AEGIS Newsletter, Vol 1, Issue 2, Sep 2021

Aegi Volume 01, Issue 02 | SEPTEMBER 2021

A Newsletter from the collaborative efforts of Quality, Risk, Safety & Clinical Survey
(QRSCS) Officers of KPJ Ampang Puteri Specialist Hospital

Editor & Design: 01 JCI - Where are we now?
Prathaban Sevaraman
02 Departmental Quality Objectives
Contributors:
Prathaban Sevaraman 03 Quality Spotlight
Fatin Najuwa Yusuff
Nor Aisyah Abd Muthalib WalkAbout Review
Nur Amalina Alia Amran
Aida Rahayu Mahmud 04 Happenings!
Faizul Yunos
KPJ Ampang Foodbank@Petron
aegis /ˈiːdʒɪs/ Blood Donation Campaign for Malaysia

.noun. 05 Awareness Corner
the protection,
backing, or support of Occupational Safety & Health
a particular person or
organisation 06 Meet the AEGIS Team

Do You Like Our Newsletter?

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 St. Louis, MO, USA

COUNTDOWN TO JCI 4TH CYCLE 159 DAYS

JCI - Where are we now?

Compiled and prepared by: Prathaban Sevaraman

Disclaimer: The boxes below represent only the measurable elements that require team leaders to prepare written policies Ⓟ or conduct
programs based on Joint Commission International Survey Process Guide book.

01 International Patient Safety Goals (IPSG)

IPSG 1 IPSG 2 IPSG 3 IPSG 4 IPSG 5 IPSG 6 87% 6%

02 Access to Care and Continuity of Care (ACC) 50%
78%
03 Patient-Centred Care (PCC) 78%
73%
04 Assessment of Patients (AOP) 83%
92%
05 Care of Patients (COP) 50%
8%
06 Anesthesia and Surgical Care (ASC) 31%
40%
07 Medication Management and Use (MMU) 77%
83%
08 Quality Improvement and Patient Safety (QPS)
01
09 Prevention and Control of Infections (PCI)

10 Governance, Leadership, and Direction (GLD)

11 Facility Management and Safety (FMS)

12 Staff Qualifications and Education (SQE)

13 Management of Information (MOI)

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021

Departmental Quality Objectives [UPDATED AS AT]

Compiled and prepared by: Quality Services 31 August 2021

Timely submission of monthly QO reports with accurate data [JAN - JULY 2021]

43% DIETARY PENDING PENDING OT 0%
20 QOs 14 QOs CSSS 0%

100% PHARMACY PENDING
14 QOs

100% HIMS LABOUR ROOM 76%

100% DIS/RADIOTHERAPY ICU/CCU 100%

19% FEMS PENDING MATERNITY 86%
17 QOs

79% BEMS SAKURA 100%

N/A PHYSIOTHERAPY SURGICAL 5A N/A

NON-NURSING 100% SQM SURGICAL 5B 96%

14% BUSINESS PENDING PENDING ORCHID 50% NURSING
8 QOs PREMIER
OFFICE 12 QOs

86% IT PENDING LILY 0%
16 QOs

100% TM PAEDIATRIC 100%

100% LABORATORY SPD 100%

100% ADMINISTRATION A&E 86%

100% OUTSOURCE PENDING HAEMO- 43%
24 QOs DIALYSIS

100% LAUNDRY EDUCATION 100%

100% LINEN PENDING PATIENT 32%
19 QOs EDU.

100% HOUSEKEEPING DAY CARE 100%

100% SECURITY MORTUARY 100%

100% PURCHASING WAQAF CLINIC N/A

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 02

WalkAbou Review Quality

Prepared by: Prathaban Sevaraman Spotlight

Quality Services had initiated a new activity called the WalkAbout session
(Frankel, 2004) in July 2021. This activity is closely supported by the Risk,
Safety & Health, and Clinical Survey Officers.

During the WalkAbout session, the team’s primary goals are to conduct a
casual inspection of the services, randomly check on their compliance,
identify any posing risks and hazards, and inspect the safety and health
aspects of the services and personnel.

This initiative allowed the respective services/units to consistently look
after their area and work processes to improve patient and staff safety and
provide quality care.

Since its inception, the WalkAbout and their follow-up sessions were quite
fruitful, with immediate rectifications on the findings as depicted as
follows:

10 services/units/areas covered = 28.6% covered versus scheduled areas

111 40 71

FINDINGS RESOLVED PENDING

(as at 03/08/2021)

Reference: Frankel, A. (2004). Patient safety leadership WalkRoundsTM. Institute for Healthcare Improvement, 1-5.

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 03

Prepared by: HAPPENINGS!
Aida Rahayu Mahmud,
Public Relations In-Charge

KPJ Ampang Foodbank@Petron

The COVID-19 pandemic has taken a toll on "Alone we can do so little; together
Malaysians in unimaginable ways. Most are struggling we can do so much."
financially, and some even have difficulty providing
basic food supplies for their families. As a healthcare – Helen Keller,
provider, we at KPJ Ampang Puteri Specialist Hospital
have reached out to our community to help with what deaf and blind American author and educator
we can. In line with that, our CEO, Mr Muhammad
Badri Hussin and Operations Manager, Mr Omar Zakir
Bawadi launched a foodbank at Petron Ampang where
local communities can get their basic food supplies
from here. We extend a special thank you to the
management of Petron Ampang for giving us the
space and assistance for our initiative.

Blood Donation Campaign for Malaysia

Please fill in the In collaboration with the National Blood Center, KPJ
Blood Donation Ampang Puteri Specialist Hospital will conduct a
Registration Form Blood Donation Campaign for Malaysia. Let's
here: invigorate our patriotism in conjunction with
Independence Day and help Malaysia increase its
Donation Location/Pilihan Lokasi Menderma: blood supply! The details are as follows:

Pusat Darah Negara, Kuala Lumpur Date

Terms, 2nd September 2021 (Thursday)
Conditions and
more info can be
found here:

Time

10:00 am - 4:00 pm

One pint of blood you donate can save up to 3 lives Venue

Level 1 Dewan Anugerah,
EAST WING

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 04

Awareness Corner

OCCUPATIONAL SAFETY & HEALTH

Prepared by: Faizul Yunos

HISTORICAL PERSPECTIVE The role of Occupational
Safety and Health (OSH)
^OSHMP has been in existence for
2020 over 120 years, dating back
to the late 19th century.
OCCUPATIONAL *OSHMP
SAFETY & 15 This department’s history,
HEALTH role, and development can
Development INDUSTRIAL be explained in six (6) eras
SAFETY & outlined in the graph on the
HYGIENE left.

INDUSTRIAL In Malaysia, OSH is
SAFETY governed by the
Department of
MACHINERY Occupational Safety and
SAFETY Health (DOSH/JKKP) under
the purview of the Ministry
STEAM *OSHMP 15 = Occupational Safety and Health Master Plan for Malaysia 2015 of Human Resources.
BOILER ^OSHMP 2020 = Occupational Safety and Health Master Plan for Malaysia 2020
SAFETY

1914 1953 1970 1994 2015 2020

Year

How do we identify whether an incident is a work (occupational) - related or not?
ACCIDENT OR EXPOSURE RESULTING IN INJURY OR POISONING OR DISEASE

On Employer’s Off Employer’s
premise premise

Employee engaged in Employee present Employee in travel Employee engaged in
work-related activity at the location as a status and engaged in activity for own
work or travel function personal use or
condition of enjoyment
employment

Presumed work-related Not work-related

A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 05

Meet the AEGIS Team

QUALITY MANAGER

PRATHABAN SEVARAMAN is the newly appointed Quality Manager of KPJ Ampang. He
graduated from UCSI University with a BPharm (Hons.) - Pharmacy in 2011. SInce then he has
worked as a Registered Pharmacist at Hospital Pakar Sultanah Fatimah, Muar and Hospital
Daerah Kudat, Sabah before joining KPJ Ampang in 2014. Prathaban brings with him more
than 9 years of experience in Hospital Pharmacy practice (including Oncology/ Haematology)
and has recently completed his Master of Business Administration (MBA) in Finance from
Universiti Kebangsaan Malaysia - Graduate School of Business (UKM-GSB). As a Hospital
Quality Manager, he is looking to further improve the clinical and non-clinical work processes
in KPJ Ampang to ensure anyone who visits or working in this hospital is well taken care of
and feel safe at all times.

QUALITY QUALITY QUALITY CLINICAL SURVEY SAFETY & HEALTH RISK
EXECUTIVE ASSISTANT ASSISTANT OFFICER OFFICER OFFICER

FATIN NAJUWA NOR AISYAH ABD NUR AMALINA SANIAH ABU FAIZUL YUNOS MOHD FAKHRI
YUSUFF MUTHALIB ALIA AMRAN obtained her nursing graduated from ROSIDI
graduated from UNIKL Royal College
graduated from joined KPJ Ampang Western Sydney certificate in 1988 of Medicine, Perak is KPJ Ampang’s Risk
Universiti Kuala in March 2017 as its University with a from Universiti with a Diploma in Officer cum Integrity
Lumpur with a Degree in Medical Pharmacy. Being a Ambassador. He is
Quality Assistant. Science (Major in Malaya and joined life-long learner, he
Degree in She graduated with a Anatomy and UMMC as a staff then pursued the predominantly
Environmental Degree in Sc. Biology Physiology). Alia nurse for 7 years. Safety & Health prof- responsible for risk,
Healthcare (Hons.). joined KPJ Ampang She then joined KPJ essional certificate
She joined KPJ (Hons.), minor in in May 2018 and had Ampang on 12th July from NIOSH. One of anti-bribery, and
Management from the opportunity to 1995 as a staff nurse his proudest achieve- business continuity
Ampang in UITM Shah Alam. participate in JCI in the medical ward. ments was when he management in the
September 2014 and With more than 4 (2018) and MSQH led his previous KPJ
has almost 6 years of years of experience She was later hospital in the award hospital. Fakhri
experience in Quality in Quality Service, (2020) transferred to SPD -winning national graduated from
recertification. She where she served for campaign for OSH Universiti Kuala
Service where she Aisyah had wishes to do more 9 years before being Award organised by Lumpur with a
has gone through 2 participated in JCI projects in the future promoted to Unit SOCSO & NIOSH.
(2018) and MSQH Manager of the A&E Faizul believes that Degree in
cycles of JCI, 2 which can instil unit in 2003. In 2011, having a work-life Environmental
cycles of MSQH, and (2020) patient-centred care Saniah was appoint- balance is the key to Healthcare (Hons.)
recertification. She ed as the Clinical be a productive has more than 6
many other wishes to continue in the hospital, Survey Officer. With a worker. He is looking years of experience
quality-related audits contributing toward ensuing in a safe forward to taking up
and activities. With nursing career further responsib- in both the
the hospital’s healthcare spanning over 26 ilities and challenges healthcare and
these experiences, constant quality environment. years, her expertise in the hospital that is manufacturing
she wishes to is invaluable to chart related to quality &
improvement a new course to industries.
establish high-level initiatives upholding further improve safety.
quality care for the patient safety and patient safety and
care in KPJ Ampang.
patients. satisfaction.

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A QRSCS Publication | KPJ Ampang Aegis Newsletter | Vol. 1, Issue 2 | September 2021 06

Quality

means doing it right when
no one is looking.

- Henry Ford -

The AEGIS team would like to call all
KPJ Ampang personnel to write an
article* for our newsletter. The
selected article will be published in
our monthly issue and the author will
be rewarded with KRA points. At the
end of every year, the best article will
win prize money and a certificate of
appreciation from the management.
Kindly submit your article by the 10th

of the following month via email to
[email protected]

*Please reach out to Quality Services for more information.

A QRSCS Publication
KPJ Ampang Aegis Newsletter

Vol. 1, Issue 2
September 2021