PELANCARA PE N LANCARAN MMiinngggguu PPeellaakkssaannaaaann AAkkttiivviittii SSuurrvveellaann PPeennccaappaaiiaann PPrrooggrraamm PPeerruubbaattaann ((CClliissQQii && HHPPIIAA)) PPeerriinnggkkaatt HHoossppiittaall SSuunnggaaii BBaakkaapp TTaahhuunn 22002244 22.7.2024 hingga 29.7.2024 Anjuran: Unit Kualiti Hospital Sungai Bakap
PENGENALAN Pelaksanaan KPI di KKM adalah bagi memastikan kualiti penyampaian perkhidmatan kesihatan pada tahap yang baik dan menetapi piawaian yang ditetapkan. Ianya diwujudkan oleh Unit Survelan Pencapaian Klinikal atau lebih dikenali sebagai Clinical Performance Surveillance Unit (CPSU) bagi menguruskan pemantauan prestasi teknikal melalui Petunjuk Prestasi Utama (KPI) di Kementerian Kesihatan Malaysia. Hospital Sungai Bakap memantau prestasi teknikal mengikut technical specification yang dikeluarkan oleh KKM. Melaksanakan semakan terhadap pencapaian KPI yang dipantau di HSB termasuk pengenalpastian punca data (traceability) yang digunakan. OBJEKTIF SURVELAN Menilai kepatuhan terhadap standard yang telah ditetapkan. Menilai pemahaman auditee mengenai aktiviti pemantauan KPI. Memastikan setiap risiko serta tindakan penambahbaikan diambil oleh masingmasing bagi ketidakcapaian sesuatu indikator. Sebagai persediaan awal bagi audit luaran dari JKNPP & KKM. HPIA: 15 INDIKATOR KPI: 19 + 6 INDIKATOR PEMANTAUAN KPI DI HSB 2024
TENTATIF bacaan doa gimik perasmian sarapan taklimat audit oleh JT Mardhiatul Rodhiah binti Din Penyelaras ClisQi & HPIA ucapan perasmian oleh Dr.Mohamad Nazmi bin Mohamad Hussain Pengarah Hospital Sungai Bakap Pasukan Juruaudit DR.ZURAINI BINTI ABDULLAH DR.PATRICK NG BOON SIEW PF JO-EY TOH KAR YIEN KJ NOR AZLIZA BINTI ISHAK PN NADIA FATIHAH BINTI AB HAMID PF KUMUTHNI A/P BALAN PPP MOHAMMAD ASRI BIN OTHMAN SN MARDHIATUL RODHIAH BINTI DIN
AUDITOR: DR.ZURAINI BINTI ABDULLAH INDIKATOR DIAUDIT Percentage of Intravenous Tranexamic Acid given in trauma patients with severe haemorrhage within 60 minutes of first medical contact Percentage of inappropriate triaging (UNDER-TRIAGING): Category Green patients who should have been triaged as Category Red Turnaround time of ≤ 3 hours for releasing bodies (non-police cases) to the appropriate claimant after body registration by the Forensic Medicine Department/ Forensic Unit Turnaround time of ≤ 12 weeks for preparing forensic autopsy reports of police cases from the autopsy performed by the Forensic Medicine Department Percentage of fire drill that has been carried out by the hospital in the corresponding year Percentage of Safety Audit findings identified whereby control measures had been taken in the corresponding year Percentage of Safety Audit findings identified whereby control measures had been taken in the corresponding year
AUDITOR: DR.PATRICK NG BOON SIEW INDIKATOR DIAUDIT Community-acquired pneumonia death rate Percentage of bills payment within 14 days Percentage of paediatric patients with unplanned readmission to Paediatric Ward within (≤) 48 hours of discharge Percentage of chronic haemodialysis patients with delivered KT/V of ≥ 1.2 Rate of Severity of Illness (SOI) 1 Death cases per 1,000 Severity of Illness (SOI) 1 Discharge Home cases. Index of paramedics who have a CURRENT trained status in Basic Life Support (BLS) in the corresponding year A: acute care area B: non acute area Hospital with Bed Waiting Time ≤ 240 minutes (4 hours)
AUDITOR: PF JO-EY TOH KAR YIEN INDIKATOR DIAUDIT Percentage of patients with Eclampsia administered magnesium sulphate (MgSO4) Percentage of massive primary Postpartum Haemorrhage (PPH) incidence in cases delivered in the hospital Timeliness of performing emergency cross-match within 30 minutes. Red Cell Expiry Rate Percentage of recommendation proposed in Root Cause Analysis (RCA) report of patient safety incident that had been implemented in the corresponding year Percentages of clinical department conducting clinical audit in the hospital/institution in the corresponding year
AUDITOR: KJ NOR AZLIZA BINTI ISHAK INDIKATOR DIAUDIT Complication rate of procedural sedation and analgesia (PSA) Percentage of suspected Acute Coronary Syndrome (ACS) patients administered oral aspirin by Prehospital Care and Ambulance Services (PHCAS) responder Percentage of hospital or medical institutional staff undergo health screening for risk of non-communicable disease Index of Patient Fall Percentage of new hospital staffswho attended the Orientation Programme within 3 months of their placement at the Unit or Department in the hospital (COMPILER) Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge Index of unplanned readmission.
AUDITOR: PN NADIA FATIHAH BINTI AB HAMID INDIKATOR DIAUDIT Percentage of assets in the hospital that were registered within 14 days Percentage of Laboratory Turnaround Time (LTAT) for AFB Smears Examination reported within 24 hours of sample receipt. Prothrombin Time (PT) and Activated Partial Prothrombin Time (APTT) External Quality Assurance (EQA) Performances
AUDITOR: PPP MOHAMMAD ASRI BIN OTHMAN INDIKATOR DIAUDIT Percentage of patients with waiting time of ≤ 90 minutes at the Specialist Clinic Percentage of reject-retake images. Percentage of patients with waiting time of ≤ 60 minutes for commencement of ultrasound examination.
AUDITOR: JT MARDHIATUL RODHIAH BINTI DIN INDIKATOR DIAUDIT (WAD 1) Non -ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate (WAD 3) Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate (WAD 5) Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate (WAD 1 ) Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge (WAD 3) Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge (WAD 5) Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge COMPILER- Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate
22/7/2024 PELANCARAN MINGGU AUDIT DEWAN SAUJANA 9AM-11AM 22 SE ~ SI 2 A 9 U /7/2024 UN DIT 8AM IT - MASING2 5PM 31 P / E 7/2024 NUTUPAN AUDIT DEWAN SAUJANA 2.30PM-5PM 30/7/2024 PELAPORAN AUDIT DEWAN SUAJANA 8AM-10AM