QA Workbook

QA Workbook – The Problem Solving Approach – 2nd Edition section 2
Appendix 3: Master Sheet

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section 2 QA Workbook – The Problem Solving Approach – 2nd Edition

APPENDIX 3: EXAMPLE OF A QA ABSTRACT

Reducing Wound Infection Rate for Diagnostic Skin Biopsy in Dermatology Clinic

Tang J.J., Kong S.H., Khairul Nizam
Tuanku Bainun Hospital, Ipoh

SELECTION OF OPPORTUNITIES FOR IMPROVEMENT
Diagnostic skin biopsy is commonly done to assist dermatology diagnosis. It can be complicated by wound infection
and delayed the healing process. Multiple risk factors can increase the risk of wound infection.
KEY MEASURES FOR IMPROVEMENT
Our monthly census in 2008 showed post-biopsy wound infection rate was around 10%. This study aimed at
reducing the rate to the national indicator standard of less than 2%.
PROCESS OF GATHERING INFORMATION
A cross sectional study was conducted from October to November 2008 to assess the wound infection rate and to
identify the contributing factors. A data collection form was used to collect demographic profile and skin biopsy
process. A post-biopsy photo was taken to determine the technique. Wound outcome was assessed during suture
removal to determine the infection rate. Implementations of remedial measures were carried out from December to
February 2009. Infection rate was reassessed from March to April 2009.
ANALYSIS AND INTERPRETATION
Pre-remedial infection rate was 20%. Important risk factors identified include choice of post operative topical
dressing, poor wound closure technique, site of biopsy below waist, lack of wound care counseling, bigger punch
size used and improper procedure room. The ABNA was 18%.
STRATEGY FOR CHANGE
A seminar on proper skin biopsy technique was conducted and a protocol was formulated. Immediate postoperative
dressing was standardized. Skin biopsy above the waist and use of smaller punch size were recommended. Wound
care counseling and pamphlet on wound dressing were given to all patients. Changes to procedure room were
made.
EFFECTS OF CHANGE
Wound infection rate was reduced from 20% to 6.7% following remedial actions.
THE NEXT STEP
Our skin biopsy wound infection rate has dropped to 0% in May 2009 There is a need for continuous monitoring
of wwound infection rate and to sustain the remedial measures.

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APPENDIX 4: EXAMPLE OF A QA WRITE-UP

Reducing wound infection rate for diagnostic skin biopsy in Dermatology Clinic

Raja Permaisuri Bainun Hospital Ipoh
Authors: Dr. Tang Jyh Jong, Kong Siew Hong, Khairul Nizam

INTRODUCTION patients underwent diagnostic skin biopsy and the section 2
Diagnostic skin biopsy is a common procedure done standard is less than 2 %.(National Indicator Value)
in a skin clinic to assist dermatology diagnosis. It
includes punch biopsy and elliptical biopsy. Wound PROCESS OF GATHERING INFORMATION
infection can complicate diagnostic skin biopsy and This is a prospective study which involved 3 phases.
increase morbidity to the patients. However it can be The first phase was to assess the post skin biopsy
prevented with appropriate measures before, during wound infection rate and to identify the possible
and after diagnostic skin biopsy. causes of high infection rate. This was done from
October till November 2008. This was followed by
SELECTION OF OPPORTUNITIES implementation of remedial measures from
The monthly census in 2008 showed that the average December till February 2009. Finally the post
skin biopsy infection rate at Dermatology Clinic of remedial evaluation was conducted to reassess the
HRPBI was as high as 10%. High incidence of wound wound infection rate from March till April 2009.Our
infection for diagnostic skin biopsy can lead to non- study population was dermatology patients (either
healing wound and increase workload and cost of inpatient or outpatient) who underwent diagnostic
health care. Multiple risk factors can influence the risk skin biopsy in clinic with sample size of 30. Exclusion
of postoperative wound infection such as poor skin criteria included those with infected preoperative skin
biopsy technique, break in aseptic technique, surface, patients who had biopsy done in wards and
inappropriate postoperative wound care counseling, those unable to turn up for suture removal.
lack of cleanliness in procedure room, inappropriate
site of biopsy, high risk patients with diabetes mellitus Diagnostic skin biopsy is defined as skin biopsy which is
and smokers.The aim of our study is to reduce skin done to assist dermatology diagnosis, including
biopsy wound infection rate to the national indicator punch biopsy and elliptical biopsy. Definition of
target of less than 2%.According to a study by wound infection is a postoperative wound
Shyamal et al (2007), wound complications as a result complicated by infection which is manifested as
of diagnostic skin biopsy occurred in 29 of 100 erythema, induration, warmth or discharge of pus. On
biopsies (29%) and out of this 27 (93%) is due to the other hand, wound gaping refer to a premature
wound infection (1). They also found that complications bursting open or splitting along surgical suture line.
occurred significantly more frequently with biopsy
performed below the waist (P=0.02), in the ward compared A data collection form will be used to collect
with the outpatient operating theater (P=0.001) and in dermographic data of patients and procedural data
smokers compared with non-smokers (P=0.001). On regarding skin biopsy process (preoperative,
the other hand, J.M. Amici et al (2005) reported only intraoperative and postoperative steps) (Appendice 5).
2.09% of infectious complications in a total of 3788 A photo of the skin biopsy wound would be taken
dermatology surgical procedures(2). after wound closure which will then be assessed by
our panel of dermatologist to determine the wound
KEY MEASURES FOR IMPROVEMENT closure technique. It will then be classified into
Our general objective is to reduce the incidence of satisfactory or non satisfactory technique. Wound
wound infection for diagnostic skin biopsy in our skin assessment and suture removal will be done on the
clinic The specific objectives of this study are: designated date according to site of biopsy
1. To verify the incidence of wound infection for (Appendice 6). Wound outcome will then be
classified into 4 groups : 1) healed with good union 2)
diagnostic skin biopsy gaped but not infected 3) Infected but not gaped 4)
2. To identify the possible contributing factors of Infected and gaped . Wound infection rate will be
calculated based on the total of group 3 and 4.
wound infection
3. To formulate and implement proper remedial measures ANALYSIS AND INTERPRETATION
4. To evaluate the effectiveness of remedial measures A total of 30 patients were recruited during the first
evaluation. All patients underwent punch biopsy and
Our clinical indicator is percentage of patients into
developed wound infection out of total numbers of

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section 2 no elliptical biopsy was done. In terms of skin biopsy STRATEGY FOR CHANGE
wound outcome, 63.3 % (19 cases) healed with good We formulated our remedial actions based on the risk
union whereas 16.7% (5 cases) were complicated with factors identified. Firstly, we decided to use antibiotic
wound gaping without any clinical features of ointment as a standardized immediate postoperative
infection. 6 (20%) out of 30 skin biopsy wounds were dressing for all diagnostic skin biopsy as it is
infected and gaped. There was no wound which was associated with lower wound infection rate. Prior to
infected but not gaped. Therefore, the total wound this, there was no standardization with type of
infection rate was 20% which is 10 times higher than the postoperative dressing. We decided to use
national indicator value of 2% and the ABNA was 18%. Chloramphenicol ointment instead of Fucidin
Besides that, we also found out that the following risk ointment as it is more cost effective.
factors were associated with higher post skin biopsy
wound infection. (Table 1): Secondly, we conducted a seminar to teach all the
1. Use of Fucidin cream and Vaseline ointment as medical staff on the proper method of performing a
diagnostic skin biopsy. Appropriate technique of
post operative dressing (50%) removing specimen, suturing and wound dressing
2. Unsatisfactory wound closure technique (42.9%) were addressed during the seminar. Prior to this there
3. Site of biopsy below the waist (40%) was no guideline on performing diagnostic skin
4. No wound care counseling given after biopsy biopsy. Hence we also formulated a protocol on skin
biopsy which encompasses all important steps in
(33.3%) performing diagnostic skin biopsy including
5. Bigger size of punch biopsy (6 mm) is used (33.3%) preparation, procedure, care of the specimen, post
6. Procedure room no. 2 is used (26.7%) operative counseling to the patient, proper
7. Diabetes mellitus (25%) documentation, proper wound dressing and proper
8. Smoker (25%) suture removal (Appendice 7). All medical staff are
9. Break in aseptic technique (25%) required to adhered to the protocol while performing
10. Bigger size (size 2/0 and 3/0) of suture is used for skin biopsy.

wound closure (22.7%) Thirdly, we recommend site of skin biopsy above
Table 1: Risk factors associated with post skin waist if possible. However it is not feasible to perform
biopsy wound infection skin biopsy above the waist all the time. If the patient
has skin lesion confined only to lower limb, then
92 biopsy below waist will be unavoidable.

The fourth remedial action involved advice and
counseling to patients after skin biopsy. All patients
must be given proper wound care counseling as
recommended in our protocol by the assisting nurses.
A pamphlet on how to perform wound dressing at
home will be given to the patients too (Appendice 8).
They will be provided with Chloramphenicol
ointment for home dressing. They are taught to
remove the dressing after 24 hours and then clean
with soap and water twice daily. After cleaning, the
wound should be covered with Chloramphenicol
ointment. Besides that, we also recommended the use
of smaller punch size (4mm) for skin biopsy if
possible. Nevertheless, bigger punch size e.g. 6 mm
are sometimes needed in certain situation when more
tissues are required for further histopathological
examination.

We also looked into the cleanliness of our procedure
rooms. Prior to this, there was no proper control of
people entering the procedure room during skin
biopsy especially in procedure room 2 where the
door was not closed most of the time. Moreover, no
proper slippers were prepared for the staff to change
before entering the procedure room. As a result of

QA Workbook – The Problem Solving Approach – 2nd Edition

this, there was higher risk of contamination in the biopsy wound infection rate has further dropped to 0 section 2
procedure room. Our remedial measures included which suggested sustainability of our remedial
putting up a signboard outside the procedure room to measures.
ensure no entry by other staff during skin biopsy.
Besides, we also put new slippers outside the LESSON LEARNT AND NEXT STEP
procedure room so that everyone will change their Our study suggested that wound infection rate for
shoes before entering the room to reduce risk of diagnostic skin biopsy in our clinic is high (20%).
contamination.(Appendice 9). Apart from that, we Consequently, our findings have altered the
also conducted a practical session on the 7 steps of diagnostic biopsy practices in our own department.
proper hand washing with all our staff and all of them With implementation of proper remedial actions, we
are required to wear mask and sterile glove during managed to bring down skin biopsy infection rate
skin biopsy. from 20 % to 6.7%. Nonetheless, there is still room
for improvement as it is still above the national
Diabetes mellitus is a known risk factor for infection indicator value of 2%.
and our study has also shown that the risk of wound
infection is higher in these patients. Prior to this, it Besides that we also have achieved the sustainability
was not a routine to check diabetic patient’s blood of improvement as shown in monthly census in May
sugar before skin biopsy. Consequently, we made a 2009 with skin biopsy wound infection rate of 0%.
rule to check our diabetic patient’s random blood All dermatology staff should ensure continuity of
sugar with a glucometer before skin biopsy. At implemented remedial measures to further improve
present, there is no guideline locally or internationally wound outcome for diagnostic skin biopsy. This will
to suggest optimal blood sugar level before subjecting benefit patient the most as faster recovery of wound
a patient for skin biopsy. As a result of this, we used improves quality of life. Continuous monitoring of this
recommendations from the American Diabetes situation will be done at our departmental level in
Association which stated that all surgical patient order to provide high quality of care for patient
should have optimal radom blood sugar of < 11.1 undergoing diagnostic skin biopsy.
mmlo/L (4). We suggested that if the level is more than
11.1 mmol/L, then the procedure should be deferred. REFERENCES
However in cases of urgent diagnostic skin biopsies, 1) Shyamal Wahie, MB, MRCP; Clifford M.
the performing doctor needs to weigh the risks and
benefits between the uncontrolled blood sugar and Lawrence, MD, FRCP Wound Complications
urgency of skin biopsy. Following Diagnostic Skin Biopsies in
Dermatology Inpatients . Arch Dermatol/Vol
Smoking has been shown to be an important risk 143 (NO. 10), Oct2007
factor for wound complications after surgery e.g. full- 2) J.M. Amici, A.M. Rogues, A. Lasheras,_ J.P.
thickness skin grafts(5). Nicotine in cigarette smoke is Gachie, P. Guillot,_ C. Beylot,_ L. Thomas and
a vasoconstrictor that causes tissue ischaemia and A. Ta›eb , A prospective study of the incidence
impairs healing of injured tissue(6) Therefore, all of complications associated with dermatological
smokers are encouraged to stop smoking for at least 1 surgery British Journal of Dermatology 2005
week after skin biopsy, longer if possible(7). 153, 967–971
3) Patrick C. Alguire, MD, Barbara M.Mathes Skin
Finally, smaller suture size (4/0) should be used if biopsy technique for internist., MD. Journal
possible for wound closure to give a better wound General Internal Medicine 1998; 13:46-54
healing outcome.
93
EFFECT OF CHANGE
We subsequently conducted a re-evaluation after
implementation of the above remedial actions. The
post skin biopsy infection rate has been reduced to
6.7% (2 out of 30 biopsies) even though it is still
higher than the national indicator value of 2 %. The
ABNA has also been reduced to 4.7% (Figure 1). This
means that our remedial actions were successful in
bringing down the wound infection rate for diagnostic
skin biopsy. All standard set in the MOGC were
improved as well following implementation of
remedial measures. (Appendice 4). Our subsequent
monthly census in May 2009 has shown that our skin

section 2 QA Workbook – The Problem Solving Approach – 2nd Edition

4) American Diabetes Association Consensus Recommendations for Target Inpatient Blood Glucose Concentrations
5) Goldminz D, Bennett RG. Cigarette smoking and flap and full-thickness graft necrosis. Arch Dermatol.

1991;127(7): 1012-1015.
6) Silverstein P. Smoking and wound healing. Am J Med. 1992;93(1A):22S-24S.
7) National Health Service United Kingdom / Patient information programme /Skin biopsy 2007
ACKNOWLEDGEMENT
We wish to thank our head of department, Dr Agnes Heng for her support in this study and gratefulness to our QA
facilitators Dr Shamsanah, Dr Norisah, Puan Sharifah for sharing and giving ideas as well as comments in the process
of this study. We would also like to thank everyone involved in Dermatology Clinic, Hospital Raja Permaisuri
Bainun, Ipoh.
APPENDICES
1) Cause-Effect Analysis

2) Process of Care

3) Gantt Chart

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4) MODEL OF GOOD CARE

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5) Skin Biopsy Data Collection Form

1. Name of Patient: __________________________________________________________________________
2. I/C : _____________________________________________________________________________________
3. Sex : M / F
4. Age : ____________________________________________________________________________________
5. Smoking status : Smoker / Non smoker

If smoker, please counsel patient to stop smoking for at least 1 week after skin biopsy, longer if possible

6. Comorbids: ______________________________________________________________________________
If Diabetic, please check FBS: ______________________________________________________________
If FBS >12 mmol/dl, please defer the procedure.

7. Dermatologic Diagnosis : __________________________________________________________________
8. Preoperative skin biopsy site: Clean / Infected
9. Type of skin biopsy : Punch/ Elliptical
10. Punch Size : 4 mm / 6 mm
11. Number of skin biopsy: 1/ 2
12. Site of biopsy: 1)_______________________________ 2)_________________________________________
13. Size of sutures : ___________________________________________________________________________
14. OT : 1/2

OT 1 : OT nearer to Room 5
OT 2 : OT nearer to computer room

15. Standard of Operating Procedure: Doctor Assistant
a. Using OT slipper: Yes / No Yes / No
b. Wearing mask : Yes / No Yes / No
c. Sterile glove : Yes / No Yes / No
d. Proper hand washing ( 6 steps) : Yes / No Yes / No
e. Proper clean and drap: Yes / No

16. Wound care counseling and pamphlet given to patient? Yes/ No
17. CMC ointment was used as immediate post op dressing? Yes/ No

If No, please state the type of dressing:_______________________________________________________
18. CMC ointment was given to patient for home wound dressing?Yes/ No

If No, please state the type of dressing:_______________________________________________________
19. Photo after biopsy : Taken / Not Taken

Skin biopsy done by : DR __________________________________________________________
Skin biopsy assisted by : S/N __________________________________________________________
Date of biopsy : ______________________________________________________________
Date of STO : ____________(Face:5 days ; Body/Arms/Scalp :7 days ;
Back and leg : 10 days )

a) Skin Biopsy : Wound Assessment Form

1) Name of patient : _______________________________________________________________________

2) Date of STO : _______________________________________________________________________

3) Biopsy technique (review by panel) : Satisfactory / Not Satisfactory

4) Wound Inspection : (please tick in the relevant box)

section 2 Healed with good union Gapping but not infected

Infected but not gapping Infected and gapping

5) Wound Care at home:

• Counseling given after biopsy? Yes / No

• CMC ointment given to patient ? Yes / No

6) If wound is infected,

• Any antibiotic given ? Yes / No

• Swab C+S taken ? Yes / No

7) Photo taken after STO? Yes / No

8) Assessed by : Dr _____________________

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2) Protocol For Diagnostic Skin Biopsy 6. Infiltrate the biopsy site with a local anesthesia section 2
7. Excise the tissue with scalpel or by using a biopsy
a) Preparation – Skin biopsy set
punch
1. Compartment tray 8. Place the biopsied tissue onto a gauze with gentle
2. Gallipot 3 oz
3. Sponge holder 7” use of forceps or a needle tip and put it into a
4. Single hook retractor (blunt) labeled specimen container
5. Single hook retractor (sharp) 9. Suture the biopsy wound. The assisting nurse
6. Bard parker handle - size 3 should repeatedly dab away the oozing blood
7. Blade - size 11, 15 (if needed) with a piece of gauze.
8. Adson dissecting forceps (non-toothed & fine-toothed) 10. Cut the sutures approximately 0.5 cm from the
9. Ultra fine mosquito artery forceps (curved and straight) knot unless instructed otherwise
10. Stitch scissors 5” 11. Apply appropriate antibiotic ointment and cover
11. Iris sharp tip 3?” (curved) with opsite dressing after the procedure
12. Webster’s needle holder 5 ”
13. Gauze/swabs (iv) Care of the specimen
14. Circumcision towel 1. Avoid traumatizing the tissue, e.g. squeezing the
15. Hand tissue
16. Local anaesthetic-Lignocaine 2%, with or without tissue with the forceps. Transfer the biopsy
specimen to the container by holding the gauze
adrenaline and not the specimen
17. Cleansing lotion-Normal saline solution, povidone 2. Place tissue specimen for histological examination
in a specimen container containing 10% formalin
iodine 10% 3. Place tissue specimen for direct immuno-
18. Skin sutures (types will depend on site to be biopsied) fluorescent studies in a patri dish and despatch
19. Disposable syringe –1 cc or 3 cc the specimen as soon as possible to En Yuszely or
20. Needle: 23G or 26G laboratory if he is not around
21. Non-adhesive dressing or pressure bandage 4. Ensure that all the specimen containers are
22. Protective disposable drape labelled correctly
23. Gown, mask
24. Sterile gloves (v) Advice to the patient
25. Specimen container 1. The dressing should be removed after 24 hours
2. Then clean with soap and water twice daily
b) Procedure 3. After cleaning, the wound should be covered

(i) Preparation of patient: with an Chloramphenicol ointment
1. Obtain informed consent from the patient 4. Consult the doctor if biopsy site becomes red or
2. Explain the procedure and purpose to the patient to
painful
allay anxiety and seek co-operation 5. Have the sutures removed on the date as
3. Lie the patient comfortable and expose the site
instructed by the doctor
chosen for biopsy 6. Avoid applying topical steroid near the wound
4. Position the protective disposable drapes to avoid
(vi) Documentation
soiling of the couch 1. Ensure that full clinical information is recorded in

(ii) Preparation of equipment: the histology form including : age, sex, race,
1. Clean the trolley with spirit swab registration number, clinical features appearance
2. Wear gown, mask and wash hands (6 steps) and site of biopsy, and any previous biopsy number
3. Open the biopsy set 2. Record the procedure carried out in the patient’s
4. Pour the required cleansing lotions-normal saline case record

solution, -povidone iodine 10%. (vii)Suture removal
5. Prepare syringes, needles, blade and suture. 1. All patients must be given a suture removal date

(iii) Procedure by doctor: according to following:
1. Wear gown and mask Face : remove 5 days
2. Wash hands with soap and water, dry hands and put Chest, abdomen, arms, scalp : remove 7 days
Back and leg: 10 days
on sterile gloves 2. During removal of suture, the suture is gently lifted
3. Clean the exposed area with cleansing lotion near the knot and 1 side cut close to the skin surface
4. Drape biopsy site with a sterile dressing towel 3. The suture is removed by pulling across the wound
5. Prepare local anesthesia and get the sutures and surface, rather pulling away from the wound puts
tension on the wound and may cause dehiscence
scalpel ready
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Wound Care Pamphlet For Patient PENJAGAAN LUKA BERJAHIT

WOUND CARE INSTRUCTION–BIOPSY WITH 1. Buka pendebatan (dressing) pada kulit selepas 24
STITCHES jam

1. The dressing should be removed after 24 2. Bersihkan luka dengan menggunakan sabun dan air
hours dua kali sehari

2. Then clean with soap and water twice daily 3. Selepas luka dibersihkan, sapukan ubat salap
3. After cleaning, the wound should be antibiotic yang dibekalkan ke atas luka berkenaan.

covered with an antibiotic ointment 4. Dapatkan nasihat daripada doctor yang berkenaan jika
4. Consult the doctor if biopsy site becomes luka menjadi kemerahan dan sakit

red or painful 5. Jahitan akan dibuka mengikut arahan doktor di
5. Have the sutures removed on the date as klinik (surat untuk buka jahitan akan diberi).

instructed by the doctor 6. Elakkan penggunaan ubat sapu (krim / salap) yang
6. Avoid applying topical steroid near the mengandungi steroid berhampiran luka

wound 7. Keputusan biopsi akan diberitahu bila berjumpa
7. Biopsy result will be informed to you on dengan doktor pada tarikh susulan.

your follow up or you will be called if it’s 7. Sekiranya wujud sebarang masalah, sila hubungi
necessary. Klinik Dermatologi, Hospital Raja Permaisuri
8. If any problem arises – call Dermatology Bainun, Ipoh di talian 05-5222340.
Clinic, Hospital Raja Permaisuri Bainun,
Ipoh at 05-5222340

Wound Care Pamphlet For Patient

section 2

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APPENDIX 5: EXAMPLE OF QA PROJECTS PRESENTED AT THE NATIONAL QA CONVENTION

SECTION TITLE OF PROJECTS

Dental Related Project • Increasing Retention Rate of Fissure Sealant among Primary School children. section 2
• Towards Achieving Acceptable Percentage of Patients Issued Complete Denture
Food Quality & Safety Related
Project within 5 Weeks of Start of Treatment..
Laboratory Services Related • Improving the Retention of Fillings Done on Permanent Posterior Teeth.
Project
Accident & Emergency • Patient Food Safety Goals: From the Farm to the Patient’s Table.
• Food Safety Information of Malaysia (FoSIM).
Anaesthetic & Intensive Care • Improving Food Processing Management.
Dermatology
• Reducing Rejection Rate of Blood Film Malaria Parasite Sample due to
Haematology Unsatisfactory Smear from Emergency and Trauma Department.
Infectious Diseases
• Improving Turn-Around-Time Of Culture & Sensitivity Testing.
Medical • Overcoming the Problems of Unnecessary Repeated Blood Specimens.

Medical Record • Masa Menunggu Lama bagi Kes Bukan Kritikal di Jabatan Kecemasan.
Obstetrics & Gynaecology • Improving the Rate of Dry Ambulance Run in Ambulance Service of Emergency
Ophthalmology
Department, Sarawak General Hospital Kuching.
Orthopaedic • High Rate of Repeated Visits to A&E Unit by Acute Asthmatics.

• Reducing the Incidence of Ventilator Associated Pneumonia among ICU Patients.
• Towards Achieving a 0% Cancellation of Elective Cases in the Operating Theatre.
• Improving Time in-between Elective Cases, Main Operating Theatre, Hospital Melaka.

• Reducing Wound Infection Rate for Diagnostic Skin Biopsy in Dermatology Clinic.
• Reducing Defaulter Rate among Leprosy Patients Receiving Multidrug Therapy

(MDT) at Department of Dermatology Hospital Kuala Lumpur.
• Patient Education and Counselling in the Management of Psoriasis – towards Better

Patient Compliances.

• Iron Chelation amongst Thalassaemics: A Need for Reappraisal.
• Preventing Febrile Transfusion Reactions in Thalassemia Patients.

• Adherence Program to Improve Treatment Response in HIV Treatment-Naive
Patients in Infectious Disease Clinic.

• Reduction of Methicillin Resistant Staphylococcus Aureus (MRSA) Infection in Alor
Star Hospital.

• Optimisation of Glycaemic Control of Diabetic Patient in Medical Outpatient Department.
• Reducing Waiting Time at the Warfarin Clinic, Medical Outpatient Department.
• The Review of In-Patient Investigation Results Received after Discharge in Hospital

Balik Pulau.

• Kelewatan (Melebihi 72 jam) Menghantar Rekod Pesakit Discaj dari Wad ke Unit
Rekod. Nephrology Reducing Continuous Ambulatory Peritoneal Dialysis
Peritonitis Rate in Hospital Tuanku Ja’afar, Seremban.

• Increasing Lower Segment Caesarian Section without Post Partum Hemorrhage.
• Reducing the Incidence of Third Degree Tear in Obstetrics & Gynaecology Department.
• Improving Pregnancy Rate of Intra Uterine Insemination.

• Reducing the Percentage of Clinical Progression of Severe Non- Proliferative
Diabetic Retinopathy Cases to Proliferative Diabetic Retinopathy Stage over 1 year
in an Ophthalmology Department.

• Re-Engineering the Cataract Surgery Wait-Time Strategy.
• Improving the Rate of Postoperative Endophtalmitis after Cataract Surgery in the

Department of Ophthalmology, Hospital Ipoh.

• Reducing the Incidence of Long Transportation Time of Patients from Orthopaedic
Ward to the Operation Theatre.

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section 2 Paediatrics • Meningkatkan Peratus Siap Laporan Perubatan Ortopedik Dalam Tempoh 4
Physiotheraphy Minggu Kepada 80%.
Psychiatry
Radiology • Prevention of Low Apgar Score Baby in Hospital Kluang.
• Improving Thalassaemia Care in Paediatrics.
Respiratory • Reducing Hypothermia in Post Caesarian Newborn Admitted to Neonatal Intensive
Surgical
Pharmacy Care Unit in Hospital Tuanku Fauziah.
Public Health Related Projects
• Mengurangkan Ketidakseimbangan Badan di kalangan Pesakit Warga Tua di Wad
Training Related Projects Kronik..

Collaborative Projects • Recurrent Referral for Low Back Pain to Physiotherapy Department.
Others
• Reducing Frequency of Readmission of Patients with Schizophrenia after Last Discharge.
• Improving the Effectiveness of Retrieval of Psychiatric Follow-up Defaulters.
• Preventable Falls amongst Long Stay Patients in Psychiatric Wards in a Government

Hospital.

• Towards Reducing Substandard Portable Chest Radiographs in Adult.
• Improving Percentage of Lens Exclusion on Routine Head Computerised

Tomography Examination.
• Audit on Defaulters for Special Radiographic Examinations in Diagnostic Imaging

Department.

• Towards Better Control of Bronchial Asthma Patients in Hospital Tengku Ampuan
Jemaah, Sabak Bernam.

• Open Access Endoscopy Service Reduces Waiting Time and Increases
Gastrointestinal Cancer Detection.

• Reducing Delay in Sending Patients to the Operating Theatre in Department of
Surgery, Hospital Tawau Sabah.

• Related Projects Re-Engineering the Process of Obtaining Special Formulary Drugs
by Oncology Patients.

• Improving Adherence to Blood Sampling Time for Therapeutic Drug Monitoring in
a Government Hospital. Optimisation of Pharmcare Service in a Tertiary Hospital.

• Improving the Percentage of Asthmatics Receiving Optimal Assessment during
Follow Up in Health

• Clinics.
• Reducing Incidence of Severe Neonatal Jaundice.
• Improving Detection Rate of Diabetic Foot Problems among Patients with Diabetes.

• Improving the Passing Rate of Nursing Students in Anatomy and Physiology Subjects.
• Implementation and Evaluation of Communication Skills Training Programme for

Pre-Clinical Medical Students: A Malaysian Context.
• Meningkatkan Kompetensi Pelatih Program Diploma Pembantu Perubatan melalui

Intervensi Simulasi Klinikal.

• Reducing Medication Administration Delays: A Collaborative Approach.
• Reducing Missing Laboratory Investigation Results Sent from O&G Department

Hospital Melaka.
• High Incidence of Follow-up Patients Coming without Appointment.

• Does Hand Hygiene Campaign Works? IJN Experience.
• Prospective Studies of Patient’s Satesfaction Level in Armed Forces Hospital

Terendak from 2003-2005.
• Quality Assurance Programme in Hospital Support Service – Managing Hospital Excellence.

For complete and detail information, please refer to Sharing Best
Practices - Compendium of Quality Assurance Projects presented
at the National QA Convention [2003-2011].

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APPENDIX 6: LIST OF POTENTIAL QUALITY JOURNAL FOR QUALITY ARTICLE

BMJ QUALITY AND SAFETY Impact factor : 2.856
Official website: www.qualitysafety.bmj.com/
INTERNATIONAL JOURNAL FOR
QUALITY IN HEALTH CARE Impact factor : 2.064
Official website: www.intqhc.oxfordjournals.org/
INTERNATIONAL JOURNAL OF
HEALTH CARE QUALITY ASSURANCE Official website:
www.emeraldinsight.com/ijhcqa.htm
QUALITY MANAGEMENT IN
HEALTH CARE Official website:
www.journals.lww.com/qmhcjournal/pages/default.aspx
THE JOINT COMMISSION JOURNAL
ON QUALITY AND PATIENT SAFETY Official website: www.jcrinc.com › Periodicals

APPENDIX 7: QIR REPORTING FORMAT [BMJ]

http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1119157/.

APPENDIX 8: SQUIRE GUIDELINE

section 2

http://qualitysafety.bmj.com/content/17/Suppl_1/i13.full

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section 2 QA Workbook – The Problem Solving Approach – 2nd Edition

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