PELANCARA PE N LANCARA PE N LANCARAN Hospital Sungai Bakap, Pulau Pinang 24 hingga 29 Julai 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. ClisQi & HPIA adalah antara salah satu 26 aktiviti di Unit Kualiti Hospital Sungai Bakap. Aktiviti audit adalah satu proses verifikasi yang sistematik. Melaksanakan semakan terhadap pencapaian KPI yang dipantau di HSB termasuk pengenalpastian punca data (traceability) yang digunakan. OBJEKTIF Menilai kepatuhan terhadap standard yang telah ditetapkan. Menilai pemahaman auditee mengenai aktiviti pemantauan KPI. Memastikan setiap risiko serta tindakan penambahbaikan diambil oleh masing-masing bagi ketidakcapaian sesuatu indikator. Persediaan audit oleh JKNPP & KKM
Tentatif Pelancaran Audit Dalaman . bacaan doa taklimat audit oleh JT Mardhiatul Rodhiah binti Din ucapan perasmian oleh Dr.Mohamad Nazmi b Mohamad Hussain bacaan doa gimik perasmian sarapan
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 PPP MOHAMMAD ASRI BIN OTHMAN SN MARDHIATUL RODHIAH BINTI DIN *PF KUMUTHNI A/P BALAN
Dr. Zuraini Percentage of Intravenous Tranexamic Acid given in trauma patients with severe haemorrhage within 60 minutes of first medical contact Percentage of inappropriate triaging (UNDERTRIAGING): 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 lndeks Prevalen Jangkitan Aliran Darah berkaitan Penjagaan Kesihatan (bacteraemia) disebabkan oleh Multidrug-resistant organisms (MDROs) tertentu bagi setiap 10,000 kemasukan di hospital KKM. (State Health Director’s KPI 2024) INDIKATOR AUDIT
Dr. Patrick Percentage of bills payment within 14 days Communityacquired pneumonia death rate Hospital with Bed Waiting Time ≤ 240 minutes (4 hours) Percentage of paediatric patients with unplanned readmission to Paediatric Ward within (≤) 48 hours of discharge 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 Rate of Severity of Illness (SOI) 1 Death cases per 1,000 Severity of Illness (SOI) 1 Discharge Home cases. Percentage of chronic haemodialysis patients with delivered KT/V of ≥ 1.2 INDIKATOR AUDIT
PF Joey Percentages of clinical department conducting clinical audit in the hospital/ institution in the corresponding year 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 recommendatio n proposed in Root Cause Analysis (RCA) report of patient safety incident that had been implemented in the corresponding year INDIKATOR AUDIT
Index of unplanned readmission. KJ NOR AZLIZA 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 noncommunicable disease Index of Patient Fall Percentage of new hospital staffs who 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 INDIKATOR AUDIT
Pn.Nadia Fatihah 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 INDIKATOR AUDIT
PPP Mohammad Asri Percentage of patients with waiting time of ≤ 90 minutes at the Specialist Clinic Percentage of rejectretake images. Percentage of patients with waiting time of ≤ 60 minutes for commencement of ultrasound examination. INDIKATOR AUDIT
SN Mardhia WAD 3 Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge WAD 1 Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate COMPILERNon-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 5 Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate WAD 3 Non-ST Elevation Myocardial Infarction (NSTEMI) Case Fatality Rate WAD 5 Percentage of medical patients with unplanned readmission to medical ward within (≤) 48 hours of discharge INDIKATOR AUDIT
22/7/2024 PELANCARAN MINGGU AUDIT DEWAN SAUJANA 9AM-11AM 22 ~ 29/7/2024 PELA A KSANAAN UDIT 30/7/2024 PELAPORAN AUDIT DEWAN SUAJANA 9AM-11AM 31/7/2024 PENUTUPAN AUDIT DEWAN SAUJANA 2.30PM-5PM