 95.0 83.0 96.2 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of less than (≤) 75 minutes to see doctor in Orthopaedic Outpatient Clinic after completion of preplanned procedure, 91.3% 0.1 0.0 0.7 0.3 0.0 0.6 1.0 0.2 0.1 0.7 0.8 0.0 0.4 0.6 0.2 0.0 0.0 0.2 0.4 0.6 0.8 1.0 1.2 Percentage of patients with surgical site infection following clean elective orthopaedic surgery, 0.4% 71
KPI CLINICAL SERVICE ORTHOPAEDIC 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 Unacceptable Internal Fixation of Fracture Number of Hospitals Involved: 55 National Performance: 0.3% Standard: ≤2% 2020 Performance: 0.2% Number of Hospitals Involved: 46 National Performance: 99.3% Standard: ≥80% 2020 Performance: 99% 4. % of Post Primary Total Knee Replacement With Length of Stay <5 Working Days 0.1 0.0 0.0 0.1 0.3 0.1 0.2 0.0 0.0 0.5 0.1 0.0 0.1 0.9 0.3 0.0 0.0 0.2 0.4 0.6 0.8 1.0 Percentage of unacceptable internal fixations of fracture requiring revision, 0.3% 100 100 99.0 100 100 98.2 99.3 100 100 99.5 93.5 100 100 98.8 100 90 92 94 96 98 100 102 Percentage of post primary total knee replacement patient with length of stay in hospital of ≤ 5 working days, 99.3% 72
KPI CLINICAL SERVICE ORTHOPAEDIC 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. Post-operative Sepsis Rate in Orthopaedic Number of Hospitals Involved: 54 National Performance: 0.1% Standard: ≤3% 0.0 0.0 0.0 0.7 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.1 0.0 0.0 0.1 0.2 0.3 0.4 0.5 0.6 0.7 0.8 Post operative sepsis rate, 0.1% 73
KPI CLINICAL SERVICE OTORHINOLARYNGOLOGY 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 Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 20 National Performance: 86.4% Standard: ≥80% Number of Hospitals Involved: 36 National Performance: 94.7% Standard: ≥90 % 2020 Performance: 94.6% 81.8 97.4 86.0 91.0 89.8 95.6 98.5 81.6 88.3 72.8 94.6 89.1 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 Otorhinolaryngology Outpatient Clinic, 86.4% 84.4 97.3 70.5 97.8 91.4 97.4 100 100 97.8 97.0 95.3 99.0 94.5 99.4 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 Otorhinolaryngology Outpatient Clinic, 94.7% 74
KPI CLINICAL SERVICE OTORHINOLARYNGOLOGY 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 Ears With Hearing Improvement 3 Months Post Myringoplasty Number of Hospitals Involved: 38 National Performance: 93.9% Standard: ≥70 % 2020 Performance: 90.7% Number of Hospitals Involved: 46 National Performance: 0.2% Standard: ≤3 % 2020 Performance: 0.3% 4. Incidence Rate of Primary Post-Tonsillectomy Haemorrhage 85.7 100 80.0 85.7 90.9 80.0 100 100 100 100 100 100 97.3 93.3 100.0 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of ears with hearing improvement 3 months post myringoplasty, 93.9% 0.0 0.0 2.1 0.3 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.6 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 Incidence rate of primary post-tonsillectomy haemorrhage, 0.2% 75
KPI CLINICAL SERVICE PAEDIATRIC 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. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 7 National Performance: 90.1% Standard: ≥80% Number of Hospitals Involved: 10 National Performance: 98.4% Standard: ≥90 % 2020 Performance: 96.1% 84.8 90.8 91.2 96.7 94.0 93.3 98.2 75.0 80.0 85.0 90.0 95.0 100.0 Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Paediatric Surgery Outpatient Clinic, 90.1% 96.6 100 100 99.4 98.9 100 97.1 94.0 95.0 96.0 97.0 98.0 99.0 100.0 101.0 Johor Kelantan Melaka P.Pinang Sabah Sarawak Selangor Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Paediatric Surgery Outpatient Clinic, 98.4% 76
KPI CLINICAL SERVICE PAEDIATRIC 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 Anastomotic Leak Requiring Surgical Intervention Number of Hospitals Involved: 13 National Performance: 2.7% Standard: ≤15% 2020 Performance: 3.6% Number of Hospitals Involved: 13 National Performance: 0.3% Standard: ≤5 % 2020 Performance: 1.2% 4. Incidence Rate of White/ Normal Appendix 3.5 2.5 0.0 0.0 0.0 0.0 0.0 11.1 1.0 6.8 1.2 10.0 4.2 0.0 2.0 4.0 6.0 8.0 10.0 12.0 Incidence rate of anastomotic leak requiring surgical intervention,2.7% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 2.7 0.0 0.0 0.0 0.5 1.0 1.5 2.0 2.5 3.0 Incidence rate of white/ normal appendix during appendicectomy, 0.3% 77
KPI CLINICAL SERVICE PLASTIC & RECONSTRUCTIVE 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. Waiting Time ≤60 Minutes To See Doctor At Clinic 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 7 National Performance: 79.3% Standard: ≥80% Number of Hospitals Involved: 7 National Performance: 98.3% Standard: ≥90% 90.0 61.0 87.9 100 63.8 93.8 0.0 20.0 40.0 60.0 80.0 100.0 120.0 JKWPKL/P Kedah Kelantan Pahang Selangor Terengganu Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Plastic Surgery Outpatient Clinic, 79.3% 97.1 100 97.0 100 100 96.3 100 94.0 95.0 96.0 97.0 98.0 99.0 100.0 101.0 HKL Johor Melaka P.Pinang Perak Sabah Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Plastic Surgery Outpatient Clinic, 98.3% 78
KPI CLINICAL SERVICE PLASTIC & RECONSTRUCTIVE 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 Cleft/Lip Palate Patients That Were Given Appointment Within 6 Weeks Number of Hospitals Involved: 14 National Performance: 100% Standard: ≥90% 2020 Performance: 99.7% Number of Hospitals Involved: 14 National Performance: 99.3% Standard: ≥90% 2020 Performance: 100% 4. % of Full Thickness Skin Graft With ≥80% Graft Take 100 100 100 100 100 100 100 100 100 100 100 100 100 0 20 40 60 80 100 120 Percentage of cleft lip/ palate patients that were given appointment for first consultation within (≤) 6 weeks at Plastic Surgery Outpatient Clinic, 100% 95.0 100 100 100 66.7 100 100 100 100 100 100 100 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Full Thickness Skin Graft (FTSG) with ≥ 80% graft take following elective surgery, 99.3% 80
KPI CLINICAL SERVICE PLASTIC & RECONSTRUCTIVE 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 5. % of Post-palatoplasty Haemorrhage Patients Reintubated / Returned to OT Number of Hospitals Involved: 14 National Performance: 0.3% Standard: ≤5% 2020 Performance: 0.4% 2.1 0 0 0 0 0 0 0 0 0 0 0 0 0.0 0.5 1.0 1.5 2.0 2.5 Percentage of post-palatoplasty haemorrhage patients reintubated and/ or returned to operating theatre within (≤) 24 hours of primary palate repair, 0.3% 81
KPI CLINICAL SERVICE UPPER GI 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. % of Patients With Clear Surgical Margin Post Resection of Gastric Tumour Number of Hospitals Involved: 5 National Performance: 95.3% Standard: ≥90% 2020 Performance: 96.6% Number of Hospitals Involved: 5 5National Performance: 1.8% Standard: ≤10 % 2020 Performance: 25.7% 2. Incidence Rate of Oesophageal Anastomotic Leak 100 72.2 100 100 96.4 0 20 40 60 80 100 120 IKN Johor P.Pinang Sabah Sarawak Percentage of patients with clear surgical margin post resection of Gastric Tumour performed with curative intent, 95.3% 1.8 0.0 0.0 4.8 0.0 0.0 1.0 2.0 3.0 4.0 5.0 IKN Johor P.Pinang Sabah Sarawak Incidence rate of oesophageal anastomotic leak requiring surgical intervention, 1.8% 82
KPI CLINICAL SERVICE UPPER GI 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 Gastric Adenocarcinoma Underwent Curative Surgical Resection Number of Hospitals Involved: 5 National Performance: 100% Standard: ≥90% 2020 Performance: 96.2% Number of Hospitals Involved: 5 National Performance: 98.0% Standard: ≥80 % 4. % of Patients With Oesophageal/ Gastric Tumour Operated Within 2 Weeks 100 100 100 100 100 0 20 40 60 80 100 120 IKN Johor P.Pinang Sabah Sarawak Percentage of patients with Gastric Adenocarcinoma who underwent curative surgical resection (RO) where ≥ 15 lymph nodes are resected, 100% 93.7 100 100 100 100 90.0 92.0 94.0 96.0 98.0 100.0 102.0 IKN Johor P.Pinang Sabah Sarawak Percentage of patients with Oesophageal or Gastric Tumour operated within (≤) 2 weeks after achieving pre-operative optimization, 98.0% 83
KPI CLINICAL SERVICE UROLOGY 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 Doctor At Clinic Number of Hospitals Involved: 5 National Performance: 62.2% Standard: ≥80% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 8 National Performance: 90.7% Standard: ≥90% 2020 Performance: 82.9% 65.6 86.8 90.6 48.8 0.0 20.0 40.0 60.0 80.0 100.0 Kedah Kelantan Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Urology Outpatient Clinic, 62.2% 83.1 92.6 100 96.7 98.2 56.9 89.8 97.3 0.0 20.0 40.0 60.0 80.0 100.0 120.0 HKL Johor Kelantan P.Pinang Pahang Perak Sabah Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Urology Outpatient Clinic, 90.7% 84
KPI CLINICAL SERVICE UROLOGY 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: 11 National Performance: 99.0% Standard: ≥90% 2020 Performance: 98.1% 3. % of Safe Transurethral Resection of the Prostate 4. % of Safe Percutaneous Nephrolithotripsy Number of Hospitals Involved: 11 National Performance: 94.6% Standard: ≥80% 2020 Performance: 99.6% 100 100 100 98.5 100 100 100 100 96.0 94 95 96 97 98 99 100 101 Percentage of safe transurethral resection of the prostate (TURP), 99.0% 92.4 100 100 85.1 100 100 100 100 88.1 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of safe percutaneous nephrolithotripsy (PCNL), 94.6% 86
KPI CLINICAL SERVICE UROLOGY 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 Ureters That Were Stone Free Following URS Lithotripsy Number of Hospitals Involved: 11 National Performance: 98.0% Standard: : ≥90% 2020 Performance: 98.0% 94.3 100 96.8 92.9 100 98.6 100 97.9 96.8 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of ureters that were stone free following ureterorenoscopy (URS) lithotripsy, 98.0% 87
KPI CLINICAL SERVICE VASCULAR 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. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 2 National Performance: 88.4% Standard: ≥80% Number of Hospitals Involved: 2 National Performance: 95.1% Standard: ≥90% 2020 Performance: 95.2% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic 80.5 90.7 74.0 76.0 78.0 80.0 82.0 84.0 86.0 88.0 90.0 92.0 Kelantan Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Vascular Surgery Outpatient Clinic, 88.4% 91.3 99.2 86.0 88.0 90.0 92.0 94.0 96.0 98.0 100.0 HKL Sabah Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Vascular Surgery Outpatient Clinic, 95.1% 88
KPI CLINICAL SERVICE VASCULAR 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. Post-Operative Mortality Rate for Elective Open Repair of AAA Number of Hospitals Involved: 5 National Performance: 0% Standard: ≤5% 2020 Performance: 3.0% Number of Hospitals Involved: 5 National Performance: 0.2% Standard: ≤0.5% 2020 Performance: 0.1% 4. % of Dialysis-Access Induced Limb Ischaemia Following Native AVF Creation 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.4 0.6 0.8 1.0 HKL Kelantan Sabah Sarawak Selangor Post-operative mortality rate for open repair of Abdominal Aortic Aneurysm (AAA), 0.0% 0.0 0.0 0.9 0.0 0.0 0.0 0.0 0.2 0.4 0.6 0.8 1.0 HKL Kelantan Melaka Sabah Sarawak Selangor Percentage of dialysis-access induced limb ischemia following native Arterio-Venous Fistula (AVF) creation, 0.2% 89
KPI CLINICAL SERVICE ANAESTHESIOLOGY 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: 61 National Performance: 97.7% Standard: ≥85% 2020 Performance: 94.6% 1. % of Patients on APS With Pain Score of ≤4 Within 24H After Surgery 2. Ventilator Care Bundle Compliance Rate Number of Hospitals Involved: 63 National Performance: 99.95% Standard: ≥95 % 2020 Performance: 99.7% 99.4 93.8 100 94.1 94.9 97.5 99.2 95.6 97.9 96.5 98.3 98.9 99.6 98.6 98.6 98.2 99.3 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Percentage of patients on Acute Pain Service (APS) with pain score of (≤) 4 at rest within (≤) the first 24 hours after surgery, 97.7% 99.9 100 100 100 99.9 100 99.9 100 100 100 100 99.8 100 100 100 99.9 100 99.8 99.8 99.9 99.9 100.0 100.0 100.1 Ventlator care bundle (VCB) compliance rate, 99.95%
KPI CLINICAL SERVICE ANAESTHESIOLOGY 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: 62 National Performance: 0.5% Standard: ≤5% 2020 Performance: 0.6% 3. % of Elective Surgical Cancellation After Pre-op Assessment 0.7 0.6 0.0 0.3 0.4 0.3 0.9 0.2 0.3 0.7 0.5 0.6 0.9 0.1 0.2 0.6 0.7 0.0 0.2 0.4 0.6 0.8 1.0 Percentage of elective surgical cancellations after pre-operative assessment in the Anaesthetic Clinic, 0.5%
KPI CLINICAL SERVICE CARDIOTHORACIC ANAESTHESIOLOGY 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: 7 National Performance: 97.4% Standard: ≥90% 2020 Performance: 97.5% 1. % of Post Elective CABG Patients With Blood Glucose ≤11mmol/L 2. % of Accidental Carotid Arterial Puncture Number of Hospitals Involved: 7 National Performance: 0.6% Standard: ≤5% 2020 Performance: 0.6% 98.3 100 100 100 100 100 95.2 92.0 94.0 96.0 98.0 100.0 102.0 Johor Kelantan P.Pinang Pahang Sabah Sarawak Selangor Percentage of post-elective cardiopulmonary bypass adult patients with blood glucose level ≤ 11 mmol/L on arrival to CICU, 97.4% 1.1 0.0 0.2 0.0 0.0 1.7 0.5 0.0 0.5 1.0 1.5 2.0 Johor Kelantan P.Pinang Pahang Sabah Sarawak Selangor Percentage of accidental carotid arterial puncture during central venous cannulation, 0.6%
KPI CLINICAL SERVICE CARDIOTHORACIC ANAESTHESIOLOGY 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: 7 National Performance: 94.8% Standard: ≥75% 2020 Performance: 93.4% 3. % of Thoracic Surgical Patients Received APS 100 100 87.7 100 100 99.2 96.4 80 85 90 95 100 105 Johor Kelantan P.Pinang Pahang Sabah Sarawak Selangor Percentage of thoracic surgical patients received Acute Pain Service (APS), 94.8%
KPI CLINICAL SERVICE GENETIC 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: 2 National Performance: 99.0% Standard: ≥90% 2020 Performance: 99.2% 1. Waiting Time ≤90 Minutes To See Doctor At Clinic 2. % of Patients With Marfan, Tuberous Sclerosis and Prader Willi Syndrome Compliant To The Care Pathway Number of Hospitals Involved: 2 National Performance: 100% Standard: ≥90% • Only 2 hospitals had this service: Hospital Kuala Lumpur & Hospital Pulau Pinang NOTES: 98.3 100 97.0 98.0 99.0 100.0 101.0 HKL P.Pinang Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Clinical Genetic Clinic, 99.0% 100 100 0 50 100 150 HKL P.Pinang Percentage of patients with Marfan Syndrome, Tuberous Sclerosis and Prader Willi Syndrome who are compliant to the Care Pathway, 100%
KPI CLINICAL SERVICE GENETIC 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 intoxication type IEM with > 3 admissions in a year for metabolic decompensation Number of Hospitals Involved: 2 National Performance: 0% (0/125) Standard: ≤5% • Only 2 hospitals had this service: Hospital Kuala Lumpur & Hospital Pulau Pinang NOTES: 0 0 0 0.2 0.4 0.6 0.8 1 HKL P.Pinang Percentage of patients with intoxication type IEM with > 3 admissions in a year for metabolic decompensation, 0%
KPI CLINICAL SERVICE EMERGENCY 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 Number of Hospitals Involved: 74 National Performance: 0.42% Standard: ≤5% 2020 Performance: 0.20% 1. Complication Rate of Procedural Sedation & Analgesia 2. % of Acute Coronary Syndrome Patients Administered Oral Aspirin by PHCAS Responder Number of Hospitals Involved: 62 National Performance: 88.8% Standard: ≥75% 2020 Performance: 88.8% 0.00 0.00 0.79 0.95 3.82 0.00 0.00 0.05 0.86 0.00 0.33 0.58 0.17 0.12 0.07 0.25 0.00 1.00 2.00 3.00 4.00 5.00 Complication rate of procedural sedation and analgesia (PSA), 0.42% 90.6 88.9 85.9 96.0 81.6 85.7 87.7 100 93.9 100 69.1 100 100 97.2 86.2 93.6 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of suspected Acute Coronary Syndrome (ACS) patients administered oral aspirin by PHCAS responder, 88.8%
KPI CLINICAL SERVICE EMERGENCY 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 Number of Hospitals Involved: 72 National Performance: 87.5% Standard: ≥70% 3. % of Tranexamic Acid Given in Trauma Patients With Severe Haemorrhage Within 60 Minutes 88.9 100 89.6 90.0 89.0 97.7 96.3 92.4 93.8 86.1 80.7 94.3 96.5 85.8 88.7 65.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of Intravenous Tranexamic Acid given in trauma patients with severe haemorrhage within 60minutes of first medical contact, 87.5%
KPI CLINICAL SERVICE FORENSIC 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 Number of Hospitals Involved: 50 National Performance: 94.2% Standard: ≥80% 2020 Performance: 93.8% 1. Turnaround Time of ≤3H For Releasing Bodies To The Appropriate Claimant 2. Turnaround Time ≤12 Weeks For Preparing Forensic Autopsy Reports of Police Cases Number of Hospitals Involved: 37 National Performance: 96% Standard: ≥80% 2020 Performance: 91.9% 80.2 75.1 97.3 97.2 98.1 99.0 100 91.0 97.6 98.0 92.3 92.6 100 81.3 100 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Turnaround time of ≤ 3 hours for releasing bodies to the appropriate claimant after body registration by the Forensic Medicine Department,94.2% 96.2 100 95.0 100 99.1 100 99.3 99.2 96.5 100 93.8 100 85.0 100 75.0 80.0 85.0 90.0 95.0 100.0 105.0 Turnaround time of ≤ 12 weeks for preparing forensic autopsy reports of police cases from the autopsy performed by the Forensic Medicine Department, 96%
KPI CLINICAL SERVICE FORENSIC 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 Number of Hospitals Involved: 49 National Performance: 100% Standard: 100% 2020 Performance: 100% 3. % of Bodies Released To The Right Claimant 100 100 100 100 100 100 100 100 100 100 100 99.98 100 100 100 99.97 99.98 99.98 99.99 99.99 100.00 100.00 100.01 Percentage of bodies released to the right claimant by the Forensic Medicine Department/ Forensic Unit, 100%
KPI CLINICAL SERVICE NUCLEAR 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 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 2 National Performance: 98.1% Standard: ≥80% Number of Hospitals Involved: 4 National Performance: 97.4% Standard: : ≥90 % 2020 Performance: 98.2% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic 92.3 99.3 98.9 98.5 88.0 90.0 92.0 94.0 96.0 98.0 100.0 HKL Johor P.Pinang Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Nuclear Medicine Outpatient Clinic, 97.4% 95.1 99.8 92.0 94.0 96.0 98.0 100.0 102.0 IKN Sabah Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Nuclear Medicine Outpatient Clinic, 98.1%
KPI CLINICAL SERVICE NUCLEAR 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 Repeat Studies in Diagnostic Nuclear Medicine Number of Hospitals Involved: 6 National Performance: 0.3% Standard: ≤1% 2020 Performance: 0.2% Number of Hospitals Involved: 6 National Performance: 100% Standard: ≥90 % 2020 Performance: 100% 4. % of Urgent Diagnostic Nuclear Medicine Studies Reports Available Within 2 Working Days 0.7 0.1 0.1 0.1 0.0 0.3 0.0 0.2 0.4 0.6 0.8 HKL IKN Johor P.Pinang Sabah Sarawak Percentage of repeat studies in Diagnostic Nuclear Medicine, 0.3% 100 100 100 100 100 100 0 50 100 150 HKL IKN Johor P.Pinang Sabah Sarawak Percentage of urgent Diagnostic Nuclear Medicine studies reports available within (≤) 2 working days, 100%
KPI CLINICAL SERVICE PATHOLOGY 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. % of Urgent FBC With Laboratory Turnaround Time Within 45 Minutes Number of Hospitals Involved: 76 National Performance: 93.1% Standard: ≥90% 2020 Performance: 95.5% Number of Hospitals Involved: 68 National Performance: 98.7% Standard: : ≥95 % 2020 Performance: 98.9% 2. % of Neonatal Total Bilirubin >300μmol/L Notified Within 30 Minutes 88.3 99.2 98.6 96.1 97.3 93.4 92.9 98.4 93.9 96.5 97.0 87.0 94.7 96.5 96.8 94.0 95.3 80.0 85.0 90.0 95.0 100.0 105.0 Percentage of urgent Full Blood Count (FBC) with laboratory turnaround time (LTAT) within (≤) 45 minutes, 93.1% 98.2 100 98.8 99.5 98.7 97.3 100 99.4 100 98.4 100 100 99.3 99.5 97.4 97.4 96.0 97.0 98.0 99.0 100.0 101.0 Percentage of neonatal total bilirubin results > 300 µmol/L notified within (≤) 30 minutes after result verification, 98.7%
KPI CLINICAL SERVICE PATHOLOGY 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. Accuracy of Assessment for Anatomic Pathology by the EQA Programme Number of Hospitals Involved:24 National Performance: 95.7% Standard: ≥90% 2020 Performance: 95.9% Number of Hospitals Involved: 65 National Performance: 99.5% Standard: ≥95 % 2020 Performance: 99.4% 4. Accuracy of Assessment for Blood Parasites (Malaria) by the EQA Programme 97.3 90.0 96.7 94.9 98.0 96.7 96.5 92.5 92.2 93.3 95.0 95.0 95.0 93.0 90.0 85.0 90.0 95.0 100.0 Accuracy of the External Quality Assurance (EQA) programme report for Anatomic Pathology (General Module),95.7% 100 100 100 100 100 99.8 100 99.9 99.8 100 99.1 100 98.8 99.7 99.2 100 98 99 99 100 100 101 Accuracy of the External Quality Assurance (EQA) programme report for blood parasites (Malaria), 99.5%
KPI CLINICAL SERVICE RADIOLOGY 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: 63 National Performance: 92.1% Standard: ≥90% 2020 Performance: 94.8% 1. % of Patients With Waiting Time ≤60 Minutes For Commencement of Ultrasound Examination 2. % of Reject-Retake Images Number of Hospitals Involved: 78 National Performance: 2.3% Standard: ≤5% 2020 Performance: 1.2% 96.7 99.9 99.9 90.7 93.7 90.3 97.6 97.3 98.1 94.7 96.5 93.0 89.6 82.6 94.6 92.4 91.7 0.0 20.0 40.0 60.0 80.0 100.0 120.0 Percentage of patients with waiting time of ≤ 60 minutes for commencement of ultrasound examination,92.1% 1.4 2.8 0.7 3.5 2.6 4.4 1.6 3.1 2.2 1.7 0.7 1.8 2.0 1.8 1.9 2.4 3.1 0.0 1.0 2.0 3.0 4.0 5.0 Percentage of reject-retake images,2.3%
KPI CLINICAL SERVICE RADIOLOGY 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: 57 National Performance: 0.11% Standard: ≤0.5% 2020 Performance: 0.08% 3. % of Patients Developed Significant Contrast Media Extravasation 0.04 0.02 0.11 0.09 0.17 0.02 0.05 0.00 0.05 0.01 0.08 0.09 0.00 0.12 0.29 0.14 0.19 0.00 0.05 0.10 0.15 0.20 0.25 0.30 Percentage of patients developed significant contrast media extravasation following CT examination with intravenous (IV) contrast media,0.11%
KPI CLINICAL SERVICE RADIOTHERAPY & ONCOLOGY 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 Doctor At Clinic Number of Hospitals Involved: 2 National Performance: 60.2% Standard: ≥80% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic Number of Hospitals Involved: 4 National Performance: 81.2% Standard: ≥90% 2020 Performance: 75.0% 50.5 88.9 0.0 20.0 40.0 60.0 80.0 100.0 IKN Johor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Radiotherapy and Oncology Outpatient Clinic, 60.2% 80.8 92.4 86.6 66.7 0.0 20.0 40.0 60.0 80.0 100.0 HKL P.Pinang Sabah Sarawak Percentage of patients with waiting time of ≤ 90 minutes to see the doctor at the Radiotherapy and Oncology Outpatient Clinic, 81.2%
KPI CLINICAL SERVICE RADIOTHERAPY & ONCOLOGY 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 NPC Patients Started on Radical Radiotherapy Within 4 Weeks Number of Hospitals Involved: 6 National Performance: 70.5% Standard: ≥70% 2020 Performance: 61.9% Number of Hospitals Involved: 6 National Performance: 0.0% Standard: ≤0.5% 2020 Performance: 0.0% 4. Chemotherapy Extravasation Rate 89.2 76.7 57.1 93.0 40.0 66.4 0.0 20.0 40.0 60.0 80.0 100.0 HKL IKN Johor P.Pinang Sabah Sarawak Percentage of Nasopharyngeal Cancer (NPC) patients who were started on radical radiotherapy within (≤) 4 weeks, 70.5% 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 IKN Johor P.Pinang Sabah Sarawak Chemotherapy Extravasation Rate, 0.0%
KPI CLINICAL SERVICE RADIOTHERAPY & ONCOLOGY 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 Patients Started On Chemotherapy Within 2 Weeks Number of Hospitals Involved: 6 National Performance: 88.1% Standard: : ≥70% 2020 Performance: 92.1% 77.3 95.5 94.1 76.8 87.7 96.2 0.0 20.0 40.0 60.0 80.0 100.0 120.0 HKL IKN Johor P.Pinang Sabah Sarawak Percentage of patients who were started on chemotherapy within (≤) 2 weeks from the date of decision for chemotherapy, 88.1%
KPI CLINICAL SERVICE REHABILITATION 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 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 6 National Performance: 96.5% Standard: ≥80% Number of Hospitals Involved: 20 National Performance: 98.3% Standard: : ≥90 % 2020 Performance: 98.2% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic 96.8 99.1 92.9 96.2 100 97.2 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 JKWPKL Johor N.Sembilan Sabah Sarawak Selangor Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Rehabilitation Medicine Outpatient Clinic, 96.5% 93.9 99.2 92.8 97.7 99.1 95.4 99.5 99.1 95.2 100 99.7 98.1 98.9 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 Rehabilitation Medicine Outpatient Clinic, 98.3%
KPI CLINICAL SERVICE REHABILITATION 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 Patients With Established Interdisciplinary Rehabilitation Plan Number of Hospitals Involved: 25 National Performance: 99.8% Standard: ≥95% 2020 Performance: 99.8% Number of Hospitals Involved: 26 National Performance: 0.01% Standard: ≤2% 2020 Performance: 0.03% 4. % of Falls and Near-Falls in Rehabilitation Medicine Clinic 100 100 100 100 100 100 99.4 100 100 98.8 100 99.6 99.2 100 98 99 99 100 100 101 Percentage of patients with established interdisciplinary rehabilitation plan within (≤) 5 working days of admission, 99.8% 0.04 0.00 0.00 0.02 0.00 0.00 0.00 0.00 0.09 0.00 0.00 0.00 0.01 0.03 0.00 0.02 0.04 0.06 0.08 0.10 Percentage of falls and near-falls in Rehabilitation Medicine Outpatient Clinic, 0.0%
KPI CLINICAL SERVICE SPORT 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 1. Waiting Time ≤60 Minutes To See Doctor At Clinic Number of Hospitals Involved: 8 National Performance: 93.6% Standard: ≥80% Number of Hospitals Involved: 13 National Performance: 96.7% Standard: : ≥90 % 2020 Performance: 93.1% 2. Waiting Time ≤90 Minutes To See Doctor At Clinic 92.3 96.8 95.8 100 95.5 92.8 88.0 90.0 92.0 94.0 96.0 98.0 100.0 102.0 Johor Kedah Pahang Sarawak Selangor Terengganu Percentage of patients with waiting time of ≤ 60 minutes to see the doctor at the Sports Medicine Outpatient Clinic, 93.6% 91.2 94.7 91.0 101.9 95.8 98.7 100 100 100 96.1 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 Sports Medicine Outpatient Clinic, 96.7%
KPI CLINICAL SERVICE SPORT 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 Post-Operative Patients Seen Within 3 Days For Initiation of Rehabilitation Number of Hospitals Involved: 18 National Performance: 99.2% Standard: ≥85% 2020 Performance: 99.8% Number of Hospitals Involved: 18 National Performance: 0.0% Standard: ≤1% 2020 Performance: 0.0% 4. Incidence Rate of Septic Arthritis Within 2 Weeks of Intra/Peri-Articular Injection 100 92.1 100 100 100 98.2 100 100 100 100 99.6 100 88 90 92 94 96 98 100 102 Percentage of post-operative sports surgery patients seen within (≤) 3 days for initiation of rehabilitation, 99.2% 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.0 0.2 0.4 0.6 0.8 1.0 Incidence rate of Septic Arthritis within (≤) 2 weeks of intra- or peri-articular injection, 0.0%