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COUNTRY PROFILE
COUNTRY PROFILE
by: by: bt. Maskon bt. Maskon
ON: ON: PATIENT SAFETY ISSUES PATIENT SAFETY ISSUES AND EFFORTS: MALAYSIA AND EFFORTS: MALAYSIA presented presented Dr. Kalsom Dr. Kalsom Deputy-Director Deputy-Director Medical Development Division Medical Development Division Ministry of Health Malaysia Ministry of Health Malaysia
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HEALTHCARE SYSTEM
DESCRIPTION OF
THE MALAYSIAN
A. A BRIEF
MINISTRY OF HEALTH MALAYSIA
MINISTRY OF HEALTH MALAYSIA
3 3
The Malaysian health
The Malaysian health
care system
care system
Maskon Maskon
By: By: Deputy Director Deputy Director Section on Quality in Healthcare Section on Quality in Healthcare Medical Development Division Medical Development Division MOH, Malaysia MOH, Malaysia
Dr. Kalsom Dr. Kalsom
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Malaysia Malaysia MALAYSIA
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S A B A H
W.P.LABUAN BRUNEI I N D O N E S I A
M A L A Y S I A SOUTH CHINA SEA S A R A W A K
SINGAPORE
TERENGGANU PAHANG JOHOR
THAILAND KELANTAN PERAK SELANGOR N.SEMBILAN MELAKA I N D O N E S I A
PERLIS KEDAH W.P. KUALA LUMPUR
P.PINANG
6 6
•Estimated population :25million (2003)
* Malaysia occupies a central position
two land masses separated by the
:32 mill (2020) * Population average growth rate 2.5%
within Southeast Asia including
(Malay, Chinese, Indian, Others)
Country Profile
Country Profile
ethnic population
South China Sea
* Multi - * Relatively young population
*
7 7
RM 14,098 (3710 USD)
Socio-Economic Indicators
Socio-Economic Indicators
87% (rural) 98.4% (rural)
5.5% 2.0% 3.1% : 58.5% safe water supply 98% (urban) :
(2003) (2003) : : Urban population : 62% adequate sanitary latrines: 100%(urban)
Per capita income :
Economic growth
Inflation rate Unemployment rate : Dependency ratio * Population served with : * Population with * 1999 data
8 8
Population trend by age group
Population trend by age group
6.8%
2020 8.93 20.87 2.19
4.3%
2000 7.89 13.77 0.99
3.7%
1990 6.75 10.56 0.67
25 20 15 10 5 0
0-14 15-64 65+
MILLION
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Health Care Provision
Health Care Provision
PUBLIC SECTOR *Ministry of Health (MOH) : Major provider *Ministry of Education *Ministry of Defense *Ministry of Housing and Local Government *Ministry of Home Affairs *Ministry of Human Resource PRIVATE SECTOR TRADITIONAL/COMPLEMENTARY MEDICINE NON-GOVERNMENTAL ORGANIZATIONS.
INSTITUTIONAL CARE PRIMARY HEALTH CARE 10 10
National Referral System, MOH, Malaysia
National Referral System, MOH, Malaysia
National Referral Centres Regional Hospital/State Hospital Hospitals with Specialists in Districts Hospitals without Specialists in Districts Health Clinics 1 : 20,000 population Rural/Community Clinics 1 : 4,000 population
Ambulatory Care Centres
4,000) 11 11
Community Clinic
RURAL PRIMARY EALTHCARE
RURAL PRIMARY EALTHCARE
(2,000 - Community Clinic
Community Clinic
20,000 population Coverage : 15,000 -
Health Clinic
Health Clinic
Community Clinic
12 12
Private clinics : > 5,000
Private clinics : > 5,000
Health facilities MOH
Health facilities MOH
PRIVATE FACILITIES
PRIVATE FACILITIES
Hospitals : 219 PRIVATE HOSPITAL PRIVATE HOSPITAL Hospitals : 219 Beds :10,405 Beds :10,405
&Private &Private
845 845 1,924 1,924 204 204 (34,089) (34,089) Medical Institutions 6 Medical Institutions 6 5,456) 5,456)
MOH FACILITIES MOH FACILITIES Public Health Public Health Health Clinics Health Clinics Community Clinic Community Clinic Mobile Teams Mobile Teams MOH HOSPITALS MOH HOSPITALS Hospitals 118 Hospitals 118 (Acute Beds) (Acute Beds) ( Chronic Beds) ( Chronic Beds)
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RELATED TO PATIENT SAFETY IN
B. PRINCIPAL PROBLEMS
by: by: bin Abdul Rahman bin Abdul Rahman
MALAYSIA
presented presented Dr. PAA Mohamed Nazir Dr. PAA Mohamed Nazir Principal Assistant Director Principal Assistant Director Section on Quality in Healthcare Section on Quality in Healthcare Medical Development Division Medical Development Division Ministry of Health Malaysia Ministry of Health Malaysia
of the of the methodological methodological 14 14
Malaysia’s Experience
Malaysia’s Experience
and no major studies no major studies and The Harvard Study of Medical Practice The Harvard Study of Medical Practice The Quality in Australian Healthcare The Quality in Australian Healthcare
So far, So far, magnitude magnitude finesse of : finesse of : or or Study Study
Quality Quality conducted in 19 conducted in 19 15 15
Malaysia’s Experience
Malaysia’s Experience
Problems concerning safety in:
Problems concerning safety in:
various various
Public Sector hospitals:
Public Sector hospitals:
by by Improvement activities in MOH Improvement activities in MOH Individual hospital’s interest, Individual hospital’s interest, “Benchmarking study” “Benchmarking study” hospitals in private sector in 2002 hospitals in private sector in 2002
addressed addressed Private sector: Private sector:
Public sector problems related to patient
Public sector problems related to patient
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e.g. preventable
e.g. preventable
adverse events
adverse events
hospital-acquired infection
hospital-acquired infection
Malaysia’s Experience
Malaysia’s Experience
surgical-related disciplines
surgical-related disciplines
certain“incidents”
certain“incidents”
safety involve :
safety involve :
Data on specific problems related to
with a will be presented together with a will be presented together description of the various Quality description of the various Quality Improvement activities that target Improvement activities that target patient safety patient safety ……. in the next section ……. in the next section 17 17
Data on specific problems related to
Malaysia’s Experience
Malaysia’s Experience
patient safety:
patient safety:
18 18
C. Patient safety initiatives
C. Patient safety initiatives
indicator approach
indicator approach
QUALITY ASSURANCE PROGRAMME QUALITY ASSURANCE PROGRAMME Started in 1985 – Started in 1985 – Presently 20 Quality Improvement Presently 20 Quality Improvement activities covering a number of activities covering a number of approaches approaches
QUALITY ASSURANCE PROGRAMME
QUALITY ASSURANCE PROGRAMME
(1990) (1990) (1990) (1990) (1992) (1992) (1992) (1992) (1992) (1992) (1996) (1996) (1998) (1998)
(with implementation of
(with implementation of
IN MINISTRY OF HEALTH
Patient Care Services QA Programme)
Patient Care Services QA Programme)
IN MINISTRY OF HEALTH
Pharmaceutical Services
Pharmaceutical Services
Public Health Services
Public Health Services
Training & Manpower
Training & Manpower
Engineering Services
Engineering Services
Laboratory Services
Laboratory Services
Dental Services
Dental Services
Services Services Planning Division Planning Division
Launched in 1985
QAP expanded to
Launched in 1985
QAP expanded to
Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð Ð
• • • •
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QAP ORGANISATIONAL
QAP ORGANISATIONAL
STRUCTURE
STRUCTURE
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The MOH Steering Committee
The MOH Steering Committee
Programme Level QAP Committee Level QAP Committee Programme State QAP Steering Committee State QAP Steering Committee State QAP technical sub-committee State QAP technical sub-committee Hospital / District QAP Committee Hospital / District QAP Committee
22 22
QI Activities That Target Patient Safety
QI Activities That Target Patient Safety
MEDICAL PROGRAMME QAP:
MEDICAL PROGRAMME QAP:
and consumer-friendly
and consumer-friendly
23 23
Facilities and services are of high quality
MOH Operational Definition of
MOH Operational Definition of
QUALITY (2001)
QUALITY (2001)
if they are: Facilities and services are of high quality if they are: SAFE SAFE Effective Effective Appropriate Appropriate Equitably accessed Equitably accessed Efficient Efficient Patient-centred Patient-centred
1. 1. 2. 2. 3. 3. 4. 4. 5. 5. 6. 6.
24 24
hospital hospital (Caring) (Caring)
IN THE MEDICAL CARE
IN THE MEDICAL CARE
….. …..
QI ACTIVITIES
QI ACTIVITIES
PROGRAMME
PROGRAMME
with with Technical aspect of Q Technical aspect of Q
deal deal performance in ……… performance in ……… Inter-personal Inter-personal aspect of Q aspect of Q
They They (a) (a) (b) (b)
25 25
National Indicator Approach (NIA)
National Indicator Approach (NIA)
Hospital Specific Approach (HSA)
Patient Safety Council of Malaysia
Hospital Specific Approach (HSA)
Patient Safety Council of Malaysia
Technical Quality
Technical Quality
Indicator Approach
Indicator Approach
(i) (i) (ii) (ii) (iii) (iii) Incident Reporting (iv) Incident Reporting (iv) Hospital Infection Control (v) Hospital Infection Control (v)
(Internal Peer
(Internal Peer
26 26
Mortality Mortality
(POMR) (POMR) Intensive Care Unit audit Intensive Care Unit audit
Perioperative
Perioperative
Clinical Audit
Clinical Audit
Review Review (ix) Nursing audit (ix) Nursing audit
Review) Review)
(vii) (vii) (viii) (viii)
27 27
Hospital Accreditation
Hospital Accreditation
External Peer Review
External Peer Review
Programme Programme Explicit Process Measurement Explicit Process Measurement (xi) Clinical Care Pathways for mgt. of: (xi) Clinical Care Pathways for mgt. of: Acute Myocardial Infarct, Acute Myocardial Infarct, (in various stages of development) (in various stages of development)
(x) (x) Asthma, Asthma, Head Injury, Head Injury, Eclampsia Eclampsia
ACTIVITIES IN THE MOH MALAYSIA
ACTIVITIES IN THE MOH MALAYSIA
CLINICAL PRACTICE GUIDELINES (CPG)
CLINICAL PRACTICE GUIDELINES (CPG)
OTHER QUALITY IMPROVEMENT
OTHER QUALITY IMPROVEMENT
TARGETING PATIENT SAFETY
TARGETING PATIENT SAFETY
MATERNAL MORTALITY REVIEW/
MATERNAL MORTALITY REVIEW/
PERINATAL MORTALITY REVIEW
PERINATAL MORTALITY REVIEW
INNOVATIONS INNOVATIONS CREDENTIALING OF MEDICAL STAFF CREDENTIALING OF MEDICAL STAFF HEALTH TECHNOLOGY ASSESSMENT (HTA) HEALTH TECHNOLOGY ASSESSMENT (HTA)
29 29
PATIENT SAFETY
PATIENT SAFETY
IN MALAYSIA
IN MALAYSIA
30 30
Making Patient Safety a National
Making Patient Safety a National
Agenda Agenda The Hon. Health Minister tabled a The Hon. Health Minister tabled a Cabinet Note on Patient Safety to Cabinet Note on Patient Safety to Malaysian Cabinet Malaysian Cabinet Recommended formation of the Recommended formation of the Patient Safety Council of Malaysia Patient Safety Council of Malaysia Approved by Malaysian Cabinet : Approved by Malaysian Cabinet : 29 th January 2003 29 th January 2003
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Patient Safety Council : Composition
Patient Safety Council : Composition
General of Health
General of Health
: Director- : Director- : Section on Q in Healthcare, Med. : Section on Q in Healthcare, Med. Development Div. MOH Development Div. MOH public and private sector public and private sector -professional bodies -professional bodies -consumer groups
Chaired by Chaired by Malaysia Malaysia Secretariat Secretariat Representatives – Representatives – Universities - Universities - -consumer groups
32 32
for for
: Terms of reference
: Terms of reference
PSCoM PSCoM Advise Hon. Health Minister on : Advise Hon. Health Minister on : national priority areas and strategies national priority areas and strategies patient safety and quality improvement in patient safety and quality improvement in healthcare healthcare Gives importance to Clinical Risk Gives importance to Clinical Risk Management Management
Consumer Education and Empowerment
Consumer Education and Empowerment
33 33
Safe Staffing and Quality of Work Life
Safe Staffing and Quality of Work Life
6 Sub-committees
6 Sub-committees
Data and Information Data and Information Continuing Education Continuing Education Medication Safety Medication Safety Transfusion Safety Transfusion Safety
34 34
NATIONAL INDICATOR
NATIONAL INDICATOR
APPROACH (NIA)
APPROACH (NIA)
to to
35 35
to
to
standards standards
National Indicator Approach (NIA):
& & measure quality in the various areas of measure quality in the various areas of investigated locally investigated locally identify shortfalls in Q identify shortfalls in Q Knowledge gained used to design better Knowledge gained used to design better
indicators indicators INDICATORS : monitored nationally INDICATORS : monitored nationally taken for correction. taken for correction. systems of care provision systems of care provision
Common Common concern concern Action Action
36 36
MEDICAL PROGRAMME
NATIONAL INDICATORS
MEDICAL PROGRAMME
NATIONAL INDICATORS
TARGETING SAFETY
TARGETING SAFETY
48 48 37 37
1. Delay in surgery for : very urgent
2. Unplanned return to operating
2. Unplanned return to operating
1. Delay in surgery for : very urgent
HOSPITAL-WIDE INDICATORS
HOSPITAL-WIDE INDICATORS
within within Incidence of pressure sores in non- Incidence of pressure sores in non- Emergency department within 24 Emergency department within 24
cases cases theatre theatre 3. Unplanned re-admissions 3. Unplanned re-admissions hours of discharge. hours of discharge. ambulatory patients ambulatory patients 5. Trauma patients returning to the 5. Trauma patients returning to the hours of first consultation. hours of first consultation.
4. 4.
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Incidence of complications following
Incidence of complications following
Incidence of Plaster of Paris cast
Incidence of Plaster of Paris cast
SURGICAL INDICATORS
SURGICAL INDICATORS
6. 6. complication. complication. 7. 7. ritual circumcision ritual circumcision
Occurrence of adverse events
Occurrence of adverse events
39 39
Unplanned admission to ICU
Unplanned admission to ICU
INDICATORS
INDICATORS
during recovery period.
during recovery period.
ANESTHESIA
ANESTHESIA
within 24 hours of surgery. hours of surgery. within 24
8. 8. 9. 9.
Morbidity from Percutaneous
Morbidity from Percutaneous
40 40
INDICATORS
INDICATORS
(PCNL) Nephrolithotripsy (PCNL) Nephrolithotripsy Morbidity from Trans- Morbidity from Trans- urethral Resection of Prostate(TURP). urethral Resection of Prostate(TURP).
UROLOGY
UROLOGY
10. 10. 11. 11.
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and and and and
DIAGNOSTIC & IMAGING
DIAGNOSTIC & IMAGING
chest needle aspiration needle aspiration chest needle aspiration needle aspiration chest chest
INDICATORS
INDICATORS
12. Morbidity associated with
12. Morbidity associated with
of of –pneumothorax –pneumothorax 13. Morbidity associated with 13. Morbidity associated with of of hemorrhage hemorrhage
Percutaneous
Percutaneous
abdomen cytology/Biopsy cytology/Biopsy abdomen Percutaneous Percutaneous cytology/Biopsy cytology/Biopsy abdomen abdomen - -
electro- electro- therapeutic modalities and thermal therapeutic modalities and thermal 42 42
PHYSIOTHERAPY
PHYSIOTHERAPY
14. Burns during delivery of
14. Burns during delivery of
INDICATORS
INDICATORS
agents. agents.
43 43
15. Incidence of physical food
15. Incidence of physical food
DIETARY INDICATORS
DIETARY INDICATORS
contamination.
contamination.
in in intravenous intravenous 44 44
Thrombophlebitis
Thrombophlebitis
NURSING INDICATORS
NURSING INDICATORS
receiving receiving
Incidence of
Incidence of
16. 16. patients patients therapy. therapy.
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/ NOSOCOMIAL / NOSOCOMIAL HOSPITAL INFECTION HOSPITAL INFECTION CONTROL CONTROL
46 46
State hospitals
State hospitals
undertaken nationally since
undertaken nationally since
Collection of data on Hospital-
Collection of data on Hospital-
'Point Prevalence Survey‘
'Point Prevalence Survey‘
acquired infections :
acquired infections :
14 14 1 July 2002 1 July 2002 data since August 2003 data since August 2003
Achievements:
Achievements:
data - data -
2003 2003 MRSA MRSA starting starting ESBL ESBL
- -
47 47
Results of monitoring (MRSA)
Results of monitoring (MRSA)
14 hospitals 14 hospitals = 3 132 = 3 132 Total In-patient Admissions = 87,9116 Total In-patient Admissions = 87,9116 = 0.35 % = 0.35 %
(Jan. - December 2003) December 2003) (Jan. - Total MRSA Total MRSA Average National Rate Average National Rate
48 48
Twice-yearly Point Prevalence Surveys :
Twice-yearly Point Prevalence Surveys :
Indicators for Monitoring of Nosocomial
Indicators for Monitoring of Nosocomial
infections infections September September
infections infections Nosocomial Nosocomial (March, (March, symptomatic & asymptomatic symptomatic & asymptomatic
types of types of surveyed surveyed yearly) yearly) - UTI - UTI Surgical site infections Surgical site infections superficial - superficial - deep incisional - deep incisional - organ / space - organ / space -
5 5 (i) (i) (ii) (ii)
49 49
infections …
infections …
continued continued Pneumonia Pneumonia Blood Stream infections Blood Stream infections Clinical sepsis Clinical sepsis
Nosocomial
Nosocomial
(iii) (iii) (iv) (iv) (v) (v)
50 50
Survey in 14 hospitals
Survey in 14 hospitals
Sept. ‘03 Sept. ‘03 583 583 9 559 9 559 6.1% 6.1%
March ‘03 March ‘03 731 731 9 407 9 407 7.7% 7.7%
Point Prevalence
Point Prevalence
Total Total Nosocomial Nosocomial cases cases Total Patients Total Patients Percentage Percentage
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