00. MSQH Performance Indicators - 6th Edition Complete Set of Performance Indicators .pdf

TITLE PAGE
CHIEF EXECUTIVE OFFICER’S FOREWORD i
Service Standard 1 Governance, Leadership & Direction
Service Standard 2 Environmental and Safety Services
Service Standard 3 Facility and Biomedical Equipment Management and
Safety
Service Standard 4 Nursing Services
Service Standard 5 Prevention and Control of Infection
Service Standard 6 Patient and Family Rights (unavailable)
Service Standard 7 Health Information Management System
Service Standard 8 Emergency Services
Service Standard 9 Clinical Services - Non-Specialist Facility
(for District Hospitals)
Service Standard 9A Clinical Services - Medical Related Services
Service Standard 9B Clinical Services - Surgical Related Services
Service Standard 9C Clinical Services - Obstetrics and Gynaecology Services
Service Standard 9D Clinical Services - Paediatric Services
Service Standard 9E Clinical Services - Cardiology Services
Service Standard 9F Clinical Services - Oncology Services
Service Standard 9G Clinical Services - Ophthalmology Services
Service Standard 9H Clinical Services - Otorhinolaryngology
Service Standard 9I Clinical Services - Psychiatry Services
Service Standard 9J Clinical Services - Orthopaedic Services
Service Standard 9K Clinical Services - Palliative Care Services (unavailable)
Service Standard 10 Anaesthetic Services
Service Standard 11 Operating Suite Services
Service Standard 12 Ambulatory Care Services - Day care Services
Service Standard 12A Ambulatory Care Services - Endoscopic Services
Service Standard 12B Ambulatory Care Services - Ophthalmology Services
(Stand-alone Centre)
Service Standard 13 Critical Care Services - ICU/CCU/CICU/CRW/HDU/
BURNS CARE UNIT
Service Standard 13A Critical Care Services - SCN/NICU/PICU/PHDW
Service Standard 13B Critical Care Services - Labour/Delivery Services
Service Standard 13C Chronic Dialysis Treatment (unavailable)
Service Standard 14 Radiology/Diagnostic Imaging Services
Service Standard 15 Pathology Services
Service Standard 16 Blood Transfusion Services
Service Standard 17 Rehabilitation Medicine Services
Service Standard 17A Allied Health Professional Services - Physiotherapy
Services
Service Standard 17B Allied Health Professional Services - Occupational Therapy
Services

Service Standard 17C Allied Health Professional Services - Dietetic Services
Service Standard 17D Allied Health Professional Services - Speech-Language
Therapy Services
Service Standard 17E Allied Health Professional Services - Audiology Services
Service Standard 17F Allied Health Professional Services - Optometry Services
Service Standard 17G Allied Health Professional Services - Health Education
Services
Service Standard 17H Allied Health Professional Services - Medical Social
Services
Service Standard 17I Allied Health Professional Services - Psychology
Counselling Services
Service Standard 17J Allied Health Professional Services - Clinical Psychology
Services
Service Standard 18 Pharmacy Services
Service Standard 19 Central Sterilising Supply Services (CSSS)
Service Standard 20 Housekeeping Services
Service Standard 21 Linen Services
Service Standard 22 Food Services
Service Standard 23 Forensic Medicine Services
Service Standard 23A Mortuary Services
Service Standard 24 Standards for General Application – Generic (unavailable)
Service Standard 25 Medical Assistant Services
Service Standard 26 Standards for Clinical Research Centre
Service Standard 27 Standards for Organ & Tissue Donation and Promotion

i
MSQH Hospital Accreditation Standards 6th
Edition
The Performance Indicators
Demonstrating performance will be a major factor in buy-in and support from all stakeholders
throughout the organization and the community. Thus, it is crucial to measure the
performance of the hospital at all stages and to track, measure, and report on the
performance of the healthcare services across all areas of its efforts, as well as specific key
performance indicator within the organization itself. Nevertheless, the goals must be clearly
defined so that the objectives are SMART with clarity. In clearly demonstrating success, we
hope that this document will guide the growth of the hospital, since will be a major factor in
buy-in and support from stakeholders throughout the organization and the community,
particularly to the potential healthcare consumers.
Establishing repeated quality assurance and platform testing processes means the
organisation can rest assured that production changes adhere to best practices. This allows
the hospital team to find the ineffective and inefficient processes and make changes to them.
Continuous Quality and Safety Improvements includes creating an iterative methodology to
ensure that everything is being done the right way, at the right time, with the right people
involved. Alongside this, there is a need to also set up retrospective processes for continuous
learning. By establishing a comprehensive documentation and records, staff can
check information and learn as they go. This will help accelerate improvements in quality.
Professor Dato Dr Hj Abdul Rahim Abdullah, CEO MSQH
11 April 2022

SERVICE STANDARD 01: GOVERNANCE, LEADERSHIP AND DIRECTION
There is tracking and trending of the following specific performance indicators for the
service:
NO INDICATOR TARGET REPORTING
FREQUENCY
1. Percentage of patients leaving hospital against
medical advice relative to all patients hospitalised
within a specified period
Downward
Trends
Monthly
2. Percentage of incidents/accidents during
hospitalisation of patients as percentage of all
admitted patients
Downward
Trends
Monthly
3. Hospital wide patient satisfaction survey (six monthly
basis)
˃ 80%
patient
satisfaction
level
6 Monthly
4. In addition, healthcare facilities are required to
monitor any other two (2) indicators with tracking and
trending analysis to support its goals and objectives
(This is Hospital Management related
performance)
6 monthly

Indicator 01 : Percentage of patients leaving hospital against medical advice
relative to all patients hospitalised within a specified period.
Rationale :
This indicator was selected as a generic indicator of the quality of in-patient care because:
● Incidence of patients discharged At Own Risk (AOR) against medical advice is still
prevalent in hospitals especially those without specialist services.
● AOR discharge occurring frequently is a proxy indication of lack of confidence of the
patients in the care given at the facility.
● The occurrence of AOR discharge should be minimised to include mainly those seeking
higher levels of care or facilities with better amenities.
Definition of Term :
Discharge against medical advice (AOR Discharge)
Patient discharges himself/herself from the hospital when he/she is deemed not fit medically
despite being advised against it.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients discharged AOR but returned for re-admission
NA
Rate Based Process Indicator
Numerator
Denominator
:
:
Total number of patients discharged against medical
advice during the month
Total number of patients admitted during the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
Downward Trend
Monthly
-

Indicator 02 : Percentage of incidents/accidents during hospitalisation of
patients as percentage of all admitted patients
Rationale :
This indicator was selected as a generic indicator of the delivery of safe patient care because:
● A key component of clinical governance framework is the responsibility of every health
care leader to ensure that their organisation monitors and acts on incidents that can
potentially compromise patient and staff safety in their organisations.
● Incident Reporting ensures sharing of lessons learnt from incidents, root cause analysis
and best practices in patient safety.
● Incident Reporting facilitates patient and staff safety efforts including the reduction of risk
to patients and staff.
Definition of Terms :
1. Incidents occurring during hospitalisation of patients:
Any deviation from usual medical care that causes an injury to the patient or poses risk of harm,
that Include near misses, errors, preventable Adverse Events and hazards:
● Near Misses - A near miss in medicine is an event that might have resulted in harm but
the problem did not reach the patient because of timely intervention
by healthcare providers or the patient or family, or due to good fortune. Near misses may
also be referred to as "close calls" or "good catches." (Ref: Institute of Medicine, USA)
● Adverse Event - An injury related to medical management rather then complications of
disease. Medical management includes all aspects of care including diagnosis and
treatment, failure to diagnose and treat and the systems and equipment used to deliver
care. Adverse events maybe preventable or non- preventable.
● Errors are mishaps that have the potential to cause an adverse event.
● Hazard refers to any threat to safety e.g. unsafe practices, conduct, equipment, labels and
names.
2. Incident Reporting :
An Incident Reporting System refers to the processes and technology involved in the
standardization, formatting, communication, feedback, analysis, learning, response and
dissemination of lessons learned from reported events; and analysing the incidents scientifically
in a structured manner through Root Cause Analysis.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All accidents & incidents, near misses, adverse events
NA
Rate Based Outcome Indicator
Numerator
Denominator
:
:
Number of incidents and accidents experienced by all
inpatients over a month
Total number of admissions over the same month
X 100%
Target
Data Collection
Comments/Review
:
:
:
Downward Trend
Monthly
-

Indicator 03 : Hospital wide patient satisfaction survey (six monthly basis)
Rationale :
This indicator was selected:
● As proxy to measurement of patient- centred services and level of client satisfaction to
meeting patient needs from registration for out-patient care to admission and hospital stay
for care and treatment.
● Patient Satisfaction Survey is one of the tools that can be used in recognizing areas for
improvement in the hospital services provided.
Patient Satisfaction Survey
Patient satisfaction survey is a measure of the extent to which a patient is content with the care
they received from their healthcare providers as well as the environment and amenities within
the facility. Refers to the survey responses through a set of Survey Questionnaire.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients who participates in the patient satisfaction survey
(out-patients and inpatients)
NA
Numerator
Denominator
:
:
Number of participating patients (out-patient & inpatients)
who indicated they were ‘satisfied’ in the patient
satisfaction survey with ˃ 80% satisfaction level
Total number of patients who participated in the Patient
Satisfaction Survey
Target
Data Collection
Comments/Review
:
:
:
˃ 80% patient satisfaction level
6 Monthly
‒

SERVICE STANDARD 02: ENVIRONMENTAL AND SAFETY SERVICES
There is tracking and trending of specific performance indicators not limited to but at least
two (2) of the following including the mandatory indicator.
No INDICATOR TARGET Reporting
Frequency
1. Percentage of issues identified during
Environmental and Safety Audit are closed or
followed through.
> 50% 3 Monthly
2. Percentage of internal and external planned
drills are carried out and documented including
recommendations and followed through
activities
100% Yearly
3. Mandatory
Percentage of workplace hazards identified and
risks managed
100% Monthly

Indicator 01 : Percentage of issues identified during Environmental and Safety
Audits are closed or followed through
Rationale :
This indicator was selected because:
● Knowledge on Environmental, Safety and Health Policy and Programme is an important
aspect of patient and staff safety for all health care personnel to acquire. It is an important
element of continuing improvement of the environment and occupational safety and health
to ensure staffs are aware of and work and provide care in a safe environment.
● The Hospital Safety and Health Committee must undertake intense surveillance of
environmental and safety issues including incidences such as needle stick injury, patient
falls among others which are proxy indicators of the effectiveness of the safety program
and risk management in the hospital.
Safety and Health Requirements: As per Environmental Quality Act 1974, Occupational Safety
and Health Act 1994 & Private Healthcare Facilities and Services Act 1998, Regulations 2006
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All hospital areas including onsite outsourced services areas
Offsite outsourced areas
Numerator
Denominator
:
:
Total number of issues closed or followed through.
Total number of issues identified during Environmental
and Safety Audits
X 100%
Target
Data Collection
Comments/Review
:
:
:
> 50%
3 Monthly
-

Indicator 02 : Percentage of internal and external planned drills are carried out
and documented including recommendations and followed
through activities.
Rationale :
This indicator was selected as a generic indicator on staff awareness and practices on safety and
health requirements because:
● Knowledge on Environmental, Safety and Health Policy and Programme is an important
aspect of patient and staff safety for all health care personnel to acquire. It is an important
element of continuing education on occupational safety and health to ensure staffs are
aware of and work and provide care in a safe environment.
● The Hospital Safety and Health Committee must undertake intense surveillance of the
compliance and effectiveness of hospital disaster management plan.
1. Drills: Drills can be actual and/or table-top where appropriate. Actual evacuation drill is
mandatory annually.
2. Environmental, Safety and Health Requirements: As per Environmental Quality Act 1974,
Occupational Safety and Health Act 1994 & Private Healthcare Facilities and Services Act 1998,
Regulations 2006
3. Specific Aspects of Environmental, Safety & Health - As per MSQH Standard No. 02, these
include:
a) Occupational Safety and Health (b) Fire Safety (c) Disaster Management : External Disaster &
Internal Disaster (d) Hazardous Material and Recyclable Waste Management (e) Security
Services (f) Vector and Pest Control
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All relevant staff and activities involved in the respective disaster
management types (including on site out-sourced service providers)
Clinical Risk Management programme
Numerator
Denominator
:
:
Total number of drills conducted (internal and external
disaster) with the issues closed or followed through
Total number of disasters identified in the Internal and
External Disaster Plans
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Yearly
-

Indicator 03 : Percentage of workplace hazards identified and risks managed
Rationale :
This indicator was selected as a generic indicator to:
● Reflect the implementation of Safety and Health activities in the Facility to provide a safe
workplace for staff as well as safe environment for patients and visitors. Hazard
Identification Risk Analysis and Control (HIRAC) Program including mitigation of risks at
the work place and processes for the various activities and coordination and linkages with
other Risk Management activities should be clearly defined and implemented to ensure a
safe environment for patients, staff and visitors.
Definition of Terms:
1. Workplace Health and Safety:
Is a multidisciplinary field concerned with the safety, health, and welfare of people at work. The
goals of occupational safety and health programs include ensuring a safe and healthy work
environment. Occupational Safety and Health also protects co-workers, patients, family
members, employers, customers and many others who might be affected by the workplace
environment. All organizations have the duty to ensure that employees and any other persons
who may be affected by the organization's activities remain safe at all times.
2. Workplace Hazards:
Workplace hazards can come from a wide range of sources. An occupational or workplace hazard
is a thing or situation with the potential to harm a worker. Occupational hazards can be divided
into two categories: safety hazards that cause accidents that physically injure workers, and health
hazards which result in the development of disease. Hazards can also be rated according to the
severity of the harm they cause - a significant hazard being one with the potential to cause a
critical injury, acute and chronic diseases and/or death.
3. Categorization of Hazards/Risks :
a) Hazards/risks can be grouped under various categories as listed below:
● Bio-mechanical and Postural
● Physical Environment and Workplace Design
● Mechanical
● Radiation
● Electrical
● Chemicals and Toxicity
● Biological and Human
● Organizational and Procedural Arrangements eg sharps injury
● Psycho- Social Environment and Task Design
● Natural Environment
b) Levels of Risks : Risk Assessments are based on two(2) key factors:
▪ the severity of any injury/illness resulting from the hazard and
▪ the probability that the injury/illness will actually occur

Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All incidences of hazards occurring in the workplace related to
employees (including on site out-sourced service providers), patients
and visitors
Clinical Risks/adverse events
Numerator
Denominator
:
:
Total number of workplace hazards occurring among
staff, patients and visitors in all sectors of the facility
identified and risks managed over a specific period
Total number of workplace hazards occurring among
staff, patients and visitors in all sectors of the Facility over
a specific period
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Three (3) Monthly
-

SERVICE STANDARD 03: FACILITY AND BIOMEDICAL EQUIPMENT MANAGEMENT &
SAFETY
three (3) of the following:
Frequency
1. Percentage of Planned Preventive
Maintenance being done on schedule
98% Monthly
2. Percentage of system/service uptime 92% Monthly
3. Response time to equipment failure BEMS
I. Critical care
equipment – 15
minute
II. Other
equipment – 2
hours
FEMS
I. Emergency – 15
minute
II. Non-emergency
– 2 hours
Monthly
4. Repair Time 7 working days Monthly

Indicator 01 : Percentage of Planned Preventive Maintenance being done on
schedule
Rationale :
This indicator was selected as a generic indicator of the delivery of safe patient care in the
hospital because:
● Planned preventive maintenance of facilities and equipment in a hospital is an important
component of Facility Management to provide safe patient care.
● Without regular maintenance there will be likelihood of increasing demands for high-cost
maintenance elements such as building services, re-roofing, or structural repairs. Therefore,
it is financially advantageous, if not essential, to have a Planned Preventative Maintenance
(PPM) schedule. A PPM schedule can ensure that routine maintenance and repair works are
implemented to ease out peaks and troughs in the annual maintenance cost cycle of buildings
and equipment and ensure safe patient care without interruptions to life saving procedures.
● Long-term benefits of preventive maintenance include:
- Improved system reliability
- Reduced replacement costs
- Decreased system downtime
- Better spares inventory management
Planned Preventive Maintenance (PPM)
Planned Preventive Maintenance (PPM) is regular repetitive work done to keep facilities and
equipment in good working order and to optimize its efficiency and accuracy. The dates and scope
of tasks are defined as Time based maintenance plans or Performance based maintenance plans.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of facilities and equipment used in all services of the
Facility/Organisation for out-patients and inpatients
NA
Numerator
Denominator
:
:
Numbers of asset undergone planned preventive
maintenance for the month
Numbers of asset scheduled for planned preventive
maintenance for the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
98%
Monthly
-

Indicator 02 : Percentage of system/service uptime
Rationale :
hospital because:
● The cost and consequences of downtime are the reasons why uptime is essential. Even
small periods of downtime of critical equipment/systems can be devastating for the
patient’s safety.
● The uptime for maintenance of facilities and equipment should be according to the existing
type of systems/services in place in accordance to the contractual agreement without
interruptions to life saving procedures.
1. Uptime:
The term uptime is a measure of systems/services/equipment reliability to provide its function for
the specific period expressed as the percentage of time it is working, available/operational to
provide for its primary function. Reliability, availability, recovery and unavailability are related
concepts. Uptime is the opposite of downtime.
2. Downtime
Downtime is used to refer to periods when a system/equipment is unavailable to perform its
primary function. The unavailability is the time-span that a system is unavailable or offline. This
is usually a result of the system failing to function because of an unplanned event, or because of
routine maintenance (a planned event).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
- All systems/service/equipment/assets in the healthcare facility
used to provide patient care for the month
- All assets used in the facility to enable staff to carry out their
clinical and Administrative functions for the month
NA
Numerator
Denominator
:
:
The uptime periods of each systems/equipment/assets in
the facility that had provided its primary function for the
month
Total numbers of each type of critical system/
equipment/asset used in the facility for the month
Note:
This indicator is to be calculated by each critical
system/ equipment used in the facility for the month as
agreed by the Management in the contract.
X 100%
Target
Data Collection
Comments/Review
:
:
:
92%
Monthly
-

Indicator 03 : Response time to equipment failure
Rationale :
hospital because:
● Prompt repairs of existing systems, facilities and equipment in a hospital is an important
element of Facility Management to provide safe patient care.
● The response time for equipment failure should be prompt to the type of service areas
e.g. critical care and others without interruptions to life saving procedures.
Response Time to Equipment Failure:
The response time to equipment failure is the measure of the duration between the call received
from the client to the Maintenance Department and when the technician arrives to the individual
location site. The response time is dependent on the urgency of the equipment, the type of
service area and impact on patient safety. Standards are usually set by the organization on the
tolerance time. Example:
BEMS – Critical care equipment – 15 minutes, Other equipment – 2 hours
FEMS – Emergency – 15 minutes, Non-emergency – 2 hours
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All calls received from individual service areas of the Facility on
complaints of equipment failure and the corresponding response
time for each event in the month
NA
Response time
Numerator
Denominator
Numerator
Denominator
:
:
:
:
Critical Care
Total cumulative number of minutes taken for response
time for all incidents of equipment failure from critical care
areas of the Facility for the month
Total numbers of calls received from critical care areas of
the Facility on equipment failure for the month
Other Service Areas
Total cumulative number of minutes taken for response
time for all incidents of equipment failure from other
service areas of the Facility for the month
Total numbers of calls received from other service areas of
the Facility on equipment failure for the month

Target
Data Collection
Comments/Review
:
:
:
BEMS
Critical care equipment – 15 minutes
Other equipment – 2 hours
FEMS Emergency – 15 minutes
Non-emergency – 2 hours
Monthly
-

Indicator 04 : Repair Time - Percentage of Repair /Work Orders completed
within 7 working days)
Rationale :
hospital because:
● Maintenance and repair work is needed for existing systems and equipment already in
place.
● Prompt maintenance of facilities and equipment in a hospital is an important element of
Facility Management to provide safe patient care.
● Without regular preventive and corrective maintenance there will be likelihood of
increasing demands for high-cost maintenance elements such structural and equipment
repairs. Therefore, it is financially advantageous, if not essential, to have a Planned
Preventative and repair works implemented to ease out peaks and troughs in the annual
maintenance cost cycle of facilities and equipment and ensure safe patient care without
interruptions to life saving procedures.
1. Repair Time (Mean Time to repair) :
Mean Time to Repair is a measure of the maintainability of a repairable item which tells the
average time required to repair a specific item or component and return it to working status.
It is a basic measure of the maintainability of equipment and parts.
2. Work Order:
● A means of communication for maintenance, repair and installation needs from approved
staff to the Maintenance Department.
● A work order is a written request that a task or project need to be completed. The order
can be sent from a customer to a contractor or vendor. It is also a written order from the
customer providing specific or blanket authorization to the contractor to proceed with the
performance of a contracted work/project.
3. Completed on Schedule:
Completed on time - The critical path of a work order may change from time to time as activities
are completed ahead of or behind schedule. The series of activities that define the total time taken
to complete the work order or repair work according to the agreed time/schedule.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All request for repairs for facilities and equipment received and the
corresponding number of work orders issued by the maintenance
department for each month
NA
Numerator
Denominator
:
:
Numbers of repair/work orders completed within 7 working
days as scheduled for the month
Numbers of repair/work orders issued for the month
X 100%

Target
Data Collection
Comments/Review
:
:
:
7 working days
Monthly
-

SERVICE STANDARD 04: NURSING SERVICES
There is tracking and trending of specific performance indicators for improvement of the
Nursing Services/patient care as follows:
Frequency
1. Percentage of intravenous (I/V) line
complications (needles out, redness of skin,
infection sites, extravasation)
≤ 0.5% Monthly

Indicator 01 : Percentage of intravenous (I/V ) line complications (needles out,
redness of skin, infection of sites, extravasation)
Rationale :
● This indicator looks at patient safety and staff competency in the Nursing Service. It is a
proxy indicator that reflects the quality of nursing care provided for in-patients.
● Intravenous line complications has a direct impact on patient safety as it can cause
discomfort, pain and prolong inpatient stay that may lead to the patient suffering from
economic consequences.
1. Intravenous line complications include infection of site, extravasation and needles being out.
2. Infection of intravenous site is characterised by pain, tenderness, warmth, localised swelling
and redness at or around the intravenous insertion site and causing reduced mobility of the
extremities.
3. Extravasation is the accidental administration of intravenously (IV) infused medications into
the extravascular space/tissue around infusion sites characterized by swelling and redness
around the site.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All in-patients who have received intravenous therapy during his/her
current hospital stay is observed until discharge.
1. Complication that has been counted in previous admission
2. Psychiatry patient
3. Neonates patient
4. Paediatric patient
Numerator
Denominator
:
:
Total number of incidences of (I/V) line site complications
among in-patients during the study period
Total number of intravenous (I/V) lines set up during the
study period
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 0.5%
Monthly
-

SERVICE STANDARD 05: PREVENTION AND CONTROL OF INFECTION
There is tracking and trending of specific performance indicators not limited to
but at least two (2) of the following:
No INDICATOR TARGET
Reporting
Frequency
1. Percentage of staff trained in Prevention and
Control of Infection Practices
100% new
staff
85% existing
staff
Monthly
2. Percentage of Healthcare Associated
Infections (HCAI)
< 5% Monthly
3. Number of Resistant Organisms to
Antibiotics within a specified period of time
MRSA 0.3%
ESBL- E.coli
0.2%
ESBL-
Klebsiellap
pneumonia
< 0.3%
CRE < 0.1%
Monthly
For Antimicrobial stewardship, there is tracking and trending of specific
performance indicators not limited to but at least three(3) of the following:
1. Percentage of appropriate and complete
antimicrobial prescriptions
2. Percentage of prescriptions with indications
that are in keeping with national or local
antimicrobial guidelines
3. Percentage of empirical prescriptions that
are reviewed by 72 hours

Indicator 01 : Percentage of staff trained in Prevention and Control of Infection
Practices
Rationale :
This indicator was selected to reflect the delivery of safe patient care in hospitals because:
● Healthcare Associated Infection (HAI) is a significant problem in hospitals and has an
impact on the safety of patient, staff and visitor.
● The Hospital Infection and Antibiotic Control Committee (HIACC) must undertake intense
training of all staff including staff of contracted services to ensure the effectiveness of the
hospital’s Prevention and Control of Infection programme. It should be compulsory rather
than optional training for all relevant staff.
Definition of Term:
Training in Infection Control:
Training on Infection Control can be defined as specific training on aspects of prevention and
control of infection that includes in- house training, orientation programme, conference, seminar
and formal training i.e. Asia Pacific Society for Infection Control (APSIC), post basic training (6
months) in Infection Control and post graduate training.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All staff including specialists, medical officers, house officers, nursing
staff and students (undergraduate medical students, post graduate
medical students, student nurses and allied health staff) and staff of
the privatised services (housekeeping, linen service, Facility and
Biomedical equipment maintenance services) should be given training
on infection control based on their scope of services and job
description
NA
Numerator
Denominator
:
:
Total number of existing staff in the facility (all categories
including all on site outsourced service providers) who
have been given training in prevention and control of
infection
Total number of existing staff in the facility (all categories
including all on site outsourced service providers) at a
given point of time.
X
100%
Target
Data Collection
Comments/Review
:
:
:
100% - Infection Control Nurse, 100% - new staff and 85% - existing
staff (including re-training)
Monthly
-

Indicator 02 : Percentage of Healthcare Associated Infections (HCAI)
Rationale :
● Healthcare Associated Infections are preventable illnesses and the prevention of these
infections continues to be top priority. Therefore, periodic surveillance is essential to
assess the effectiveness of the infection control programme in the hospital setting.
● Healthcare Associated Infection (HAI) is a significant potential problem in hospitals and
has an important impact on the safety of patient, staff and visitor.
surveillance of the incidence of HAI including incidence of sentinel organisms such as
MRSA, which is a proxy indicator on the effectiveness of the hospital’s Prevention and
Control of Infection programme.
Definition of Term:
Hospital Acquired Infection (HAI)
Healthcare Associated Infection: An infection occurring in a patient in a hospital or other
healthcare facility in whom the infection was not present or incubating at the time of admission.
This includes the infections acquired in the hospital, but appearing after discharge, and also
occupational infections among staff of the facility.
(Ref: Technical Specifications (HPIA) Version 4.0, Ministry of Health, Malaysia)
The diagnosis of a nosocomial infection is based on a combination of clinical and laboratory
findings.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who were admitted to the ward before or at 8.00 am and
were not yet discharged at time of the survey.
Cases admitted to the hospital with pre- admission HAI (infected
during stay at another healthcare facility) and patients admitted in the
Psychiatric ward, Emergency Department, Labour/Delivery ward,
Out-
Patient Department and Day Care.
Numerator
Denominator
:
:
Number of patients with Healthcare Associate Infection
(HCAI) in the hospital on the day of survey
Number of hospitalised patients in the hospital on the day
of survey
X
100%
Target
Data Collection
Comments/Review
:
:
:
< 5%
6 Monthly- Hospital wide cross sectional point prevalence survey,
collected twice a year ( one day in month of March & September)
(Ref: Technical Specifications (HPIA) Version 4.0, Ministry of Health,
Malaysia)

Indicator 03 : Number of Resistant Organisms to Antibiotics within a specified
period of time
Rationale :
● One of the major issues in our health care today is that of controlling the increase in
antimicrobial resistance. Although multiple factors play a role in this problem, the
selective pressures of inappropriate and widespread use of antimicrobials are
considered as major contributors.
● Monitoring antimicrobial use or antimicrobial surveillance will serve as a tool for:
- Comparison in antimicrobial use by having national benchmark data (aggregated
from all hospitals);
- Identifying and developing strategies to improve antimicrobial control through multi-
disciplinary efforts involving Infectious Disease Physicians/Clinicians, Clinical
Microbiologist/ Microbiologist, Pharmacist and Infection Control Nurses.
(Source: Policies and Procedures on Infection Control, Ministry of Health Malaysia 2nd
Edition 2010)
● The Hospital Infection and Antibiotic Control Committee must undertake studies on the
presence of resistant organisms to antibiotics and develop a hospital specific policy on
the Use of antibiotics.
● Monitoring the magnitude of the presence of resistant organisms to antibiotics is an
indicator of the effectiveness of the hospital’s policy on the use of antibiotics and the
Prevention and Control of Infection Programme.
Definition of Term:
Drug-Resistant Organisms
Drug-Resistant Organisms (DROs) are bacteria and other organisms that have developed a
resistance to certain drugs. In other words, a particular drug is no longer able to kill or control a
specific bacteria or organism. Other terms used to describe this situation include antibiotic
resistance, antibacterial resistance, and antimicrobial resistance. Examples of drug-resistant
organisms include:
1. MRSA - methicillin/oxacillin-resistant Staphylococcus aureus
2. VRE - vanomycin-resistant enterococci
3. ESBLs - extended-spectrum beta lactamases (resistant to cephalosporins and
monobactams)
4. PRSP - penicillin-resistant Streptococcus pneumoniae
5. GISA - glycopeptide-intermediate Staphylococcus aureus
6. VISA - vancomycin-intermediate Staphylococcus aureus
7. VSRA - vancomycin-resistant Staphylococcus aureus (not yet found in nature, but it is
believed it will emerge or evolve from VISA), and
8. MDR-TB - multidrug-resistant tuberculosis.
9. CRE- Carbapenem - resistant Enterobacteriaceae
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
The number of patients admitted to the hospital and had developed
resistance to antibiotics
Pre-existing infection prior to admission
Sentinel Event

Numerator
Denominator
:
:
Number of patients developing resistance to antibiotics
within a specified period of time
Target
Data Collection
Comments/Review
:
:
:
MRSA 0.3%, ESBL-E.coli 0.2%, ESBL-Klebsiellap pneumonia <0.3%,
CRE < 0.1%
Monthly
-

SERVICE STANDARD 07: HEALTH INFORMATION MANAGEMENT SYSTEM
There is tracking and trending of specific performance indicators which include but not
limited to at least two (2) of the following:
Frequency
1. Percentage of Medical Reports prepared within
the stipulated period:
Secondary and Tertiary Care
(Public & Private) Facility: ≤ 4 weeks
Primary Care Facility: ≤ 2 weeks
Reference: HPIA version 7.3.1
90% Monthly
2. Percentage of medical records that were
dispatched within 72 hours of discharge
Reference: National Indicator Approach version
5.0
95%
Monthly

Indicator 01 : Percentage of Medical Reports prepared within the stipulated
period
Rationale:
● There is a need to hasten the preparation of medical reports in order to satisfy our
customers especially for their insurance claims, police investigations, court proceedings
etc.
● Timeliness of preparation of medical reports is an indication of the efficiency of the Health
Information Management Services
1. Medical Reports:
Written report of the results of a medical examination of a patient describing the findings
during hospitalization, diagnosis and treatment and any other information on the progress,
and events that happened to the individual patient during hospitalization and subsequent
follow up.
2. Stipulated Period:
The preparation of completed requests for medical report must meet the following norms:
- Secondary and Tertiary Care (Public & Private) Hospitals: ≤ 4 weeks
- Primary Care Facility: ≤ 2 weeks
The period of preparing completed requests for medical reports is to be calculated exclusive
of public holidays.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
- Plain medical reports
- Report for Insurance claims
NA
Numerator
Denominator
:
:
Number of Medical Reports completed within the
stipulated period in the month
Total number of requests for Medical Reports in the month X 100%
Target
Data Collection
Comments/Review
:
:
:
1. Secondary and Tertiary Care (Public & Private) Hospitals: ≤ 4
weeks
2. Primary Care Facility: ≤ 2 weeks
Monthly
Reference: Technical Specifications of Hospital Performance
Indicators for Accountability (HPIA) & Specific Indicators Version
7.3.1

Indicator 02 : Percentage of Medical Records that were dispatched within 72
hours of discharge
Rationale:
● There is a need to hasten the preparation of case summaries for continuity of care.
● Timeliness of preparation of case summaries and dispatch of patient’s medical records
to the medical records department is an indication of the timely access to records for
continuity of care.
1. Medical Records:
Medical Records refers to all records and/or documents relating to the treatment of a patient
including but not limited to family histories, medical histories, report on clinical findings and
diagnosis, laboratory test results, x-rays, reports of examination and/or evaluation and all
outpatient/ hospital admission/discharge records.
2. Case Summary:
Patient Case Summary is a standardized set of basic medical data that includes the most
important clinical facts required to ensure safe and secure healthcare. This summarized version
of the patient’s medical data gives health professionals the essential information they need to
provide care in the case of an unexpected or unscheduled medical situation (e.g. emergency or
accident). Though this data is mainly intended to aid health professionals in providing
unscheduled care, it can also be used to provide planned medical care/continuity of care (e.g. in
the case of citizen movements or cross-organizational care paths).
3. Dispatch
Dispatch is to send off in this case the patents medical records with speed to a destination
(medical records department) within the specified time. The completion of case summaries and
dispatch of patient’s medical records must meet the following:
- Within 72 hours of discharge: ≥ 72 working hours after the patient is discharged.
- The period of completing case summaries is to be calculated exclusive of public holidays.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases discharged in a given month
NA
Numerator
Denominator
:
:
Number of case summaries completed within 72 working
hours of discharge in a month
Total number of patients discharged in a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
95%
Monthly
Reference: National Indicator Approach Version 5.0

SERVICE STANDARD 08: EMERGENCY SERVICES
There is tracking and trending of specific performance indicators not limited to but at
least two (2) of the following including the mandatory indicator:
Frequency
1. Mandatory:
Percentage of inappropriate triaging (under
triaging): Category Green patients who should
have been triaged as Category Red.
(Target:
≤ 0.5%)
Monthly
2. Waiting time relative to Triage Category:
i) Malaysian Triage Category
(MTC) Red seen immediately
ii) Malaysian Triage Category
(MTC) Yellow seen within 30
minutes
iii) iii) Malaysian Triage Category
(MTC) Green seen within 90
minutes
100%
≥ 85%
> 70%
Monthly
3. Unplanned return of patient seen at Emergency
Department within 24 hours for similar complaint
Sentinel
Event Monthly

Indicator 01 : Percentage of inappropriate triaging (under triaging): Category
Green patients who should have been triaged as Category Red
Rationale:
● Triage is an essential function of the Emergency Departments (EDs), whereby many
patients may present multiple ill conditions simultaneously. Triage aims to ensure that
patients are treated in the order of their clinical urgency and that treatment is appropriate.
Triage also allows for the allocation of the patient to the most appropriate access,
assessment and treatment area.
● It is a scale for rating clinical urgency. The scale directly relates triage category with a
range or outcome measures (inpatient length of stay, ICU admission, mortality rate) and
resource consumption (staff time, cost).
● Studies have shown that the “under triaging” of critically ill patients can increase their
morbidity and mortality due to delay in their resuscitation and the provision of definitive
care. Urgency refers to the need for time- critical intervention.
● This indicator measures the accuracy and appropriateness of the Triaging System in the
Emergency Department (ED) to ensure that critically ill patients are not missed and
categorized as “non- critical”.
(Ref: Technical Specifications (KPI) Clinical Services, Medical Programme Version 04, Ministry
of Health Malaysia, 2016)
Under- triaged:
Critically ill patient (MTC RED) who was triaged as non- critical patient (MTC GREEN)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who were triaged under the Green Zone
Period of time when the hospital is unable to function as usual due to
mass casualty/disaster/crisis
Numerator
Denominator
:
:
Number of MTC GREEN patients who should have been
triaged as MTC RED
Total number of MTC GREEN patients
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 0.5%
Monthly
(Ref: Technical Specifications (KPI) Clinical Services, Medical
Programme Version 4.0, Ministry of Health, Malaysia, 2016)

Indicator 02 : i) Waiting time relative to triage category: Malaysian Triage
Category(MTC) Red seen immediately (100%)
ii) Waiting time relative to triage category : Malaysian Triage
Category (MTC) Yellow seen within 30 minutes (≥85%)
iii) Waiting time relative to triage category: Malaysian Triage
Category (MTC) Green seen within 90 minutes (> 70%)
Rationale:
● Waiting time relative to triage category is the clinical performance indicator for the
Emergency Department
● Triage is an essential function in the Emergency Department where many patients may
present simultaneously.
● Triage aims to ensure that patients are treated in the order of their clinical urgency and
that their treatment is appropriately timely. It also allows for allocation of the patient to
the most appropriate assessment and treatment area.
● This indicator measures the time taken for the patient to be seen by the medical officer
at the Emergency Department (from the time of his/her registration) based on the
relevant waiting times of the Malaysian Triage Category (MTC).
1. Patients in MTC Red seen Immediately: Initiation of assessment and/or treatment within 5
minutes as (defined in MTC)
Exclusion Criteria:
i. During Mass Casualty Incident as defined by local Disaster Action Plan
ii. Patients retriaged from green/ yellow
2. Patients in MTC Yellow seen within 30 minutes: Initiation of assessment and/or treatment
within 30 minutes
Exclusion Criteria:
i. During Mass Casualty Incident as defined by local Disaster Action Plan
ii. Patients retriaged from green/ yellow
3. Patients in Green seen within 90 minutes: Initiation of assessment and/or treatment within
90 minutes as defined in MTC.
Exclusion Criteria:
i. Non-emergency cases: G4 (OPD cold cases seen at Emergency Department as
defined in MTC.
ii. Klinik Rawatan Pesakit Selepas Waktu Pejabat (in Ministry of Health Hospitals)
4. Emergency Department (ED) staff:
i. Hospital with resident Emergency Physician, Medical officers/House officers,
paramedics
ii. Hospital without resident Emergency Physician: Medical officers, Paramedics
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
: Waiting Time

Malaysian Triage Category (MTC) - RED
Numerator : The number of patients allocated MTC Red who are
attended by ED staff IMMEDIATELY
Denominator : The total number of patients attending ED who are triaged
to MTC Red in the time period under study.
X 100%
Target : 100%
Data Collection : Monthly
Comments/Review :
Malaysian Triage Category (MTC) - YELLOW
Numerator : The number of patients allocated MTC Yellow who are
attended by ED Staff within 30 minutes
to MTC Yellow in the time period under study.
X 100%
Target : ≥ 85%
Comments/Review :
Malaysian Triage Category (MTC) - GREEN
Numerator : The number of patients allocated MTC Green who are
attended by ED Staff within ≥ 90 minutes
to MTC Green in the time period under study.
X100%
Target : > 70%
Comments/Review : Ref: 1. Technical Specifications (KPI) Clinical Services, Medical
Programme Version 4.0, Ministry of Health, Malaysia, 2016
2. Technical Specifications Performance Indicators for
Medical Programme KPI & NIA, Ministry of Health Malaysia,
2012

Indicator 03 : Unplanned return of patients seen at Emergency Department
within 24 hours for a similar complaint
Rationale:
● It is a proxy indicator on safety and effectiveness of care in the Emergency Department.
● This indicator measures the quality of care provided to patient attending the Emergency
Department, It acts as a check and balance to ensure that the patients attending the
Emergency Department do not receive sub-optimal care.
● Patients who are well managed should not be subject to unplanned return this early within
24 hours for similar complaint.
Unplanned return:
Return to the Emergency Department that was unplanned for similar complaint after the initial
treatment.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases seen at the Emergency Department and returns within 24
hours for the same complaint
Planned return for follow up for the same complaint
Sentinel Event
Numerator
Denominator
:
:
Number of unplanned return of patients seen at the
Emergency Department within 24 hours for similar
complaint in the month
Target
Data Collection
Comments/Review
:
:
:
Sentinel Event
Monthly

SERVICE STANDARD 09: CLINICAL SERVICES (NON-SPECIALIST FACILITY)
There tracking and trending of specific performance indicators which include but not
limited to at least two (2) of the following indicators:
No INDICATOR TARGET REPORTING
FREQUENCY
1. Number of Mortality/Morbidity audits/meetings
being conducted in the department with
documentation of cases discussed
6 Monthly
2. Percentage of unplanned re-admission within 72
hours of discharge
Monthly
3. Case fatality rate for two diseases (Facility to
decide based on local disease prevalence i.e. 2
top causes of admission within the
service/discipline)
Monthly
4. Notification of infectious diseases within the
stipulated period
100% Monthly

Indicator 01 : Number of Mortality and Morbidity audits/meetings being
conducted in the department with documentation of cases
discussed
Rationale:
● The main purpose of the mortality and morbidity meetings is to improve patient
management and quality of care. Regular mortality and morbidity meetings serve to look
at the weakness and the shortfalls in the overall management of patients, hence it will be
learnt and the same mistake could be prevented and would not be repeated in the future.
Morbidity: A diseased state
Mortality: The quality or state of being mortal
Morbidity Audits/Meetings: Discussion of case management in regards to patient morbidity,
incidence reporting, issue of patient safety, clinical audit (at the hospital level).
Mortality Meeting: Discussions related to the management of the case and cause of death of
the patient. (eg: Clinical audit, POMR, MMR, Dengue Mortality, TB Mortality, Mortality under 5
years of age (MDG5), Perinatal Mortality Reviews(MDG4) Inquiries ) at hospital level.
Documentation: Official minutes or notes taken during the meeting with attendance list(certified
by the Hospital Director/ Person-In Charge (PIC)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All Morbidity and /or Mortality meetings being conducted at the hospital
level.
Time period when the hospital was unable to function as usual due to
This is a Process Indicator
Numerator
Denominator
:
:
Number of documented mortality and morbidity meetings
that were conducted in six (6 ) months
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

Indicator 02 : Percentage of unplanned re-admission within 72 hours of
discharge
Rationale:
● Unplanned re- admissions is often considered to be the result suboptimal care in the
previous admission leading to re- admission
● Patients receiving good quality clinical services should not be subjected to unplanned
re-admissions within 72 hours of discharge.
1. Unplanned re-admission:
Patient being readmitted for the management of the same clinical condition he or she was
discharged with and the admission was not scheduled. (The same patient readmitted in the
same unit/hospital ≤ 72 hours of previous discharge)
2. Same condition:
Same diagnosis as referred to the ICD 10
Comments:
Number of readmission of one patient is considered as one case. Those on home leave or
transferred to other unit is not considered as discharge
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Re- admission with similar conditions (primary diagnosis) within 72
hours of discharge
At Own Risk (AOR) discharge patients during first admission
Numerator
Denominator
:
:
Number of patients with unplanned re-admission to the
ward within 72 hours of discharge
Total number of patients discharged during the same
period of time the numerator data was collected
X 100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 04 : Notification of Infectious Diseases within the stipulated period of
time.
Rationale:
● Infectious Diseases are required to be notified by law to the relevant authority in Malaysia
i.e. Ministry of Health within a stipulated period of time. This indicator is a measure of the
outcome of care of patients with infectious diseases and control of the disease within the
community.
● The outcome can be expected to be good with early diagnosis and compliance to standard
protocols.
● This indicator measures the outcome of the management and prevention of transmission
of infectious diseases within the community.
1. Notification of Infectious Diseases
a) Reporting or notifying of infectious diseases is mandated by law in Malaysia under the
Prevention and Control of Infectious Disease Act 1988. A Notification Regulation was
subsequently gazette in 1993 whereby a total of 26 infectious diseases are required to be
notified to the relevant Authority i.e. Ministry of Health Malaysia within a stipulated time.
A further Enactment saw the Emergency Ordinance (Prevention and Control of Infectious
Disease) Amendment 2021, Malaysia (National).
b) An effective an efficient disease surveillance and notification system allows early detection
of disease outbreaks that will prompt intervention for the reduction of mortality and
morbidity that may result from the epidemic/pandemic of these infectious diseases. The
notification of infectious diseases are mandated to be done within a stipulated period of
time for specific diseases as per listing under the Prevention and Control of Infectious
Disease Act e.g. Dengue (DF& DHF) within 24 hours.
2. Notifiable Diseases
There are 26 infectious diseases as listed under the Prevention and Control of Infectious Disease
Act which upon detection and confirmation by laboratory findings are required to be reported to
the Public Health Authorities within the specified period of time.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of dengue fever admitted in the paediatric ward during the
study period
NA

Numerator
Denominator
:
:
Total number of cases with infectious diseases admitted
and notified within the stipulated time period during the
month
Total number of cases with infectious diseases admitted
and requiring notification within a stipulated period of time
during the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly

SERVICE STANDARD 09A: CLINICAL SERVICES (MEDICAL RELATED SERVICES)
Frequency
6 Monthly
2. Percentage of unplanned re-admission for the
same condition within 72 hours of discharge
Monthly
3. Dengue Case Fatality Rate Monthly
4. Percentage of patients who had blood culture
taken prior to starting treatment with the
carbapenem group of antibiotics.
Monthly
5. Number of deaths occurring within 24 hrs of
admission.
6 Monthly
6. Percentage of identification of causative
pathogen of community acquired pneumonia.
6 Monthly
7. Number of healthcare worker infected with
tuberculosis (or any other infectious diseases),
the source of which is likely hospital-related.
Yearly

Indicator 01 : Number of mortality and morbidity audits/meetings being
discussed
Rationale:
Morbidity Audits/Meetings:
Discussion of case management in regards to patient morbidity, incidence reporting, issue of
patient safety, clinical audit (at the hospital level).
Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient. (eg: Clinical
audit, POMR, MMR, Dengue Mortality, TB Mortality, Mortality under 5 years of age (MDG5),
Perinatal Mortality Reviews (MDG4) Inquiries) at hospital level.
Documentation:
Official minutes or notes taken during the meeting with attendance list (certified by the Hospital
Director/ Person-In Charge (PIC)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All Morbidity and /or Mortality meetings being conducted at the
hospital level.
Numerator
Denominator
:
:
that were conducted in six (6) months
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

Indicator 02 : Percentage of unplanned re-admission for the same condition
within 72 hours of discharge
Rationale:
Unplanned re-admission:
discharged with and the admission was not scheduled. (The same patient readmitted in the same
unit/hospital ≤ 72 hours of previous discharge)
Same condition:
Comments:
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Re-admission with similar conditions (primary diagnosis) within 72
hours of discharge
Numerator
Denominator
:
:
X 100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 03 : Dengue Case Fatality Rate
Rationale:
● Dengue fever has now become endemic in Malaysia and is a potentially fatal condition
whose severity and frequency may be decreased by careful management planning. This
indicator is a measure of the OUTCOME of care of patients with dengue.
● This indicator measures the clinical effectiveness of management of dengue fever (both
haemorrhage and non-haemorrhage).
Dengue: Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF)
This is a clinical diagnosis decided by the doctor based on clinical findings as well as the relevant
investigations.
Remarks
(a) The 2nd Revision of the Malaysian CPG on the Management of Dengue Infection in Adults
2009 strongly recommends the monitoring of Dengue CFR and DHF Fatality rate
(b) According to the said CPG, all dengue deaths should be audited at individual hospital/state/
national level
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All deaths caused by dengue fever
Deaths caused by other causes
Rate Based Output Indicator
Numerator
Denominator
:
:
Number of cases admitted with DF & DHF/DSS and died
from DF & DHF/DSS
Total number of (DF & DHF) CASES admitted
X100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 04 : Percentage of patients who had blood culture taken prior to
starting treatment with the carbapenem group of antibiotics.
Rationale:
● The carbapenem group of antibiotics is currently being used widely, at times without any
form of monitoring.
● This indicator will address the awareness of the appropriateness of the use of the
carbapenem group of antibiotics among prescribers.
Definition of terms:
Carbapenem group of antibiotics: ertapenem, meropenem, imipenem etc
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients prescribed with the carbapenem group of antibiotics
Patients prescribed with the antibiotics other than the carbapenem
group of antibiotics
Numerator
Denominator
:
:
Number of patients prescribed the carbapenem group of
antibiotics and had blood culture taken prior to starting
treatment.
Number of patients prescribed the carbapenem group of
antibiotics.
X100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 05 : Number of deaths occurring within 24 hours of admission.
Rationale:
● To address the appropriateness and effectiveness of initial treatment of patients at
presentation
● To address the timeliness of instituting care/treatment to patients at presentation
Definition of terms:
1. At presentation:
Time of arrival at Emergency Department
2. Within 24 hours of admission:
Starting time is on arrival to emergency department
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All deaths within 24 hours of admission
Patients surviving beyond 24 hours of admission
Output Indicator
Numerator
Denominator
:
:
Number of deaths within 24 hours of admission
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

Indicator 06 : Percentage of identification of causative pathogen of community
acquired pneumonia.
Rationale:
● Community acquired pneumonia is a diagnosis widely made without much consideration
of common local causative organism, and hence leading to possible inappropriate use of
broad-spectrum antibiotics.
● The identification of common local causative organism may guide future use of antibiotics
and reduce resistance rate.
● To pick up new unknown pathogen in the community.
Community Acquired Pnuemonia
Community acquired pneumonia is defined as pneumonia that is acquired outside the hospital.
In community acquired pneumonia (CAP) one gets infected in a community setting. It does not
happen in a hospital, nursing home or other healthcare setting and involves the lower respiratory
tract infection mostly caused by bacteria.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients admitted with the diagnosis of community acquired
pneumonia.
All patients admitted with diagnosis other than community acquired
Pneumonia
Numerator
Denominator
:
:
Number of patients admitted with community acquired
pneumonia and the causative organism is identified.
Total number of patients admitted with the diagnosis of
community acquired pneumonia
X100%
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

Indicator 07 : Number of healthcare workers infected with tuberculosis (or any
other infectious diseases), the source of which is likely hospital
related.
Rationale:
● Reflects safety for healthcare workers
● To identify areas for improvements in terms of hospital infection control policy
1. Healthcare worker:
A healthcare worker is one who delivers care and services to the sick and ailing either directly as
doctors and nurses including emergency medical personnel, dental professionals and students,
medical and nursing students or indirectly as aides, laboratory scientists and technicians,
pharmacists, hospital volunteers and administrative staff. Healthcare workers also include the
support services staff i.e. housekeeping staff, medical waste handlers and others.
2. Hospital related Infection:
The Healthcare industry is one of the most hazardous environments to work in. Employees in this
industry are constantly exposed to a complex variety of health and safety hazards in the course
of their work. Hazards range from biological exposure to disease causing organisms such as
tuberculosis and human immunodeficiency virus (HIV). Hospital related Infection refers to the
source of acquiring infections in a hospital setting.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All healthcare worker diagnosed with tuberculosis (or any other
infectious diseases), the source of which is likely hospital-related
NA
Output Indicator
Numerator
Denominator
:
:
Number of healthcare workers infected with tuberculosis
(or any other infectious diseases)
Total number of healthcare workers in the facility
100%
Target
Data Collection
Comments/Review
:
:
:
Yearly

SERVICE STANDARD 09B: CLINICAL SERVICES (SURGICAL RELATED SERVICES)
Frequency
6 Monthly
hours of discharge
Monthly
3. Unplanned return to Operating Theatre within the
same hospital admission following surgery
Monthly
4. Percentage of patients with waiting time of more
than seven (7) working days for fixation of long
bone closed fracture
Monthly

discussed
Rationale:
Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient. (e.g.
Clinical audit, POMR, MMR, Dengue Mortality, TB Mortality, Mortality under 5 years of age
(MDG5), Perinatal Mortality Reviews (MDG4) Inquiries at hospital level.
Documentation:
Director/ Person-In Charge (PIC).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
hospital level.
Numerator
Denominator
:
:
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

discharge
Rationale:
● Unplanned re-admission is often considered to be the result suboptimal care in the
Patient being re-admitted for the management of the same clinical condition he or she was
Same condition: Same diagnosis as referred to the ICD 10
Comments:
transferred to other unit is not considered as discharge.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Re-admission with similar conditions (primary diagnosis) within 72
hours of discharge
Numerator
Denominator
:
:
X 100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 03 : Rate of unplanned return to Operating Theatre within the same
hospital admission following surgery
Rationale:
● Any unplanned return to the operation theatre may indicate a quality care problem due to
the occurrence of intra-operative problems that are serious enough to warrant intervention
post-operatively. It refers to the need for an unexpected return to the operating theatre to
address a previous complication of the original operation.
● This indicator measures the clinical effectiveness of care and patient safety.
Unplanned return to the operating theatre:
Cases requiring unplanned return to the operating theatre for further intervention during the same
admission after a surgical procedure (under GA)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases that had undergone surgery Inclusive of day of surgery
admission
Endoscopy cases and day care cases
Numerator
Denominator
:
:
Number of cases (of unplanned return to OT) after a
surgical procedure under GA requiring further intervention
during the same admission in the month
Total number of cases undergone surgical procedure
under GA in the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 04 : Percentage of patients with waiting time of more than seven (7)
working days for fixation of long bone closed fracture
Rationale:
● The long waiting time for long bone closed fracture internal fixation varies from few days
to weeks, thus reflecting on the workload, facilities available and planning besides
increased intra-operative difficulties.
● Prolonged waiting time will lead to morbidity, extended hospital length of stay and
increased health cost and also the fracture is technically more difficult to fix.
● It indicates Timely Access & Clinical Effectiveness
Fractures: Defined as long bone closed fractures
Long bones: Humerus, Radius, Ulna, Femur, Tibia, Fibula
Internal Fixation: Any form of device used to hold the bone fragments internally, includes any
form of plate, nail, screw and wire buried under the skin. Combination of internal and external
fixation will be considered as internal fixation
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients admitted for long bone closed fractures
i) Medically unfit patients
ii) Difficulty in obtaining consent and/or implant
iii) Patient with additional open fracture(s)
Numerator
Denominator
:
:
Number of patients with long bone closed fracture fixations
with waiting time of more than seven (7) working days
Total number of patients with long bone closed fracture
fixations done during the study period
X 100%
Target
Data Collection
Comments/Review
:
:
:
Monthly

SERVICE STANDARD 09C: CLINICAL SERVICES
(OBSTETRICS & GYNAECOLOGY SERVICES)
limited to at least two(2) of the following:
FREQUENCY
FACILITY WITH SPECIALITISTS
1. Emergency and Elective Caesarean Rates < 30% Monthly
2. Percentage of Undiagnosed ureteric injury for
benign gynaecological surgery/condition
≤ 1% 6 Monthly
3. Maternal Mortality Ratio (sentinel event) 0 Monthly
4. Incidence of 3rd and 4th degree perineal tear
following vaginal delivery
≤ 10% Monthly
DISTRICT FACILITY WITHOUT SPECIALITISTS
(MATERNITY SERVICES)
1. Emergency and Elective Caesarean Rates Monthly
2. Maternal Mortality Ratio (sentinel event) 0 Monthly
3. Incidence of 3rd and 4th degree perineal tear
following vaginal delivery (Target: less than 5%)
< 5% Monthly

Indicator 01 : Emergency and Elective Caesarean Rates
Rationale:
1. There is concern about whether high rates of caesarean section are justified because the
procedure is not without risk. Women may experience complications after caesarean
section such as haemorrhage, infection, and thrombosis, and they have an increased risk
of complications in subsequent pregnancies.
2. Neonatal complications, although infrequent, include fetal respiratory distress syndrome,
pulmonary hypertension, iatrogenic prematurity, and difficulty with bonding and breast
feeding.
3. Adding to these concerns is the considerable variation in rates of caesarean section
between the public and private healthcare facilities.
4. It is also known that an elective planned caesarean section is safer than an emergency
surgery. It is good practice to track and trend the rates of elective and emergency
caesarean sections.
Caesarean Section (CS)
CS is surgery done for the delivery of the fetus via an abdominal and uterine incision.
Emergency Caesarean Section (CS):
CS done after admission for a clinical reason without prior plan during antenatal care is termed
an emergency caesarean section.
Elective caesarean section
CS is done on planned basis during antenatal care. An elective caesarean section carries lesser
risks to the mother and fetus compared to an emergency CS.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of caesarean sections conducted during a specific period
All modes of deliveries other than Caesarean sections
Numerator
Denominator
:
:
Target
Data Collection
Comments/Review
:
:
:
Facility with Specialists: < 30%
Monthly

Indicator 02 : Percentage of undiagnosed ureteric injury for benign
gynaecological surgery/condition
Rationale:
● Patient safety is the important emphasis in delivering medical care. However,
complications during surgery do occur but failure to recognize the complication is not
acceptable.
● In gynaecological surgery, ureteric injury is a recognized complication but it is the
responsibility of the surgeon to recognize it during surgery when primary repair can be
arranged.
● The incidence of undiagnosed ureteric injury is a debilitating injury to the patient with
possible long term complications. The use of this indicator would be reflective of the
prompt diagnosis and speed of instituting care that would prevent the patient from
enduring prolonged discomfort, excuriating pain and infection.
● To ensure competency and adherence to safety in performing hysterectomy for benign
gynaecological conditions.
1. Ureteric injury – Any type of ureteric injury
Ureteric injuries can occur during “simple” routine pelvic surgeries, such as hysterectomies, and
the risk increases in the presence of comorbidities i.e., pelvic inflammatory diseases and is
associated with significant morbidity. The anatomic proximity of the ureters to the genital tract
places them at risk of injury during pelvic surgery i.e., gynaecological procedures.
2. Benign Gynaecological Surgery ‒ Hysterectomy for benign gynaecological condition.
3. Undiagnosed ureteric injury ‒ Failure to recognise ureteric injury during surgery
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of unrecognised intraoperative ureteric injury who had
undergone obstetric & gynaecological surgery including LSCS
NA
Numerator
Denominator
:
:
Number of patients with undiagnosed intraoperative
ureteric injury
Total numbers of hysterectomy done for benign
gynaecological condition
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 1% (facilities with specialists)

Indicator 03 : Maternal Mortality Rate (MMR)
Rationale:
● This indicator reflects maternal health and enables safety considerations in reducing
maternal mortality.
● Most maternal deaths are avoidable, as the health-care solutions to prevent or manage
complications are well known. All women need is access to antenatal care in pregnancy,
skilled care during childbirth, and care and support in the weeks after childbirth. It is
particularly important that all births are attended by trained and skilled health
professionals, as timely management and treatment can make the difference between life
and death. To improve maternal health, barriers that limit access to quality maternal health
services must be identified and addressed at all levels of the health system.
Maternal Death
According to the World Health Organization (WHO), maternal death is defined as the death of a
woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration
and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes.
Generally, there is a distinction between a direct maternal death resulting from complications
arising during pregnancy, labour or during the post-partum period. Deaths may result from
interventions, omissions, incorrect treatment or from a chain of events resulting from any of the
above. The indirect obstetric deaths may result from previous existing disease or diseases, which
are aggravated by the pregnancy resulting in her death. An example would be heart disease.
Fortuitous deaths are those deaths that occur in a pregnant woman which are unrelated to her
pregnancy and may have caused her death even if she were not pregnant.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All direct and indirect maternal deaths
Fatalities during but unrelated to a pregnancy are termed fortuitous
maternal deaths.
Sentinel Event
Numerator
Denominator
:
:
Total number of Maternal Deaths
Total number of Live Births
Remarks: Maternal Mortality Rate is expressed as per
100,000 live births.
X 1000
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

Indicator 04 : Incidence of 3rd and 4th degree perineal tear following vaginal
delivery
Rationale:
● Obstetric Trauma is a debilitating injury to the patient. The injury of third and fourth degree
perineal tears during vaginal delivery extends to the perineal muscles, anal sphincter and
bowel wall, and these require surgical treatment post- delivery. Possible long-term
complications include continued perineal pain and anal incontinence. These types of tears
can be prevented/reduced by employing appropriate labour management and care
standards.
3rd
and 4th
degree perineal tear ‒ refers to incidence of Perineal Laceration /tear following
vaginal delivery.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients who underwent vaginal deliveries in the hospital:
● Without instrumentation
● Sustained third (3rd) degree and fourth (4th) degree perineal
laceration/tear
Patients who delivered outside of the hospital
Numerator
Denominator
:
:
Number of patients with 3rd and 4th degree tear following
vaginal delivery without instrumentation in the hospital
Total number of vaginal deliveries without instrumentation
in the hospital
X 100
Target
Data Collection
Comments/Review
:
:
:
● District Facility without specialist: ≤ 5
● Facility with specialists: ≤ 10%
Monthly

SERVICE STANDARD 09D: CLINICAL SERVICES (PAEDIATRIC SERVICES)
limited to at least three (3) of the following:
Frequency
6 monthly
2. Percentage of paediatric patients with unplanned
re-admission for the same condition within 48
hours of discharge
≤ 2% Monthly
3. Community acquired pneumonia death rate in
previously healthy children aged between one (1)
month and five (5) years.
≤1% Monthly
4. Percentage of patients with waiting time of
≤ 90 minutes to see doctor at Paediatric
Specialist Clinic.
≥ 90%
Monthly
5. Percentage of survival of inborn very low birth
weight infants between 1000 – 1499 g birth
weight.
≥ 90%

discussed
Rationale:
● Majority of children die below the age of 5 years. Review of all deaths among children will
enable healthcare providers to rectify and improve services to children.
patient safety, clinical audit (at the department/hospital level).
Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient. (e.g.:
Clinical audit, POMR, Dengue Mortality, TB Mortality, Mortality under 5 years of age (MDG5),
Perinatal Mortality Reviews (MDG4) Inquiries at hospital level.
Documentation:
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
hospital level.
Process Indicator
Numerator
Denominator
:
:
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

Indicator 02 : Percentage of paediatric patients with unplanned re-admission
for the same condition within 48 hours of discharge
Rationale:
● Unplanned re-admission is often considered to be the result of suboptimal care in the
previous admission leading to re-admission.
● This indicator measures Clinical Effectiveness & Patient Centered care
1. Unplanned re-admission:
Patient being re-admitted for the management of the same clinical condition he or she was
discharged with and the admission was not scheduled. Return to hospital that was not planned
for during initial admission
2. Within 48 hours:
≤ 48 hours (2 days)
3. Readmission:
The same patient readmitted in the same unit/hospital ≤ 48 hours of previous discharge for the
same condition (regardless of the number of times being admitted that is multiple readmission
within 48 hours is considered as one admission)
4. Discharge:
Patients name has been removed from ward register.
Comments: Number of readmission of one patient is considered as one case. Those on home
leave or transferred to other unit is not considered as discharge
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Re-admission to hospital for the same or related problem within 48
hours of discharge
i) Neonates and patients of > 12 years of age
ii) AOR (at own risk) discharge patients during first admission
iii) Patients readmitted to other/different hospital
iv) Patients with chronic illnesses
v) Re- admission requested by next of kin or other team
Numerator
Denominator
:
:
Number of paediatric patients with unplanned readmission
to the paediatric ward/hospital within 48 hours of discharge
Total number of paediatric patients discharged during the
same period of time the numerator data was collected
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 2%
Monthly

Indicator 03 : Community acquired pneumonia death rate in previously healthy
children aged between one (1) month and five (5) years.
Rationale:
● Pneumonia is a common childhood infection where mortality can be reduced by careful
management.
1. Community Acquired Pneumonia (CAP):
Pneumonia acquired from normal social contact as opposed to being acquired during
hospitalization and confirmed by radiological or laboratory investigations
2. Previously healthy children:
Paediatric patients who are not known to have any serious medical illness before (e.g. ) Chronic
childhood asthma, severe malnutrition, etc)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Previously healthy children aged between one month and five (5)
years
i) Patients younger than one month and older than five(5) years
ii) Hospital acquired pneumonia
iii) Children with co-morbid conditions e.g. cardiac, chronic lung
disease, severe neurological conditions causing restrictive lung
disease etc.
iv) Epidemics of CAP
Numerator
Denominator
:
:
Number of deaths due to community acquired pneumonia
among previously healthy children aged between 1 month
and 5 years
Total number of cases admitted for community acquired
pneumonia among previously healthy children aged
between 1 month and 5 years
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 1 %
Monthly

Indicator 04 : Percentage of Patients with waiting time of ≤ 90 minutes to see
doctor at Paediatric Specialist Clinic.
Rationale:
1. MOH aims for waiting time to see the doctor at outpatient services, to be less than 90
minutes, in line with patient-centred services. Waiting time is time patient first registers in
the hospital till the time patient is seen by doctor.
2. The waiting time is based on patient’s experience from the time the patient first registers
at the first counter in the hospital till seen by doctor. In view of many counters being
involved in some hospitals some clinical departments have opted for monitoring of
registration from department counter, as any process prior to that appears out of the
clinical department’s control.
3. For hospitals to eliminate or reduce waiting time, it is important to balance between the
demand for appointments and the supply of appointments. One needs to identify
opportunities for improvement by strengthening the policy of outpatient services in
hospital, apply Queuing Theory and having contingency plans.
(Ref: MOH Technical Specifications Key Performance Indicators (KPI) Clinical Services,
Medical programme, version 7.0 2021)
Waiting time:
Time of registration counter at department counter or time of appointment given to patient
(whichever is later) till the time the patient is first seen by the doctor, which is the beginning of a
consultation.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All outpatients of Paediatric Outpatient Clinic
v) Patients who come without an appointment (“walk in patients”)
vi) Patients that need to do procedures on the same day before
seeing the doctors (e.g., blood taking or imaging).
vii) Patients who state their preference to see only a specific doctor
at the clinic.
Numerator
Denominator
:
:
Number of sampled patients with waiting time of ≤ 90
minutes to see the doctor at the Paediatric Outpatient
Clinic in the month
Total sample of patients seen by doctor at the Paediatric
Outpatient Clinic in a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly
Sampling: Using an average of total patients seen in a month, 30%
of the patients in each month needs to be sampled for this indicator.
Randomised sampling to ensure each clinic day of the week to
ensure proper representation of data.

Indicator 05 : Percentage of survival of inborn livebirths with birthweight
between 1000-1499g
Rationale:
● This group of infants comprises a significant proportion of patients who utilize NICU and
special care nursery resources.
● Their survival impacts significantly on the under 5 survival target.
1. Livebirth: Born alive
2. Inborn: Born in the same hospital.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All inborn livebirth infants of birthweight between 1000-1499 g.
Babies born with major/ lethal congenital anomalies (LCM)
Numerator
Denominator
:
:
Number of survival of inborn livebirths with birthweight
between 1000 – 1499 g
Total number of inborn livebirths of birthweight between
1000 – 1499 g
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90 %

SERVICE STANDARD 09E: CLINICAL SERVICES (CARDIOLOGY)
There is tracking and trending of the following specific performance indicators where
appropriate:
No. INDICATOR TARGET Reporting
Frequency
1. Electrocardiogram taken within 10 minutes after
triaging as possible Acute Coronary Syndrome
patients
100% Monthly
2. Mortality and morbidity review of patients with acute
myocardial infarction. (Morbidity discussion based on
the department’s discretion)
100% Monthly
3. Thrombolytic Therapy within 30 minutes after hospital
arrival in patient with acute myocardial infarction
“Door to Needle” Time.
90% Monthly
4.
Percentage of patient who received Thrombolytic
Therapy (TT) in patients admitted for acute
myocardial infarction.
90%
Monthly
5. Percentage of “Normal” Diagnostic Angiogram <5% Monthly
6. Major complication rate during Diagnostic Coronary
Angiogram (Death, acute myocardial infarction,
stroke)
<1%
Monthly
7. Major complication rate during Percutaneous
Coronary Intervention (Death, acute myocardial
infarction, stroke)
<1%
Monthly
8. Percutaneous Coronary Intervention (PCI) within 90
minutes after hospital arrival “Door to Balloon” Time
90% Monthly

Frequency
9. Percentage of high risk Acute Coronary Syndrome
(ACS) cases undergoing Cardiac Catheterisation
during the index admission.
≥ 90%
Monthly
10. Percentage of Heart Failure Mortality Rate during
index hospitalization
≤ 10% Monthly
11. Percentage of Heart Failure Readmission Rate at 1-
month
≤ 15% Monthly

Indicator 01 : Electrocardiogram taken within 10 minutes after triaging as
possible Acute Coronary Syndrome patients
Rationale:
● Acute Myocardial Infarction is a frequent cause of hospital death nationally.
● Patients with acute coronary syndrome (ACS) should have an electrocardiogram taken
immediately upon arrival at the hospital.
● This indicator measures quality of care and adherence to practice guidelines.
1. Acute Coronary Syndrome:
Includes patients with unstable angina, non- ST elevation myocardial infarction (NSTEMI) and ST
elevation myocardial infarction (STEMI). Acute coronary syndrome (ACS) Diagnosis of STEMI is
in accordance with the Clinical Practice Guidelines- Management Of Acute ST Segment Elevation
Myocardial Infarction (STEMI) 2014 - (3rd edition)
2. Electrocardiogram
Electrocardiography is a commonly used, noninvasive procedure for recording electrical changes
in the heart. The record, which is called an electrocardiogram (ECG or EKG), shows the series of
waves that relate to the electrical impulses which occur during each beat of the heart. Output
usually appears on a long scroll of paper that displays a printed graph of activity.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases with complaints of Chest pain and suspected Acute
Myocardial Infarction.
NA
Numerator
Denominator
:
:
Number of patients triaged as possible Acute Coronary
Syndrome and electrocardiogram done within 10 minutes
Total number of patients triaged as possible Acute
Coronary Syndrome and electrocardiogram done
X100%
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly

Indicator 02 : Mortality and morbidity review of patients with acute myocardial
infarction.
Rationale:
at the weakness and the shortfalls in the overall management of patients with acute
myocardial infarction, hence lessons will be learnt and the same mistake could be
prevented and would not be repeated in the future.
1. Morbidity Meetings:
Discussion of case management in regards to patient morbidity, incident reporting, issue of
2. Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient (i.e. Clinical
Audit, PMOR, Enquiries, deaths of patients with Acute Myocardial Infarction) conducted at
department/hospital level.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All Morbidity and /or Mortality meetings on patients with Acute
Myocardial Infarction being conducted at the department/hospital
level.
Time period when the department/hospital was unable to function as
usual due to disaster/crisis
Numerator
Denominator
:
:
Number of patients (admitted with Acute Myocardial
Infarction) that had mortality and morbidity reviews
conducted on each case
Total number of cases (admitted with Acute Myocardial
Infarction) scheduled for mortality and morbidity reviews
X 100 %
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly

Indicator 03 : Thrombolytic Therapy (TT) within 30 minutes after hospital
arrival “Door to Needle” Time
Rationale:
● It is important to measure the quality of care and adherence to practice guidelines.
Thrombolytic Therapy:
Thrombolytic Therapy is widely used to treat Acute Myocardial Infarction to open up an acutely
occluded artery. Thrombolytic Therapy should be instituted within 30 minutes after the arrival of
patient and diagnosis is made at the hospital’s Emergency Department.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases with Acute Myocardial Infarction with indications for
Thrombolytic Therapy.
NA
Numerator
Denominator
:
:
Number of Acute Myocardial Infarction patients who had
Thrombolytic Therapy done within 30 minutes after hospital
arrival and diagnosis is made
Total number of Acute Myocardial Infarction patients
admitted and who received Thrombolytic Therapy.
X 100%
Target
Data Collection
Comments/Review
:
:
:
90%
Monthly

Indicator 04 : Percentage of patient who received thrombolytic therapy (TT) in
patients admitted for Acute Myocardial Infarction
Rationale:
● It is important to measure the quality of care and adherence to practice guidelines.
Thrombolytic Therapy:
Thrombolytic Therapy (TT) is widely used to treat Acute Myocardial Infarction (AMI) to open up
an acutely occluded artery. Thrombolytic Therapy should be instituted in all patients with AMI
presenting within 12 hours of chest pain with no contraindication for receiving TT.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases with Acute Myocardial Infarction with indications for
Thrombolytic Therapy.
NA
Numerator
Denominator
:
:
Number of AMI patients who were admitted and received
Thrombolytic Therapy
Total number of AMI patients who were admitted with no
contraindications for TT
X 100%
Target
Data Collection
Comments/Review
:
:
:
90%
Monthly

Indicator 05 : Rate of “Normal” Diagnostic Coronary Angiogram
Rationale:
● Coronary Angiogram is a frequent investigation to diagnose Coronary Artery Disease
● This indicator measures clinical effectiveness.
1. Coronary Angiogram:
Coronary Angiogram is used to diagnose and/or treat various heart conditions. Doctors may
recommend this procedure for a number of different reasons. The most common reason is to
evaluate chest pain. Chest pain can be a symptom of coronary artery disease (CAD), and
coronary angiogram can show whether plaque is narrowing or blocking the heart’s arteries.
2. “Normal” Coronary Angiogram
“Normal” findings from a coronary angiogram will indicate mild (<30%) or no stenosis of the
coronary arteries.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who had undergone coronary angiogram.
NA
Numerator
Denominator
:
:
Number of patients who had coronary angiogram done and
found ‘normal’
Total number of patients who had coronary angiogram
done
x100%
Target
Data Collection
Comments/Review
:
:
:
< 5%
Monthly

Indicator 06 : Major Complication Rate during Diagnostic Coronary Angiogram
Rationale:
● Chest pain can be a symptom of coronary artery disease (CAD), and coronary angiogram
can show any stenosis or occlusion of coronary arteries.
● Coronary angiogram test does involve some risks. This indicator measures the clinical
effectiveness of care and competency of the healthcare professional.
1. Diagnostic Cardiac Catheterization:
Diagnostic Cardiac Catheterization is used to diagnose and/or treat various heart conditions.
Doctors may recommend this procedure for a number of different reasons. The most common
reason is to evaluate chest pain. Chest pain can be a symptom of coronary artery disease (CAD),
and cardiac catheterization can show whether plaque is narrowing or blocking the heart’s arteries.
2. Complications from diagnostic cardiac catheterization:
Similar to all surgical procedures, the cardiac catheterization test does involve some risks. Major
complications that may occur during the procedure include:
● Death
● Acute Myocardial Infarction
● Stroke
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who had cardiac catheterization done
NA
Numerator
Denominator
:
:
Number of patients who had major complications during /
and within 24 hours after diagnostic coronary angiogram.
Total number of patients who had diagnostic coronary
angiogram done
X100%
Target
Data Collection
Comments/Review
:
:
:
< 1%
Monthly

Indicator 07 : Major Complication Rates during Percutaneous Coronary
Rationale:
● Percutaneous Coronary Intervention is frequently used to treat significant lesions in
patient with Coronary Artery Disease.
● This indicator measures the clinical effectiveness of care and competency of the
healthcare professional.
1. Percutaneous Coronary Intervention;
Percutaneous Coronary Intervention is used to treat significant Coronary Artery Disease. These
specialized catheters include balloon catheters and devices that can open up narrowed arteries
which include stents, rotablator, etc
2. Major Complications from Percutaneous Coronary Intervention include:
● Death
● Acute Myocardial Infarction
● Stroke
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who had Percutaneous Coronary Intervention done
NA
Numerator
Denominator
:
:
Number of patients who had major complications during /
and within 24 hours after Percutaneous Coronary
Intervention
Total number of patients who had Percutaneous Coronary
Intervention done
X100%
Target
Data Collection
Comments/Review
:
:
:
< 1%
Monthly

Indicator 08 : Percutaneous Coronary Intervention (PCI) within 90 minutes
after hospital arrival “ Door to Balloon” Time
Rationale:
● This indicator measures clinical effectiveness
1. Primary Percutaneous Coronary Intervention (PCI):
Commonly known as coronary angioplasty or simply angioplasty, is a non-surgical procedure
used to treat the stenotic (narrowed) coronary arteries of the heart found in coronary heart
disease. PCI is usually performed by an interventional cardiologist.
2. Percutaneous Coronary Intervention (PCI):
Percutaneous Coronary Intervention is a specific term for opening up totally occluded arteries in
Acute Myocardial Infarction. Primary PCI is performed within 90 minutes after the arrival of the
patient at the hospital’s emergency department
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases with Acute Myocardial Infarction with indications for Primary
NA
Numerator
Denominator
:
:
Number of Acute Myocardial Infarction patients who had
primary PCI done within 90 minutes after hospital arrival
Total number of Acute Myocardial Infarction patients
admitted and had primary PCI done
X 100%
Target
Data Collection
Comments/Review
:
:
:
90%
Monthly

Indicator 09 : Percentage of high risk Acute Coronary Syndrome (ACS) cases
undergoing Cardiac Catheterisation during the index admission
Rationale :
● Acute Coronary Syndrome (ACS) is a frequent cause of hospital death nationally.
1. High risk Acute Coronary Syndrome (ACS)
For STEMI – TIMI Risk Score ≥ 6
For NSTEMI – TIMI Risk Score ≥ 5
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of high risk acute coronary syndrome (ACS)
NA
Numerator
Denominator
:
:
Number of high risk acute coronary syndrome (ACS)
Total number of patients of high risk acute coronary
syndrome (ACS) admitted and undergoing coronary
angiogram during index admission
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly
-

Indicator 10 : Percentage of Heart Failure Mortality Rate during index
hospitalisation
Rationale :
● Heart failure is a debilitating and deadly condition with high re-hospitalisation rates and
dismal survival rates comparable to most cancers. In Asian countries, heart failure is the
commonest cardiac cause of hospitalization (representing ~ 24% of all cardiac
admissions), and the 5-year survival rate in patients with heart failure is only 32%. The 1-
year mortality rate for South-East Asia is 13%.
● This indicator measures clinical effectiveness.
1. ICD 10 – Code for heart failure 150 which include:
150.0 Congestive Heart Failure (CHF)
150.1 Left Ventricular Failure (LVF)
150.9 Heart Failure, Unspecified
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of heart failure
NA
Numerator
Denominator
:
:
Number of mortality cases due to heart failure during index
hospitalisation
Total number of hospitalised heart failure patients
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 10%
Monthly
-

Indicator 11 : Percentage of Heart Failure Readmission Rate at 1-month
Rationale :
● Heart failure is a debilitating and deadly condition with high re- hospitalisation rates and
dismal survival rates comparable to most cancers. 30-day readmission rate ranges from
2.5 - 25% globally with Malaysian 30-day readmission rate of 17.8%.
● In Asian countries, heart failure is the commonest cardiac cause of hospitalization
(representing ~24% of all cardiac admissions), and the 5-year survival rate in patients with
heart failure is only 32%. The 30-day readmission rate (RR) for heart failure (HF) was
chosen as the indicator because it is one of the quality representations of inpatient and
outpatient care and potential cost reduction by preventing readmission. The United States
national rate of readmission for HF is 23%.
1. ICD 10 – Code for heart failure 150 which include:
150.0 Congestive Heart Failure (CHF)
150.1 Left Ventricular Failure (LVF)
150.9 Heart Failure, Unspecified
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of heart failure
NA
Numerator
Denominator
:
:
Number of heart failure patients readmitted within one
month after discharge of the index admission
Total number of hospitalised heart failure patients in one
Year
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 15%
Monthly
-

SERVICE STANDARD 09F: CLINICAL SERVICES (ONCOLOGY)
Frequency
1. Number of mortality/morbidity audits/meetings being
conducted in the department with documentation of
cases discussed
6 Monthly
2. Percentage of patients developed extravasation
during chemotherapy treatment
< 5% 6 Monthly
3. Percentage of oncology therapy prescription errors
(from prescription to administration)
Monthly

discussed
Rationale :
1. Morbidity Audits/Meetings:
2. Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient at
department/hospital level.
3. Documentation:
Official minutes or notes taken during the meeting with attendance list(certified by the Hospital
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
hospital level.
Process Indicator
Numerator
Denominator
:
:
that were conducted in six (6 ) months
Target
Data Collection
Comments/Review
:
:
:
-
6 Monthly
-

Indicator 02 : Percentage of patients developed extravasation during
chemotherapy treatment
Rationale :
● Extravasation is a grave complication of chemotherapy miss-delivery and can lead to
devastating effects on the patient.
● The aim of this indicator is to ascertain that chemotherapy delivery is being monitored by
the specialists through continuing medical education and dissemination of knowledge
about chemotherapy delivery to all stakeholders involved with the patient.
● It is an indirect measurement of adherence to stipulated chemotherapy delivery guidelines
essential to ensure safe practice, provide evidence based care and increase awareness
amongst healthcare givers.
1. Chemotherapy Treatment:
All types of intravenous administration of chemotherapeutic agents.
2. Extravasation:
Inadvertent infiltration of chemotherapy preparations and fluids into the subcutaneous or
subdermal tissues surrounding the intravenous administration site. The accidental leakage of
cytostatic/vesicant agents into the perivascular tissues may have devastating short-term and
long-term consequences for patients. In recent years, the increased focus on chemotherapy
extravasation has led to the development of international guidelines that have proven useful tools
in daily clinical practice.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Only hospitals with resident oncologists are included.
2. All patients that were given intravenous chemotherapy including
patients with chemoport access
3. Grade 3 or 4 of extravasation at any point during the Chemotherapy
treatment
Patients whose chemotherapy is given in hospitals where there is
only a visiting oncologist
Numerator
Denominator
:
:
Numbers or frequency of extravasation during
chemotherapy treatment
Total number of chemotherapy infusions (including via
Chemoport)
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 5%
6 Monthly
-

Indicator 03 : Percentage of oncology therapy prescription errors (from
prescription to administration)
Rationale :
● The occurrence of oncology therapy prescription error/misadventure in the delivery of
chemotherapy is a potentially preventable serious adverse event where there is much
pain and suffering or temporary/permanent disability or even death.
● The occurrence of error in oncology therapy prescription can lead to devastating effects
on the patient. The large amount of medications used for infusion as well as the availability
of new and potent chemotherapy requires further enhancement on the awareness on
medication safety.
Oncology Therapy Prescription Error (from prescription to administration) :
Any preventable event that may cause or lead to inappropriate use or patient harm while the
chemotherapy drug is in the control of the healthcare provider from prescription to administration.
Such events may be related to errors in professional practice, healthcare products, procedures,
and systems, including order communication; product labeling, packaging, prescribing;
reconstitution; dispensing; administration; monitoring and use.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients on chemotherapy drugs ( oral & infusion)
NA
Sentinel Event
Numerator
Denominator
:
:
Numbers of Oncology Therapy Prescription Errors made in
the process of prescribing, ordering, dispensing,
reconstitution and administration of cytotoxic drug in the
month
Total number of Oncology Therapy Prescriptions (from
prescription to administration) in the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

SERVICE STANDARD 09G: CLINICAL SERVICES (OPHTHALMOLOGY)
There is tracking and trending of specific performance as follows:
Frequency
1. Percentage of patients developed infectious
endophthalmitis following cataract surgery.
< 0.2 %
2 cases
per 1000
operations
6 Monthly
2. Percentage of patients without pre-existing
ocular co-morbidity obtained visual acuity of 6/12
or better within (<) 3 months following cataract
surgery.
≥ 90%
6 Monthly

Indicator 01 : Percentage of patients developed infectious endophthalmiti
following cataract surgery
Rationale :
● Infectious Endophthalmitis is a rare but devastating complication after cataract surgery
which may lead to permanent blindness. Morbidity associated with post-operative
Infectious Endophthalmitis can be substantial and is related not only to acute process
but also to late sequelae.
● The causes can be multifactorial from patient to surgical environmental factors
(contamination of sterilized instruments, disposable supplies, theatre environment, etc.
● Monitoring of this KPI is mandatory to ensure safety of the service.
Infectious Endophthalmitis:
Infection involving both the anterior and posterior segments of the eye after cataract surgery. A
patient post cataract can develop Infectious Endophthalmitis any time after the cataract surgery.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All elective cataract surgeries
All emergency and semi-emergency cataract surgeries.
Numerator
Denominator
:
:
Number of patients developed Infectious Endophthalmitis
following cataract surgery during the specified period
Total number of patients underwent cataract surgery during
the specified period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 0.2 % (2 cases per 1000 operations)
6 Monthly
-

Indicator 02 : Percentage of patients without pre-existing ocular co- obtained
visual acuity of 6/12 or better within (<) 3 months following
cataract surgery
Rationale :
● Cataract is a preventable blindness.
● Cataract surgery is indicated to improve the quality of life. Therefore, by measuring this
indicator, we can monitor the quality of service given.
Pre-existing ocular comorbidities:
● Diabetic Maculopathy.
● Advanced Diabetic Eye Disease.
● Macula Scar from any cause.
● Amblyopia.
● Optic neuropathy from any cause.
● Cornea opacities from any cause.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Patients with pre-existing ocular co-morbidity that will affect visual
outcome.
2. All emergency and semi-emergency cataract surgeries.’
Numerator
Denominator
:
:
Number of patients without pre-existing ocular co-morbidity
obtained visual acuity 6/12 or better within (≤) 3 months
Total number of patients without pre-existing ocular co-
morbidity underwent cataract surgery
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
6 Monthly
-

SERVICE STANDARD 09H: CLINICAL SERVICES (OTORHINOLARYNGOLOGY)
Frequency
1. Percentage of patients with waiting time of ≤
90 minutes to see the doctor at the
Otorhinolaryngology(ORL) Outpatient Clinic
≥ 90% Monthly
2. Percentage of ears with hearing
improvement 3 months post myringoplasty
≥ 70% Monthly
3. Incidence rate of primary post-tonsillectomy
haemorrhage
≤ 3% Monthly

Indicator 01 : Percentage of patients with waiting time of ≤ 90 minutes to see
the doctor at the Otorhinolaryngology (ORL) Outpatient Clinic
Rationale :
● MOH aims for waiting time to see the doctor at outpatient services, to be less than 90
● The waiting time is based on patient’s experience from the time the patient first registers
at the first counter in the hospital until seen by doctor. In view of many counters being
involved in some hospitals, some clinical departments have opted for monitoring of
registration from department counter, as any process prior to that appears out of the
clinical department’s control.
● For hospitals to eliminate or reduce waiting time, it is important to balance between the
hospital.
Waiting time:
Time of registration at department counter or time of appointment given to patient (whichever is
later) till the time the patient is first seen by the doctor, which is beginning of a consultation.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All outpatients of the Otorhinolaryngology Outpatient Clinic.
1. Patients who come without an appointment (“walk-in” patients).
2. Patients that need to do procedures on the same day before
seeing the doctors (e.g. blood taking or imaging).
Sampling:
Using an average of total patients seen in a month, 30% of the patients
in each month needs to be sampled for this indicator. Hospital/
department to ensure randomised sampling of data by ensuring each
clinic day of the week is included to ensure proper representation of
data.
Numerator
Denominator
:
:
minutes to see the doctor at Otorhinolaryngology
Outpatient Clinic
Total sample of patients seen by the doctor at the
Otorhinolaryngology Outpatient Clinic
X100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly
-

Indicator 02 : Percentage of ears with hearing improvement 3 months post
myringoplasty
Rationale :
● Myringoplasty is not a complicated surgery, can be done by general ORL surgeons. It is
a procedure that is performed in all ORL centres which allows comparison of services
between different centres.
● Outcome which is hearing improvement post-myringoplasty can be measured objectively
by pure tone audiometry.
Improvement of hearing:
It is the improvement 3 months post myringoplasty by a minimum of 5 dB at least one frequency
by pure tone audiometry. Patient should be seen in ORL clinic within 3 to 6 months post
myringoplasty to assess on hearing improvement. The number used in this indicator is based on
number of ears with myringoplasty done and not the number of patients.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients of ≥ 18 years of age
1. Patients of < 18 years of age
2. Revision surgery
3. Total perforation
4. Combine procedure (e.g. combined with mastoidectomy)
Numerator
Denominator
:
:
Number of ears with hearing improvement 3 months post
Myringoplasty
Total number of ears with myringoplasty done
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 70%
Monthly
-

Indicator 03 : Incidence rate of primary post-tonsillectomy haemorrhage
Rationale :
● Tonsillectomy is one of the commonest otorhinolaryngology surgical procedures and can
be conducted by the specialist as well as trained medical officers. It can potentially cause
significant morbidity and mortality.
● Internationally, the standard for primary post-tonsillectomy haemorrhage is less than 3%.
Primary haemorrhage:
1. Haemorrhage which occurs within 24 hours of surgery.
2. The haemorrhage shall be objectively identified clinically (e.g. active bleeding on the tonsillar
bed).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All tonsillectomies performed.
1. Tonsillectomy done as part of other procedures (e.g. sleep
apnoea surgery).
2. Bleeding due to patient’s premorbid (e.g. bleeding disorder).
3. Secondary haemorrhage: bleeding after 24 hours of surgery.
Numerator
Denominator
:
:
Number of primary post-tonsillectomy haemorrhages
Total number of tonsillectomies performed
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 3%
Monthly
-

SERVICE STANDARD 09 I: CLINICAL SERVICES (PSYCHIATRY AND MENTAL HEALTH)
two (2) of the following:
Frequency
6 Monthly
hours of discharge
Monthly
3. Dengue Case Fatality Rate 0% Monthly
4. Subspecialties units in the Psychiatry Services,
e.g. Respiratory Medicine, Gastroenterology,
Nephrology, Rheumatology, etc. shall monitor
any other two (2) indicators to support its goals
and objectives.

discussed
Rationale :
Mortality Meeting:
Discussions related to the management of the case and cause of death of the patient. (eg: Clinical
audit, POMR, MMR, Dengue Mortality, TB Mortality, Mortality under 5 years of age (MDG5),
Perinatal Mortality Reviews(MDG4) Inquiries ) at hospital level.
Documentation:
Official minutes or notes taken during the meeting with attendance list(certified by the Hospital
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
hospital level.
Process Indicator
Numerator
Denominator
:
:
Target
Data Collection
Comments/Review
:
:
:
-
6 Monthly
-

discharge
Rationale :
Same condition:
Comments:
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Re- admission with similar conditions (primary diagnosis) within 72
hours of discharge
Numerator
Denominator
:
:
X 100%
Target
Data Collection
Comments/Review
:
:
:
-
Monthly
-

Indicator 03 : Dengue Case Fatality Rate
Rationale :
● Dengue fever has now become endemic in Malaysia and is a potentially fatal condition
whose severity and frequency may be decreased by careful management planning. This
indicator is a measure of the OUTCOME of care of patients with dengue.
● This indicator measures the clinical effectiveness of management of dengue fever (both
haemorrhage and non- haemorrhage).
Dengue: Dengue Fever (DF) and Dengue Hemorrhagic Fever (DHF)
This is a clinical diagnosis decided by the doctor based on clinical findings as well as the relevant
investigations.
Remarks
(a) The 2nd Revision of the Malaysian CPG on the Management of Dengue Infection in Adults
2009 strongly recommends the monitoring of Dengue CFR and DHF Fatality rate
(b) According to the said CPG, all dengue deaths should be audited at individual hospital/state/
national level
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All deaths caused by dengue fever
Deaths caused by other causes
Numerator
Denominator
:
:
Number of cases admitted with DF & DHF/DSS and died
from DF & DHF/DSS
Total number of (DF & DHF) CASES admitted
X 100%
Target
Data Collection
Comments/Review
:
:
:
0%
Monthly
-

SERVICE STANDARD 09J: CLINICAL SERVICES (ORTHOPAEDICS)
Frequency
6 Monthly
hours of discharge
Monthly
3. Unplanned return to Operating Theatre within the
same hospital admission following surgery
Monthly
4. Percentage of patients with waiting time of more
than seven (7) working days for fixation of long
bone closed fracture
Monthly

SERVICE STANDARD 10: ANAESTHETIC SERVICES
two (2) of the following and this shall include monitoring of pain score upon discharge and
one other performance indicator:
Frequency
1. Mandatory indicator:
Pain score on discharge from recovery room should
be less than four (4)
100% Monthly
2. Number of adverse events following regional
anaesthesia, e.g. prolonged motor blockade,
inadvertent dural puncture, Local Anaesthetic (LA)
toxicity
Downward
Trend
Monthly
3. Number of patients having prolonged stay in recovery
room for more than two (2) hours (sentinel event)
0 Monthly
4. Patient satisfaction survey with acute pain service
and anaesthetic clinic
Upward
Trend
6 Monthly
5. Percentage of cancellation of elective cases after
being passed in the anaesthetic clinic
10% Monthly
6. Subspecialties units in the Anaesthetic Services, e.g.
Obstetrics and Gynaecology Services, cardiac
anaesthesia, etc shall monitor any other two (2)
indicators to support its goals and objectives of their
subspecialty.

Indicator 01 : Pain score on discharge from recovery room should be less
than four (4)
Rationale :
● Post- operative patients should be monitored closely and the pain score should be less
than four (4) on discharge from the recovery room as sometimes they may not have
adequate pain relief despite being managed by the acute pain team in the wards.
Pain Score :
Measures the patients’ pain intensity using the MOH Pain Scale (zero to ten)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who had undergone surgery under general anaesthesia
and are resting in the recovery room of the operating theatre
Cases operated under sedation or local anaesthesia administered by
surgeons
Numerator
Denominator
:
:
Number of patients with pain score less than four (4) on
discharge from the OT Recovery Room for the month
Total number of patients observed and monitored in the
OT Recovery Room for the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly
-

Indicator 02 : Number of adverse events following regional anaesthesia, e.g.
prolonged motor blockade, inadvertent dural puncture, Local
Anaesthetic (LA) toxicity
Rationale :
● The occurrence of adverse events leading to anaesthetic complications of regional a
naesthesia may indicate less than optimal anesthetic care. Patients should receive
adequate and effective regional anaesthesia and analgesia for certain types of surgery.
● Epidural anaesthesia is one of the techniques used for instillation of local anaesthetic into
the epidural space to provide anaesthesia.
● This indicator measures the clinical effectiveness of care and safety.
Complications of anaesthesia:
Refers to patients experiencing adverse events following regional anaesthesia both intra and
post- operative during or after elective surgery. The types of adverse events may vary but the
following to be considered:
i)Prolonged motor blockade following Regional Anaesthesia :
Refers to unexpected prolonged motor and sensory block and delayed recovery beyond the
expected duration of the local anaesthetic following regional anaesthesia. Peripheral nerve blocks
enjoy great importance in anaesthesia practice; they can provide safe and effective anaesthesia
with long-lasting analgesia.
(ii) Inadvertent dural puncture:
Process whereby epidural needle or catheter accidently punctures the dura at the level of the
injection site
iii) Local Anaesthetic (LA) toxicity:
While generally safe, local anesthetic agents can be toxic if administered inappropriately, and in
some cases may cause unintended reactions even when properly administered. The toxicity of
local and infiltration anesthetics can be local or systemic. Systemic toxicity of anesthetics most
often involves the central nervous system (CNS) or the cardiovascular system.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Epidural anaesthesia , Epidural analgesia, Obstetric Analgesia
Service, Combine Spinal Epidural (CSE), Spinal anaesthesia,
Peripheral Nerve Block, inclusive of day surgery cases
All general anaesthetic (GA) cases

Prolonged Motor Blockade
Numerator : Number of patients who develop prolonged motor
blockade
Denominator : Total number of patients operated under regional
anaesthesia
Inadvertent Dural Puncture
Numerator : Number of cases of inadvertent dural puncture
Denominator : Total number of cases received epidural anaesthesia/
analgesia and CSE
Local anaesthesia (LA) toxicity
Numerator : Number of patients who developed Local Anaesthetic
toxicity inadvertent dural puncture
Denominator : Total number of patients who received local anaesthetics
operated for regional anaesthesia
X 100%
X 100%
X 100%
Target
Data Collection
Comments/Review
:
:
:
Downward Trend
Monthly
-

Indicator 03 : Number of patients having prolonged stay in recovery room for
than two (2) hours (sentinel event)
Rationale :
● The occurrence of prolonged stay in the recovery room leading to operative
complications of anaesthesia may indicate less than optimal care.
● This indicator measures the clinical effectiveness of care and safety.
Prolonged stay in Recovery Room:
The occurrence of prolonged stay in the recovery room for more than two (2) hours may be multi-
factorial. Patients after surgeries are often kept in the recovery room until their condition is
stabilized before shifting them to their designated wards. Patients undergoing extensive surgery
will require extended recovery. A prolonged patient stay in the recovery room is a crucial issue
as it creates bottlenecks that may result in the slowing down of the surgical schedule, leading to
dissatisfaction for surgeons, nurses, patients, and their families. A medically appropriate length
of stay in the recovery room needs to be defined. The reasons for the prolonged stay in the
recovery room for more than two (2) hours need to be categorized under surgical or anaesthesia
causes.
Ref: Prolonged-stay patients in the Post Anaesthesia Care Unit (PACU): A review of the
literature. Lalani SB1, Ali F, Kanji Z.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients under regional anaesthesia of general anaesthesia
Patients operated under sedation or local anaesthesia administered
by surgeons
Sentinel Event
Numerator
Denominator
:
:
Number of patients having prolonged stay in recovery room
( ˃ 2 hrs) hours
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 04 : Patient satisfaction survey with acute pain service and
anaesthetic clinic
Rationale :
meeting patient needs for acute pain service and anaesthetic assessment clinic
1. Patient Satisfaction Survey on acute pain service:
Patient satisfaction survey on acute pain service is a measure of a patient’s need for the pain
service being met by the health care provider/service.
2. Patient satisfaction survey of the anaesthetic clinic:
Is a measure of a patient’s need for the anaesthetic services being met by the health care
provider/service.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All out-patients and inpatients managed by the Pain Management
Team and the Anaesthetic Clinic staff
NA
Numerator
Denominator
:
:
Numbers of patient satisfaction survey feedback with ≥80%
satisfaction level
Total numbers of patient satisfaction survey feedback
received
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Number of patient satisfaction survey feedback with ≥ 80%
satisfaction level done every six months (Upward trend)
6 Monthly
-

Indicator 05 : Percentage of cancellation of elective cases after being passed
in the anaesthetic clinic
Rationale :
● The effectiveness of the anaesthetic clinic service should reflect in the reduced rate of
cancellation for elective surgeries.
Elective Cases
Is defined as planned surgery; patients have been admitted and have been reviewed by the
Anaesthetic Team and put on the operating list.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Cancellation by Anaesthetic Team
2. Cancellation due to anaesthetic and/or medical reasons such as
uncontrolled diabetes, hypertension, heart disease etc.
1. Lack of ICU bed
2. URTI
3. Lack of OT time
4. Mechanical and electrical problem
5. Operation is cancelled by surgeon
Numerator
Denominator
:
:
Number of elective surgical cancellations after assessment
performed in Anaesthetic Clinic
Total number of preoperative assessment performed in
the Anaesthetic Clinic
X 100 %
Target
Data Collection
Comments/Review
:
:
:
10%
Monthly
-

SERVICE STANDARD 11: OPERATING SUITE SERVICES
five (5) of the following indicators:
Frequency
1. Mandatory indicator
Rate of compliance to Safe Surgery Saves Lives
(SSSL) practice
Monthly
2. Percentage of Elective Operation Cancellation Rate <10% Monthly
3. Percentage of patients awaiting emergency surgery
for more than 24 hours due to lack of OT time
<1% Monthly
4. Number of patients returning to surgery within 24
hours
sentinel
event
Monthly
5. Time taken for lower segment caesarean section
(LSCS) for fetal distress within 30 minutes of
informing operating theatre
sentinel
event
Monthly
6. Number of unnecessary delay in starting surgery after
induction of anaesthesia due to lack of personnel or
equipment
sentinel
event
Monthly
7. Number of incidents reported in the operating room 0 Monthly
8. Number of peri-operative mortality and morbidity
review
6 Monthly
9. Percentage of cases done as day care or Day Of
Surgery Admission (DOSA)
30% of all
surgeries
Monthly

Frequency
10. Number of adverse events following positioning
(sentinel event)
Sentinel
Event
Monthly

Indicator 01 : Rate of compliance to Safe Surgery Saves Lives (SSSL) practice
Rationale :
● The 2nd Global Patient Safety Challenge was the safety of surgical care. The goal of the
WHO Patient Safety Safe Surgery Saves Lives Challenge is to improve the safety of
surgical care around the world by defining a core set of safety standards that can be
applied in all countries and settings
● While surgical procedures are intended to save lives, unsafe surgical care can cause
substantial harm. To assist operating teams in reducing the number of adverse events,
WHO Patient Safety has identified ten essential objectives for safe surgery. These were
compiled into the WHO Surgical Safety Checklist.
● Using the WHO Patient Safety surgical safety checklist ensures that steps to promote safe
surgery are accomplished in a systematic and timely fashion.
1. Safe Surgery Saves Lives (SSSL):
The Safe Surgery Saves Lives programme was established by WHO Patient Safety as part of the
World Health Organization’s efforts to reduce the number of surgical deaths across the globe. To
assist operating teams in reducing the number of these events, WHO Patient Safety—in
consultation with surgeons, anaesthetists, nurses, patient safety experts and patients around the
world—has identified ten essential objectives for safe surgery. These were compiled into the
WHO Surgical Safety Checklist. The aim of this Checklist (available at www.who.int/safesurgery)
is to reinforce accepted safety practices and foster better communication and teamwork between
clinical disciplines. The Checklist is intended as a tool for use by clinicians in improving the safety
of their operations and reducing unnecessary surgical deaths and complications. Its use has been
demonstrably associated with significant reductions in complication and death rates in diverse
hospitals and settings, and with improvements in compliance to basic standards of care.
Reference; WHO Guidelines for Safe Surgery 2009- Save Surgery Saves Lives
2. Compliance to Safe Surgery Saves Lives (SSSL) practice:
Adherence to the use of WHO Surgical Safety Checklist for all patients undergoing surgery by
the operating team.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases sent to operating theatre and scheduled for surgery
There should be no exclusion criteria
Numerator
Denominator
:
:
Number of cases where WHO Surgical Checklist was
used for each patient that had undergone surgery
(evidence of copy of the checklist)
Total number of cases operated under General/Regional
Anaesthesia in a month
X 100 %

Target
Data Collection
Comments/Review
:
:
:
100%
Monthly
-

Indicator 02 : Percentage of Elective Operation Cancellation Rate
Rationale :
● Surgical procedure executed as planned reflects on customer satisfaction. Cancellation
may lead to patient’s disappointment and may jeopardise surgeon- patient rapport.
● This indicator reflects the quality of planning for elective operations in surgical based
disciplines.
1. Elective Surgery:
Surgery is planned for the patient by a surgeon
2. Operation Cancellation:
The surgery is cancelled in spite of already in the list for the operating day. Cancellations maybe
due to:
● Patients not turning up for surgery
● Inadequate OT time caused by over-listing/interruptions by emergencies
● Surgeon not available, blood not available, elective operations are common. The rates
vary depending on how the elective list is prepared.
● No consent, instrument failure and other reasons
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All elective surgeries scheduled
Cancellation due to acute medical problems rendering patient unfit for
surgery or anaesthesia
Numerator
Denominator
:
:
Number of elective surgery cancelled in the corresponding
period
Total number of elective surgery scheduled in the
corresponding period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 10%
Monthly
-

Indicator 03 : Percentage of patients awaiting emergency surgery for more
than 24 hours due to lack of OT time
Rationale :
● Emergency surgery has to be performed as early as possible in order to reduce patient
morbidity and mortality as well as potential public complaints.
● This indicator also reflects the timely access and patient centeredness.
Waiting time:
From the time the patient is ready for emergency surgery to the time the operation takes place.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Cases with the only reason for delay in Emergency Surgery of more
than (>) 24 hours is due to lack of OT Time.
NA
Numerator
Denominator
:
:
Total number of patients who waited more than (>)24
hours for emergency operation under general
anaesthesia/regional anaesthesia/monitored sedation/LA
due to lack of OT time
Total number of emergency surgeries done under general
anaesthesia/regional anaesthesia/monitored sedation/LA
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 1%
Monthly
-
Time patient is ready needs to be clearly defined/stated as ready alone
can be interpreted in many ways that can lead to marked data variation.
Hence the following aspects need to be fulfilled when patient is booked
for OT:
1. Fasting – appropriate fasting time according to guideline
2. Consent has been taken and ready
3. Medical condition appropriately optimised, if permissible
4. All relevant investigations, if required has been taken and results
ready

Indicator 04 : Number of patients returning to surgery within 24 hours
Rationale :
● Any return of patients within 24 hours to the theatre may indicate a quality problem due
to occurrence of intraoperative problems that are serious enough to warrant
intervention post-operatively.
Returning to surgery within 24 hours:
Unexpected return to the operating theatre within 24 hours of surgery to address a complication
of the original operation/surgery.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Elective surgical procedure performed under general anaesthesia/
regional anaesthesia/monitored sedation/LA
1. Endoscopy cases
2. Day Care cases
Sentinel Event
Numerator
Denominator
:
:
Number of patients returning to OT/surgery within 24
hours following an elective surgical procedure
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 05 : Time taken for Lower Section Caesarean Section for Grade 1
Level of Urgency (i.e. immediate danger to mother or fetus)
within 30 minutes of Informing operating theatre
Rationale :
● Good communication is central to timely delivery of the fetus, while avoiding unnecessary
risk to the mother. All members of the multidisciplinary team must be informed of the need
(or likely need) for caesarean delivery as early as possible, as well as specific instructions
on the degree of urgency.
● A target decision-to-delivery interval (DDI) for caesarean section for ‘fetal compromise’ of
30 minutes is an audit tool that allows testing of the efficiency of the whole delivery team
and has become accepted practice; however certain clinical situations will require a much
quicker DDI than 30 minutes and units should work towards improving their efficiency.
● Once a decision to deliver has been made, therefore, delivery should be carried out with
an urgency appropriate to the risk to the baby and the safety of the mother
Ref: Royal College of Obstetricians & Gynaecologists; Royal College of Anaesthetists: Good
Practice No: 11; April 2010.
1. Lower Section Caesarean Section for Grade 1 Level of Urgency
Emergency caesarean section (CS) should be undertaken where the health professional
concerned suspects maternal or fetal compromise. Guidelines on electronic fetal monitoring
recommend that delivery should occur as soon as possible, ideally within 30 minutes taking into
account fetal heart rate and maternal factors. Grades:
GRADE 1: Immediate threat to the life of the mother or fetus. Needs to be done within 30
minutes from decision. Paediatrician should be present in all cases. Examples:
• Prolonged fetal bradycardia,
• Cord prolapse
• Uterine rupture
• APH/abruption
• Cord PH <7.20
• Pathological CTG
2. Fetal Distress
Fetal distress occurs when the baby's oxygen supply is compromised in utero, usually during
labor but occasionally in the third trimester of pregnancy. Oxygen deprivation can result in
decreased fetal heart
rate and can be serious for the baby. The standard of within 30 minutes for fetal distress on
informing the operating theatre for a C- Section has become the criterion by which good and bad
practice is being defined both professionally and medico-legally. The implication is that caesarean
section for fetal distress that takes longer than 30 minutes represents suboptimal or even
negligent care.

Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases of emergency caesarean sections for fetal distress
NA
Sentinel Event
Numerator
Denominator
:
:
Number of emergency Caesarean Sections done for fetal
distress within 30 minutes of informing the operating
theatre (OT) in proportion to the number of emergency
caesarean sections done that exceeded the standards.
The number of Emergency Caesarean Sections done
for fetal distress within 30 minutes of informing OT
over the total number of Emergency Caesarean
Sections for fetal distress.
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 06 : Number of unnecessary delay in starting surgery after induction
of anaesthesia due to lack or personnel or equipment
Rationale :
● The occurrence of unnecessary delay in starting surgery after induction of anaesthesia
indicates less than optimal care.
● This indicator also reflects timeliness of care and patient centeredness.
1. Delay in starting Surgery
Start time delays in the operating room have a negative effect on its efficiency and the working
environment and are signs of an imperfect system. Starting late means considerable wait time for
staff, patients and waste of resources.
2. Induction of Anaesthesia
i. The administration of a drug or combination of drugs at the beginning of an
anesthetic that results in a state of general anesthesia.
ii. The process of causing general anesthesia by the administration of
pharmaceutics.
iii. For regional anaesthesia or peripheral nerve block, completion of administration of block
is equivalent to the phase of induction of Anaesthesia in general anaesthesia.
Ref: Medical-dictionary.thefreedictionary.com/induction of anesthesia
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All cases listed for surgery under anaesthesia (general or regional)
All cases undergoing surgery under local anaesthesia administered
by the surgeon
Sentinel Event
Numerator
Denominator
:
:
Number of cases with delay in starting surgery after
induction of anaesthesia
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 07 : Number of incidents reported in the operating room
Rationale :
This indicator was selected as a generic indicator of the delivery of safe patient care because:
● A key component of clinical governance is the responsibility of the head of the operating
theatre (OT) to ensure that the service monitors and acts on incidents that can potentially
compromise patient safety.
● Incident Reporting ensures sharing of lessons learnt from incidents, root cause analysis
and best practices in patient safety.
● Incident Reporting facilitates patient safety efforts including the reduction of risk to patients
1. Incidents occurring in the operating theatre
Any deviation from the usual clinical care that causes an injury to the patient or poses risk of
harm, that include near misses, errors, preventable Adverse Events and hazards:
● Near Misses - A ‘near miss’ is an event that might have resulted in harm but the problem
did not reach the patient because of timely intervention by healthcare providers or the
patient or family, or due to good fortune. Near misses may also be referred to as "close
calls" or "good catches." (Ref: Institute of Medicine, USA)
● Adverse Event - An injury related to medical management rather than complications of
disease. Medical management in the operating theatre includes all aspects of care
including surgical procedure, wrong patient, wrong surgical site, failure of equipment and
the systems used to deliver care. Examples of adverse events include: Respiratory
Distress leading to intubation, Cardiac Arrest in the Recovery Room, A stay of ˃ 2 hours
in the Recovery Room etc. Adverse events maybe preventable or non- preventable.
● Errors are mishaps that have the potential to cause an adverse event.
● Hazard refers to any threat to safety e.g. unsafe practices, staff conduct, equipment, labels
and names.
2. Incident Reporting:
An Incident Reporting System refers to the processes and technology involved in the
standardization, formatting, communication, feedback, analysis, learning, response and
dissemination of lessons learned from reported events; and analysing the incidents scientifically
in a structured manner through Root Cause Analysis.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of incidents, near misses, adverse events
NA
Sentinel Event
Numerator
Denominator
:
:
Number of incidents (clinical) reported in the operating
theatre over a month
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 08 : Number of peri-operative mortality and morbidity review
Rationale :
● The main purpose of the perioperative mortality and morbidity review is to improve
patient management and quality of care.
● Regular perioperative mortality and morbidity reviews serve to examine the weakness
and shortfalls in the clinical care of the patients. These reviews are not punitive and serve
to improve management of the patients; hence the same mistakes could be prevented
and would not be repeated in the future.
1. Perioperative Mortality:
Is death in relation to surgery. An important consideration in the decision to perform any surgical
procedure is to weigh the benefits against the risks. Anesthesiologists and surgeons employ
various methods in assessing whether a patient is in optimal condition from a medical standpoint
prior to undertaking surgery.
2. Peri-Operative Mortality Review:
Review of all deaths occurring within total length of hospital stay following a surgical or
gynaecological procedure performed under general or regional anaesthesia. Also included are
deaths in operation theatre before induction of anaesthesia.
3. Length of Hospital Stay:
Is defined as “a hospital admission during the course of which surgery was performed FOR
WHATEVER REASON”. Death during this period is considered a `POMR death’ regardless of the
period of death from the time of surgery provided it occurs WITHIN THE SAME ADMISSION.
Ref: Peri-Operative Mortality Review Ministry of Health, Malaysia.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All deaths occurring within total length of hospital stay following a
surgical or gynaecological procedure performed under general or
regional anaesthesia. Also included are deaths in the operation
theatre before induction of anaesthesia.
1. Surgery performed elsewhere/during previous admission but
patient was admitted and died during the present admission
WITHOUT SURGICAL INTERVENTION.
2. Diagnostic and/ or therapeutic procedures carried out by physician
and other non- surgeons.
3. Radiological procedures performed solely by the Radiologist
without a surgeon’s involvement
4. Endoscopy(eg.OGDS/Colonoscopy/ERCP) performed under
sedation or/and LA
5. Surgery performed outside OT complex. E.g. Procedure room
6. Obstetric deaths (Pregnancy > 28 weeks). Ectopic pregnancy (<
28 Weeks gestation are included)

Numerator
Denominator
:
:
Number of perioperative mortality and morbidity reviews
in six (6) months
Target
Data Collection
Comments/Review
:
:
:
6 Monthly
-

Indicator 09 : Percentage of cases done as day care or day of surgery
admission (DOSA)
Rationale :
● This indicator measures the use of appropriate resources in the hospital for surgery
Day Care/ Day of surgery admission (DOSA)
Day surgery or Day of surgery admission (DOSA) describes the process whereby patients are
admitted to hospital and have surgery, and discharged home on the same day. Hospital
management has embraced the concept of DOSA. If the DOSA policy is to continue it is
imperative that an adequate preoperative assessment clinic is established to prevent negative
outcomes for our patients.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All surgeries done ( day care cases & inpatients)
NA
Numerator
Denominator
:
:
Total number of surgeries done as day care/ DOSA in the
month
Total number of surgeries ( inpatients & DOSA) done in a
month
X 100%
Target
Data Collection
Comments/Review
:
:
:
30% of all surgeries
Monthly
-

Indicator 10 : Number of adverse events following positioning (sentinel event)
Rationale:
● The occurrence of peripheral nerve injuries following positioning during anaesthesia
(surgery) is a reflection of poor patient care. These injuries may produce lasting disability;
hence recognition of risks and prevention is essential.
● This indicator measures the clinical effectiveness of care and patient safety. Positioning
is the joint responsibility of the surgeon and anesthesiologist.
● Failure to follow professional standards and guidelines may result in
positioning injuries and liability.
1. Surgical Positioning (Recommended to be monitored under Surgical Services)
All positioning has 3 goals:
● Maximum exposure to the surgical area while maintaining homeostasis and preventing
injury
● Position must provide the Anesthetist with adequate access to the patient for airway
management, ventilation, medications, and monitoring
● Promote the enhancement of a satisfactory surgical result
2. Lithotomy Position
Lithotomy position is used for variety of procedures including gynaecological and urological
surgery.
With the patient in the supine position, the hips are flexed from the torso so that legs are
parallel to it and legs are abducted by 30 ‐45 degrees to expose the perineal region. The
patient’s buttocks are even with the lower back in the OR bed (to prevent lumbosacral strain).
The legs and feet are placed in stirrups that support the lower extremities. The perineum
should be in line with the longitudinal axis of the OR bed.
3. Peroneal Injury
Perioperative peripheral neuropathy refers to postoperative signs and symptoms related to
peripheral nerve injury and have been associated with use of the lithotomy position; resulting
in peroneal injury with foot drop noted within 24 hours post-operatively.
● Caused by direct pressure on the nerve with the legs in lithotomy position.
● Nerve compressed against neck of fibula
● anesthetists should monitor and assess patient positioning and protective measures at
frequent intervals.
● Prevented by adequate padding of lithotomy poles.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients undergoing surgery in Lithotomy position under General
Anaesthesia
Pre-existing foot drop prior to surgery
Sentinel Event

Numerator
Denominator
:
:
Number of cases that developed adverse events following
positioning e.g. foot drop within 24 hours post-surgery
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

SERVICE STANDARD 12: AMBULATORY CARE SERVICES
Frequency
1. Unplanned admissions of Ambulatory Care patients
as inpatient.
<5% Every 3 Monthly
2. Cancellation rate of Ambulatory Care cases <15% Every 3 Monthly

Indicator 01 : Unplanned admissions of Ambulatory Care patients as inpatient.
Rationale :
● Ambulatory Care patients are usually more stable and can be treated on an outpatient
basis. Proper screening and selection of the patient with set criteria should be a
prerequisite to select patients for Ambulatory Care Services.
● This indicator can be used to assess the quality of Ambulatory Care Services by the
number of unplanned admissions as inpatients.
● Generally, patients receiving safe clinical services as per protocol unless due to patient
factor should not be subjected to unplanned admissions.
1. Ambulatory Care:
Ambulatory Care is defined as Clinical services, scheduled, and completed in the same day
(same calendar day) and does not require the patient to stay overnight in the hospital. The
services should include 4 criteria:
(a) The patient are scheduled / elective) to undergo treatment.
(b) The scheduled Procedures have been done
(c) Procedures carried out require a short recovery period together with the complete
documentation and the progress of the patient during the observation period.
(d) Patients are discharged from the observation ward in the same calendar day.
2. Unplanned Admission:
Admission of Ambulatory Care cases as inpatients that was not planned for during initial
screening. Admitted to any clinical discipline/ward regardless of length of stay and diagnosis that
was unplanned.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of Ambulatory Care registered patients within the
Ambulatory Care unit.
Patients who request for admission for varying reasons e.g. for
purpose of insurance claims.
Quality of Care Indicator
Numerator
Denominator
:
:
Number of unplanned admissions of Ambulatory Care
patient as inpatients.
Target
Data Collection
Comments/Review
:
:
:
< 5%
3 Monthly
-

Indicator 02 : Cancellation rate of Ambulatory Care cases
Rationale :
● This indicator reflects the quality of planning for Ambulatory Care Services.
● The cancellation of cases listed for elective procedures is common. The rates vary
depending on how the list and patients have been prepared.
● Proper screening and selection of the patient with set criteria should be a prerequisite
to
select patients for Ambulatory Care Services.
Case Cancellation:
Cases listed on the Ambulatory Care list but the procedure is not done on that particular schedule.
Cancellations maybe due to:
● Patients not turning up for the procedure.
● Patients found unfit for procedure on the scheduled day of the Ambulatory Care service
● Clinician not available, no consent, instrument failure and other less common reasons
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of Ambulatory Care cases registered patients within the
Ambulatory Care Unit.
NA
Numerator
Denominator
:
:
Number of Ambulatory Care patients scheduled for
procedures and cancelled during the study period
Total Number of Ambulatory Care patients registered and
scheduled for procedures during the study period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 15%
3 Monthly
-

SERVICE STANDARD 12A : AMBULATORY CARE SERVICES – ENDOSCOPY SERVICES
Frequency
1. Cancellation Rate of Ambulatory Endoscopy cases. < 15% Monthly
2. Percentage of ‘No Show’ of Ambulatory Endoscopy
cases
< 2% 3 Monthly

Indicator 01 : Cancellation Rate of Ambulatory Endoscopy cases
Rationale :
● This indicator reflects the quality of planning for Ambulatory Endoscopy Services.
● The cancellation of endoscopy cases listed for elective procedures is common. The rates
vary depending on how the list and patients have been prepared.
● Proper screening and selection of the patient with set criteria should be a prerequisite to
select patients for Ambulatory Endoscopy Services.
Case Cancellation:
Cases listed on the Ambulatory Endoscopy list but the procedure is not done on that particular
schedule. Cancellations maybe due to:
● Patients not turning up for the Endoscopy procedure.
● Patients found unfit for the procedure on the day of appointment.
● Inadequate time for the endoscopy procedure caused by over-listing, interruptions by
emergencies or inefficiency related
● Surgeon/Gastroenterologist not available, no consent, instrument failure and other less
common reasons
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All ambulatory patients registered for endoscopy procedure within the
Ambulatory Care Unit.
NA
Numerator
Denominator
:
:
Number of ambulatory patients scheduled for endoscopy
procedure and cancelled for the specified period
Total number of ambulatory patients scheduled for
Endoscopy procedure for the specified period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 15%
Monthly
-

Indicator 02 : Percentage of ‘No Show’ of Ambulatory Endoscopy cases
Rationale :
● This indicator reflects the quality of planning for Ambulatory Endoscopy services and
measures the use of appropriate resources in the hospital for Ambulatory Procedures.
● Cases for Ambulatory Endoscopy needs to be carefully selected and counselled on
keeping their appointments as provided; for optimal use of resources and facilities that
needs to be optimized so that needing cases are attended to in a timely manner.
● Proper screening and selection of the patients with set criteria should be a prerequisite to
select patients for Ambulatory Endoscopy services.
‘No Show’ for Ambulatory endoscopy Services
‘No Show’ for Ambulatory endoscopy Services refers to patients not turning up for the Endoscopy
procedure appointment although already being listed for any given time and date for the
procedure without any prior notification.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All Ambulatory Endoscopy cases registered and scheduled for the
procedure on the specific day within the Ambulatory Care Unit for the
study period
NA
Numerator
Denominator
:
:
Number of Ambulatory Endoscopy cases registered and
scheduled for Endoscopic procedure but did not turn up
(‘No Show’) without notification for the procedure during the
study period
Total Number of Ambulatory Endoscopy cases registered
and scheduled for endoscopy procedures during the study
period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 2%
3 Monthly
-

SERVICE STANDARD 12B: AMBULATORY CARE SERVICES (OPHTHALMOLOGY)
There is tracking and trending of specific performance as follows:
Frequency
1. Percentage of patients developed infectious
endophthalmitis following cataract surgery.
< 0.2 %
2 cases
per 1000
operations
6 Monthly
2. Percentage of patients with post - operative
visual acuity of 6/12 or better within 3 months
following cataract surgery and refractive
procedure in patients without pre-existing ocular
co-morbidity
< 85 % 6 Monthly

Indicator 01 : Percentage of patients developed infectious endophthalmitis
Rationale :
● Infectious Endophthalmitis is a rare but devastating complication after cataract surgery
which may lead to permanent blindness. Morbidity associated with post-operative
Infectious Endophthalmitis can be substantial and is related not only to acute process
but also to late sequelae.
● The causes can be multifactorial from patient to surgical environmental factors
(contamination of sterilized instruments, disposable supplies, theatre environment, etc.
● Monitoring of this KPI is mandatory to ensure safety of the service.
Infectious Endophthalmitis:
Infection involving both the anterior and posterior segments of the eye after cataract surgery. A
patient post cataract can develop Infectious Endophthalmitis any time after the cataract surgery.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All emergency and semi-emergency cataract surgeries.
Numerator
Denominator
:
:
Number of patients developed Infectious Endophthalmitis
following cataract surgery during the specified period
Total number of patients underwent cataract surgery during
the specified period
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 0.2 % (2 cases per 1000 operations)
6 Monthly
-

Indicator 02 : Percentage of patients with post - operative visual acuity of 6/12
or better within 3 months following cataract surgery and
refractive procedure in patients without pre-existing ocular co-
morbidity
Rationale :
● Cataract is a preventable blindness.
● Cataract surgery is indicated to improve the quality of life. Therefore, by
measuring this indicator, we can monitor the quality of service given.
Pre-existing ocular comorbidities:
● Diabetic Maculopathy.
● Advanced Diabetic Eye Disease.
● Macula Scar from any cause.
● Amblyopia.
● Optic neuropathy from any cause.
● Cornea opacities from any cause.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Patients with pre-existing ocular co-morbidity that will affect
visual outcome.
2. All emergency and semi-emergency cataract surgeries.
Numerator
Denominator
:
:
Number of patients without pre-existing ocular co-morbidity
obtained visual acuity 6/12 or better within 3 months
Total number of patients without pre-existing ocular co-
morbidity underwent cataract surgery
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 85 %
6 Monthly
-

SERVICE STANDARD 13: CRITICAL CARE
(ICU/CCU/CICU/CRW/HDU/BURNS CARE UNIT)
Frequency
1. Rate of pressure ulcers < 3% Monthly
2. Rate of unplanned extubation < 5% Monthly
3. Rate of Ventilator Associated Pneumonia (VAP) < 10 per
1000
ventilator
days
Monthly
4. Rate of Catheter Related Blood Stream Infection < 5 per
1000
catheter
days
Monthly
5. Compliance rate to hand hygiene > 75% Monthly
6. For Level 2 & 3 Care, standardized mortality ratio and
benchmarking with other Units Yearly

Indicator 01 : Rate of Pressure Ulcers
Rationale :
This indicators was selected because:
● Pressure ulcers/sores result in patient discomfort, increased length of stay, morbidity and
mortality
● This indicator looks at patient safety and measures the quality of nursing care.
Pressure Ulcer/Sore:
Pressure ulcer/sore is defined as a localized injury to the skin and/or underlying tissue usually
over the bony prominence as a result of pressure or pressure in combination with shear and/or
friction. It is a circumscribed area in which cutaneous tissue has been destroyed and there is
progressive destruction of underlying tissue caused by interference with circulation and nutrition
to the area. Signs include blister or broken skin or sore formation over pressure areas (redness
is excluded).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who develop new pressure ulcers during their stay in the
critical care unit (including those with pre-admission pressure sores
which have worsened during the stay in critical care unit)
All patients with pre- admission pressure sores which have become
better
Numerator
Denominator
:
:
Number of patients who developed new pressure ulcers
(including those with pre-admission pressure sores which
have worsened) during their stay in the critical care unit in
the month
Total number of patients admitted to the critical care unit
during the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 3 %
Monthly
-

Indicator 02 : Rate of unplanned extubation
Rationale :
● Unplanned extubation in the critical care unit is associated with increased risk of re-
intubation, aspiration pneumonia and ventilator associated pneumonia.
● This indicator measures patient safety and quality of care.
Unplanned Extubation: (UEX)
Unplanned extubation refers to unintended or accidental dislodgement or removal of
endotracheal or tracheostomy tube from the trachea by the patient or staff. Simple measures
should be adopted to minimize the incidence of UEX and its related complications: more vigilance
during procedures at patients' bedsides, appropriate management of agitated patients, strong
fixation of the tracheal tube, attention to the oral endotracheal tube in terms of anchorage and
level of tube, and daily assessment of the possibility of weaning from the ventilator.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients who are on invasive ventilator
NA
Numerator
Denominator
:
:
Number of unplanned extubation in the Critical Care Unit
Total number of patients invasively ventilated in the Critical
Care Unit
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 5 %
Monthly
-

Indicator 03 : Rate of Ventilator Associated Pneumonia
Rationale :
● Ventilator-associated pneumonia (VAP) is a complication in invasively ventilated patients
which carries high morbidity and mortality. Ventilator Care Bundle (VCB) is a set of 4
evidence-based interventions to reduce the incidence of VAP. The 4 interventions are:
- Head of bed elevation> 30 degrees
- Use of stress ulcer prophylaxis
- Use of deep vein thrombosis prophylaxis
- Daily sedation vacation
Ventilator-associated pneumonia
Ventilator-associated pneumonia is defined as pneumonia occurring more than 48 hours of
invasive mechanical ventilation. Patients who have been ventilated before admission should be
determined if they have ventilator-associated pneumonia. Those patients who have ventilator-
associated pneumonia on admission to a critical care unit are excluded.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All invasively ventilated patients who developed ventilator-associated
pneumonia after 48 hours of ventilation
All patients who have been ventilated before ICU admission and are
diagnosed to have developed ventilator-associated pneumonia on
admission to the critical care unit
Numerator
Denominator
:
:
Number of patients who developed ventilator associated
pneumonia in the Critical Care Unit in the month
Total number of patient ventilated days in the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 10 per 1000 ventilator days
Monthly
-

Indicator 04 : Rate of Catheter Related Blood Stream Infection
Rationale :
● Catheter-related bloodstream infection (CRBSI) represents a serious complication in a
critical care unit and is potentially lethal. Central venous catheter care bundle consists of
5 evidence-based interventions as having the greatest effect on the rate of CRBSI and
the lowest barrier to implementation. The 5 interventions are:
- Hand hygiene
- Maximal barrier precautions upon insertion
- Chlorhexidine skin antisepsis
- Optimal catheter site selection, with subclavian vein as the preferred
site of non-tunneled catheters
- Daily review of line necessity with prompt removal of unnecessary
lines
Catheter Related Blood Stream Infection (CRBSI):
Catheter Related Blood Stream Infection (CRBSI) is defined as bacteremia/fungemia in a patient
with a central catheter for more than 48 hours. The following criteria must be met before the
diagnosis of CRBSI is made:
1. The catheter must be in use for more than 48 hours
2. Patients have clinical signs of sepsis
3. Blood culture taken from the catheter and a peripheral vein grow the same organsims
4. There is no apparent source for the bloodstream infection except the catheter
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients with central venous catheter/s in the critical care unit
NA
Numerator
Denominator
:
:
Number of patients who developed catheter-related blood
stream infection
Total number of patients - days with central venous
catheter/s in the critical care unit
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 5 per 1000 catheter days
Monthly
-

Indicator 05 : Compliance rate to hand hygiene
Rationale :
● Healthcare Associated Infection (HAI) is a significant problem in hospitals and has an
impact on the safety of patient, staff and visitor.
surveillance of all staff including staff of contracted services to ensure the effectiveness of
the hospital’s Prevention and Control of Infection programme as well as the
implementation of WHO Patient Safety Solution on ‘Improved Hand Hygiene to Prevent
Healthcare Associated Infections’
● Compliance to Hand Hygiene should be compulsory rather than optional for all relevant
staff to avoid transmission of harmful germs and prevent healthcare associated infections.
1. Hand Hygiene:
Any action of hygienic hand antisepsis in order to reduce transient microbial flora (generally
performed either by hand rubbing with an alcohol-based formulation or handwashing with plain
or antimicrobial soap and water).
2. Compliance to Hand Hygiene:
Hand hygiene (HH) is the single most important factor in the prevention of healthcare associated
infections. The 3 most frequently reported methods of measuring HH compliance are: (1) direct
observation, (2) self-reporting by health care workers (HCWs), and indirect calculation based on
HH product usage. A compliance audit is a comprehensive review of staff adherence to regulatory
guidelines/ protocols/directives/initiatives etc.
3. The Opportunity:
Is an accounting unit for action; it determines the need to perform hand hygiene action, whether
the reason (the indication that leads to the action) be single or multiple.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All staff including specialists, medical officers, house officers, nursing
staff, allied health staff and students (undergraduate and post
graduate medical students, student nurses and students of allied
health) and staff of the privatised services (housekeeping, linen
service, Facility and Biomedical equipment maintenance services)
involved in direct or indirect patient care.
NA
Numerator
Denominator
:
:
Number of hand hygiene actions performed
Number of opportunities observed X 100%

Target
Data Collection
Comments/Review
:
:
:
> 75%
Monthly
Ref:
1. Hand Hygiene Performance “ My 5 moments for Hand Hygiene”
2. Technical Specification: Performance Indicators For Medical
Programme 2012, Medical Development Division Ministry of
Health

Indicator 06 : For Level 2 & 3 Care, standardized mortality ratio and
benchmarking with other Units
Rationale :
● Standardized mortality ratio (SMR) takes into account varying case-mix of different
Critical care units and is a useful performance indicator for different units over time.
● SMR also allows benchmarking with other units so as to improve product and service
quality
Standardized Mortality Ratio (SMR):
SMR is the ratio of observed deaths in the study group to expected deaths in the general
population. This ratio can be expressed as a percentage simply by multiplying by 100. The
expected deaths are calculated by a formula which utilizes severity scoring systems e.g Simplified
Acute Physiology Score (SAPS II) or Acute Physiology And Chronic Health Evaluation (APACHE
II). All patients must be scored within 24 hours of admission using SAPS or APACHE to obtain
the expected deaths.
The SMR may be quoted as either a ratio or a percentage. If the SMR is quoted as a ratio and is
equal to 1.0, then this means the number of observed deaths equals that of expected deaths. If
higher than 1.0, then there is a higher number of deaths than is expected.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
The SMR for all Level 2 & 3 Critical Care Units
NA
Process Based Indicator
Numerator
Denominator
:
:
Target
Data Collection
Comments/Review
:
:
:
Yearly

SERVICE STANDARD 13A: CRITICAL CARE
(SCN/NICU/PICU/PHDW)
Frequency
1. Rate of central line associated blood stream infection
(CLABSI)
(Refer to Central Venous Catheter Care Bundle
Manual A quality initiative for the prevention of Central
Venous Catheter-Related Blood Stream Infection
(CVC-BSI) April 2008)
< 5% per
1000
catheter
days
Monthly
2. Rate of Ventilator Associated Pneumonia (VAP) < 15% per
1000
ventilator
days
Monthly
3. Percentage of survival of inborn very low birth weight
infants between 1000 – 1499g birthweight
(Refer Technical Specifications for Key performance
indicators (KPI) Clinical Services Medical Programme
2021)
90% Monthly
4. Report of mortality/morbidity audits/meetings being
conducted in the unit with documentation of cases
discussed
6 Monthly

Indicator 01 : Rate of central line associated blood stream infection (CLABSI)
Rationale :
● Catheter-related bloodstream infection (CRBSI) represents a serious complication in a
critical care unit and is potentially lethal. Central venous catheter care bundle consists of
5 evidence-based interventions as having the greatest effect on the rate of CRBSI and
the lowest barrier to implementation. The 5 interventions are:
▪ Hand hygiene
▪ Maximal barrier precautions upon insertion
▪ Chlorhexidine skin antisepsis
▪ Optimal catheter site selection, with subclavian vein as the preferred site of non-
tunneled catheters
▪ Daily review of line necessity with prompt removal of unnecessary
▪ lines
Catheter Related Blood Stream Infection (CRBSI):
CRBSI is defined as bacteremia/fungemia in a patient with a central catheter for more than 48
hours. The following criteria must be met before the diagnosis of CRBSI is made:
1. The catheter must be in use for more than 48 hours
2. Patients have clinical signs of sepsis
3. Blood culture taken from the catheter and a peripheral vein grow the same organsims
4. There is no apparent source for the bloodstream infection except the catheter.
Method of calculating CRBSI :
No of episodes CRBSI
X 1000 catheter days = %
No of catheter days
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients with central venous catheter/s in the critical care unit
(SCN/NICU/PICU/PHDW)
NA
Numerator
Denominator
:
:
Number of paediatric patients that developed catheter -
related blood stream infection
Total number of paediatric patients with central venous
catheter/s in the NICU/PICU
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 5% per 1000 catheter days
Monthly

Indicator 02 : Rate of Ventilator Associated Pneumonia
Rationale :
● Ventilator-associated pneumonia (VAP) is a complication in invasively ventilated
patients
which carries high morbidity and mortality. Ventilator Care Bundle (VCB) is a set of 4
evidence - based interventions to reduce the incidence of VAP.
Ventilator-associated pneumonia
Ventilator-associated pneumonia is defined as pneumonia occurring more than 48 hours of
invasive mechanical ventilation. Patients who have been ventilated before admission should be
determined if they have ventilator-associated pneumonia. Those patients who have ventilator
associated pneumonia on admission to a critical care unit are excluded.
Method of calculating VAP :
Total patient with VAP
X 1000 ventilator days = %
No of ventilator days
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All invasively ventilated patients who developed ventilator-associated
pneumonia after 48 hours of ventilation
All patients who have been ventilated before ICU admission and are
diagnosed to have developed ventilator-associated pneumonia on
admission to the critical care unit
Numerator
Denominator
:
:
Number of patients who developed ventilator associated
pneumonia in the Critical Care Unit
(SCN/NICU/PICU/PHDW) in the month
Total number of patient ventilated days in the critical care
unit (SCN/NICU/PICU/PHDW) in the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 15% per 1000 ventilator days
Monthly

Indicator 03 : Percentage of survival of inborn very low birth weight infants
between 1000 – 1499 gm birthweight
Rationale :
● This group of infants comprises a significant proportion of patients who utilize NICU and
special care nursery resources.
● The survival of these infants impacts significantly on the under 5 survival target.
1. Very Low Birth (VLBW): Birth weight below 1500 gm
2. Live Birth: Born alive
3. Inborn: Born in the same hospital
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Inborn infants of birth weight between 1000- 1499 gm
2. Livebirths
Babies born with major/lethal congenital anomalies (LCM)
Numerator
Denominator
:
:
Number of inborn livebirths of birthweight between 1000 –
1499 gm, without lethal congenital malformations, who
survive to discharge
Total number of inborn livebirths of birthweight between
1000-1499 gm without lethal congenital malformations
X 100%
Target
Data Collection
Comments/Review
:
:
:
90%
Monthly

discussed
Rationale :
● Regular mortality and morbidity meetings among department staff examine weaknesses
and shortfalls in the overall management of patients. These meetings are not punitive
and serve to improve management of patients.
● Majority of children die below the age of 5 years. Review of all deaths among children
will enable healthcare providers to rectify and improve services to children.
● This indicator measures Clinical Effectiveness and Safety in reducing mortality and
morbidity.
1. Mortality and morbidity audits/meetings:
2. Mortality Review:
Discussions related to the management of the case and cause of death of the patient [e.g.
Clinical Audit, PMOR, Dengue Mortality, Mortality under 5 years of age (MDG5), Perinatal
Mortality Reviews (MDG4), Inquiries] at department/hospital level.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Number of mortality & morbidity meetings conducted at
department/hospital Level
Babies born with major/lethal congenital anomalies (LCM)
Process Indicator
Numerator
Denominator
:
:
Number of mortality and morbidity meetings in 6 months
period
Target
Data Collection
Comments/Review
:
:
:
6 Monthly

SERVICE STANDARD 13B: CRITICAL CARE SERVICES
(LABOUR DELIVERY SERVICES)
Frequency
1. Percentage of massive Primary Post-Partum
Haemorrhage (PPH) incidence in cases
delivered in the hospital (exclusion criteria :
placenta previa and adherence placenta)
(Ref: Technical Specifications Key Performance
Indicators (KPI) Clinical Services, Medical
Programme, MOH version 7.0, 2021)
< 0.5% Monthly
2. Complication rate from instrumental/vaginal
deliveries: incidence of 3rd and 4th degree tears < 10%
Monthly
3. Maternal Mortality Sentinel
Event
Monthly
4. Perinatal Mortality Monthly

Indicator 01 : Percentage of massive Primary Post-Partum Haemorrhage (PPH)
incidence in cases delivered in the hospital (exclusion criteria :
placenta previa and adherence placenta)
Rationale :
This is an indicator of the quality of obstetric care because:
● The incidence of massive obstetric haemorrhage is reflective of the effectiveness of the
management of haemorrhage at delivery. Post-partum haemorrhage (PPH) occurs in 3-
5% of pregnant mothers and is still the leading cause of maternal death in Malaysia.
● The use of this indicator would be reflective of prompt diagnosis and speed of instituting
multidisciplinary care.
Massive Post- Partum Haemorrhage (PPH):
Total amount of blood loss of more than (>) 1.5 litres within (≤) 24 hours of delivery. Delivery
includes both the vaginal and abdominal routes
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All deliveries within the facility - Both vaginal and abdominal routes.
1. Adherent Placenta (e.g. Accreta/ Increta/ Percreta).
2. Placenta Previa.
3. Abruption Placenta.
4. Patients delivered outside of the facility.
Numerator
Denominator
:
:
Number of patients with massive Primary Post-Partum
Haemorrhage (PPH) in the hospital
Total number of deliveries (all modes of delivery) in the
hospital
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 0.5 %
Monthly
As PPH remains the leading cause of Maternal mortality, an indicator
measuring the effectiveness and efficiency of care in this condition
should be measured in all hospitals

Indicator 02 : Complication rate from instrumental/vaginal deliveries: Incidence
of 3rd and 4th degree tears
Rationale :
● This indicator was selected to ensure good care to the mother and baby during delivery.
With effective obstetric care, most of the complications during instrumental delivery can
be anticipated and reduced or avoided.
● Obstetric Trauma is a debilitating injury to the patient. The injury of third and fourth degree
perineal tears during vaginal delivery may lead to possible long term complications. These
types of tears can be prevented/reduced by employing appropriate labour management
and care standards
1. An instrumental delivery, or also called assisted birth or operative vaginal birth: Is one where
a pair of forceps or ventouse is used when the baby needs help to be born.
2. 3rd
and 4th
degree perineal tear: Refers to incidence of Perineal Laceration /tear following
vaginal delivery.
3. Complications of instrumental deliveries:
a) Ventouse (Vacuum):
Maternal: Vaginal laceration due to entrapment of vaginal mucosa between suction cup
and foetal head
Foetal Complications: scalp injuries, cephalohaematoma, intracranial haemorrhage,
subgaleal haemorrhage, birth asphyxia, retina haemorrhage neonatal jaundice
b) Forceps:
Maternal: Trauma to soft tissue, bleeding from laceration ,trauma to urethra and bladder-
fistula, pain
Foetal: Bruising and laceration to the face, injury to the foetal scalp, cephalohaematoma,
retina haemorrhage, skull fracture, permanent nerve damage. The risk of shoulder
dystocia is increased following instrumental deliveries.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients who underwent vaginal deliveries in the hospital:
● With instrumentation/without instrumentation
● Sustained third(3rd) degree and fourth (4th ) degree perineal
laceration/tear
● Complications from instrumental delivery i.e. cephalohaematoma,
intracranial haemorrhage etc
Patients who delivered outside of the hospital
Numerator
Denominator
:
:
Total number of patients with complications from
instrumental /vaginal deliveries
Total number of instrumental/vaginal deliveries
X 100%

Target
Data Collection
Comments/Review
:
:
:
< 10%
Monthly

Indicator 03 : Maternal Mortality
Rationale :
● This indicator reflects maternal health and enables safety considerations in reducing
maternal mortality.
● Most maternal deaths are avoidable, as the health-care solutions to prevent or manage
complications are well known. All women need is access to antenatal care in pregnancy,
skilled care during childbirth, and care and support in the weeks after childbirth. It is
particularly important that all births are attended by trained and skilled health
professionals, as timely management and treatment can make the difference between life
and death. To improve maternal health, barriers that limit access to quality maternal health
services must be identified and addressed at all levels of the health system.
Maternal Death
According to the World Health Organization (WHO), maternal death is defined as the death of a
woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration
and site of the pregnancy, from any cause related to or aggravated by the pregnancy or its
management but not from accidental or incidental causes.
Generally, there is a distinction between a direct maternal death resulting from complications
arising during pregnancy, labour or during the post-partum period. Deaths may result from
interventions, omissions, incorrect treatment or from a chain of events resulting from any of the
above. The indirect obstetric deaths may result from previous existing disease or diseases, which
are aggravated by the pregnancy resulting in her death. An example would be heart disease.
Fortuitous deaths are those deaths that occur in a pregnant woman which are unrelated to her
pregnancy and may have caused her death even if she were not pregnant.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All direct and indirect maternal deaths
Patients who delivered outside of the Fatalities during but unrelated to
a pregnancy are termed fortuitous
maternal deaths.
Sentinel Event
Numerator
Denominator
:
:
Total number of Maternal Deaths
Total number of Live Births
Remarks: Maternal Mortality Rate is expressed as per 100,
000 live births.
X 1000
Target
Data Collection
Comments/Review
:
:
:
Sentinel Event
Monthly

Indicator 04 : Perinatal Mortality
Rationale :
● This indicator reflects maternal health and perinatal care of mothers and enables safety
considerations in reducing perinatal mortality.
● This indicator was selected to ensure good care to the mother and baby during delivery.
● Pre-term births and multiple pregnancies, and birth defects are the most common causes
of perinatal mortality besides respiratory distress syndrome, birth defects and toxaemia in
pregnancy. Hence safe prenatal care and monitoring of pregnant mothers as well as
skilled and trained medical staff including midwives, paediatricians and the availability of
facilities for managing complicated cases are important factors in reducing perinatal
mortality.
Perinatal Mortality:
Perinatal mortality is defined as the number of fetal deaths pass 22 or 28 completed weeks of
pregnancy plus the number of deaths among live born babies up to 7 completed days of life, per
1000 total births (live births and still births).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All perinatal deaths occurring among foetus/livebirths who had been
delivered in the hospital
All perinatal deaths occurring among births occurring outside the
hospital
Quality Indicator
Numerator
Denominator
:
:
Total number of foetal deaths pass 22 weeks-28 completed
weeks of pregnancy plus deaths among live births up to 7
completed days of life.
Target
Data Collection
Comments/Review
:
:
:
Monthly

SERVICE STANDARD 14: RADIOLOGY/DIAGNOSTIC IMAGING SERVICES
(Facility with Radiologist)
Frequency
1.
FACILITY WITH RADIOLOGIST
Percentage of Plain Films/Images Reported by
Radiologists
< 5% Monthly
2. Percentage of reject / retake of mammogram images < 3% Monthly
3. Percentage of Radiological Examination Errors i.e.
wrong marker, use of primary markers, wrong site X-
rayed, wrong patient X-rayed
Monthly
4. Complication rate for Post-Interventional Procedures Monthly
5. Perfect, Good, Moderate, Inadequate (PGMI) audits for
mammography
≥ 97% for
Perfect, Good
& Moderate
Monthly
6. Percentage of patients with significant
pneumothorax/haemorrhage requiring intervention
following percutaneous interventional procedures in the
thorax, abdomen and pelvis
≤10% Monthly
7. Percentage of patients with waiting time of ≤60 minutes
for commencement of ultrasound examination
≥ 90% Monthly
8. Turnaround time of ≤ 2 working days for final report of
special radiological examination done on inpatients
≥ 97%
Monthly
9. Turnaround time of ≤ 14 days for final report of special
radiological examination done on outpatients
≥ 90% Monthly

Frequency
10. Percentage of patients developed significant contrast
media extravasation following CT examination with
intravenous (IV) contrast media
< 1% Monthly

Indicator 01 : Percentage of plain films/images reported by Radiologists
Rationale :
● For radiological examination to have an impact on patient management, the films/images
should be reported by radiologists and in a timely manner.
A Radiological Report :
Is a clinical and source document that provides interpretation and describes any radiology
procedure conducted by a Radiologist. The only person who is privileged to prepare and
document a radiology report is a qualified physician (radiologist) who has been granted specific
clinical privileges in that hospital or clinical settings. It is an official medical document that provides
description and interpretation for any officially requested radiological exam.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All inpatients and out patients undergoing radiological examinations
Cases done when the resident radiologist is not available in the
Hospital.
Numerator
Denominator
:
:
Total number of radiological examinations (plain images
and special examination) reported by Radiologist
Total number of patients undergoing radiological
examinations (plain images and special examination)
X 100 %
Target
Data Collection
Comments/Review
:
:
:
< 5%
Monthly

Indicator 02 : Percentage of reject/retake mammogram images
Rationale :
● This indicator is a reflection of many of the processes carried out in an imaging
department.
● This indicator has great relevance as it reflects on almost all the processes in the
department namely radiographic techniques, performance of X-ray machines, film/ image
processing and storage of films.
● Internationally, the percentage of reject-retake images is quoted to be around 4-11% in
average. This indicator was selected as an indicator to assess the appropriate use of
special equipment and conduct of radiological examinations such as mammogram as they
have an impact on the cost of radiographic techniques and time spent when there are
rejects retakes.
1. Mammogram:
Mammograms are used as a screening tool to detect early breast cancer in women
experiencing no symptoms. They can also be used to detect and diagnose breast disease in
women experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge
2. Radiographic images: Images acquired using digital (DR/ CR) system.
3. Rejected images:
Any radiographs or images acquired during radiographic examinations/ radiological
procedures that has no diagnostic value and has to be repeated/ retake. This refers to
radiographs or images of patients that are assessed by the radiographer or the requesting
clinician/ radiologist to be clinically unacceptable.
4. Image retake: Repeat exposure to the patient due to earlier non-diagnostic image or
rejected by the radiologists and clinicians.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All mammogram images done in the facility
2. All mammogram images rejected by radiographers, radiologist
and clinicians.
1. Images discarded due to testing purposes.
2. Images used for quality assurance procedures
Numerator
Denominator
:
:
Total number of number of rejected mammogram images
Total number of mammogram images made in the same
period
X 100%

Target
Data Collection
Comments/Review
:
:
:
< 3%
Monthly

Indicator 03 : Percentage of Radiological Examination Errors i.e.
wrong marker, use of primary markers, wrong
site x-rayed, wrong patient x-rayed
Rationale :
● There is a need for adequate quality control in performing Radiological examinations to
ensure the effectiveness of the Radiological Services.
● This indicator is a reflection of the many processes carried out in an imaging department.
In a conventional imaging department this indicator has great relevance as it reflects on
all the processes namely radiographic techniques, performance of x- ray machines, film
processing and storage of films. It also takes into account instances when the radiological
examination was not performed according to what was requested by the referring doctor.
Radiological Examination Errors:
Errors in performing Radiological Examinations that include a repeat of plain x-rays and all
contrast examinations, CT, MRI, and ultrasound due to wrong marker or use of primary marker,
wrong part or wrong view, wrong site or wrong patient.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All radiological examinations that had to be repeated due to the Wrong
Part or Wrong View being taken by the radiographer/radiologist.
NA
Numerator
Denominator
:
:
Total number of radiological examinations that had to be
repeated due to wrong part, wrong view, wrong site or
wrong patient X-rayed
Total number of radiological examinations/imaging done in
the same period
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 04 : Complication rate for post interventional procedures
Rationale :
● Commonly performed interventional radiological procedures may be associated with
morbidity such as pneumothorax and haemorrhage. Thus the morbidity arising from these
procedures should be kept to an absolute minimum.
● This indicator addresses the safety of the process of diagnostic procedures in patient
management.
1. Radiological Interventional Procedure:
Radiological Interventional Procedures include the performance of biopsy of lung, mediastinum
or abdominal organs under image guidance. The first post- procedural chest imaging is defined
as occurring from 0-4 hours after the procedure.
2. Post interventional procedural complications:
This refers to unexpected complications of interventional radiological procedures, typically met in
the monitoring of patients during and after interventional procedures. Examples are
pneumothorax or haemorrhage following percutaneous interventional procedures of the
thorax/abdomen/pelvis.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients undergoing interventional radiological procedures
NA
Numerator
Denominator
:
:
Number of patients with post procedural complications
following interventional radiological procedures
Total number of patients underwent interventional
radiological procedures
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 05 : Perfect, Good, Moderate, Inadequate (PGMI) audits for
mammography
Rationale :
● Breast cancer is one of the most frequent cancers among women in both developed and
developing countries. In Malaysia breast cancer is the most commonly diagnosed cancer
among women of all ethnic groups.
● Mammography remains the most effective screening tool in comparison to clinical breast
examination and breast self-examination.
● Radiology and allied professionals in the field of mammography needs to carry out
appropriate radiologic practice that is as effective as possible and safe for the patient.
Mammography, as in other fields of radiologic practice requires specific training, skills and
techniques.
● Image classification in relation to PGMI system maximizes high quality of images and
minimizes technical repeats.
1. Mammogram
Mammograms are used as a screening tool to detect early breast cancer in women experiencing
no symptoms. They can also be used to detect and diagnose breast disease in women
experiencing symptoms such as a lump, pain, skin dimpling or nipple discharge.
2. Perfect, Good, Moderate, Inadequate (PGMI)
PGMI is a method of evaluation of clinical image quality in mammography developed by the
United Kingdom Mammography Trainers Group with the support of the Royal College of
Radiographers, aimed to ensure the maintenance of a high standard of mammography in Breast
Screening and to facilitate a method of external audit.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All mammogram images for breast screening taken in the month
NA
Audit on Quality of Mammogram images
Numerator
Denominator
:
:
Number of mammogram images with PGM results
Total number of mammogram images taken in the month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 97% for Perfect, Good & Moderate
Monthly

Indicator 06 : Percentage of patients with significant pneumothorax /
haemorrhage requiring intervention following percutaneous
interventional procedures in the thorax, abdomen and pelvis
Rationale :
● Commonly performed interventional radiological procedures may be
associated with morbidity such as pneumothorax and haemorrhage. Thus
the morbidity arising from these procedures should be kept to an absolute
minimum.
● This indicator addresses the safety of the process of diagnostic procedures
in patient management.
1. Pneumothorax:
Defined as the presence of air in FIRST post-procedural chest imaging. The first post-
procedural chest imaging is defined as occurring from 0-4 hours after the procedure.
2. Significant pneumothorax:
One that requires chest tube insertion.
3. Significant Haemorrhage:
Defined as bleeding requiring fluid resuscitation within (≤) 24 hours of the procedure.
4. Percutaneous Interventional Procedures:
Include the performance of biopsy of lung, mediastinum, pelvis or abdominal organs under image
guidance.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All percutaneous interventional procedures performed on organs within
the thorax/abdomen/pelvis.
Procedures performed on breasts, superficial lesions and for vascular
access.
Numerator
Denominator
:
:
Number of patients with significant
pneumothorax/haemorrhage requiring intervention
following percutaneous interventional procedures in the
thorax, abdomen and pelvis
Total number of patients underwent percutaneous
interventional procedures in the thorax, abdomen and
pelvis
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≤ 10%
Monthly

Indicator 07 : Percentage of patients with waiting time of ≤60 minutes for
commencement of ultrasound examination
Rationale :
● Waiting time for patient to undergo an ultrasound examination should be kept to a
minimum.
● This indicator measures Patient Satisfaction.
Waiting Time:
Time of appointment/registration (whichever is later) to the time the ultrasound examination is
performed
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients with scheduled appointments
1. Patients without prior appointments/unscheduled
2. Unprepared cases
Numerator
Denominator
:
:
Number of patients with waiting time of ≤ 60 minutes for
commencement of ultrasound examination
Total number of patients commenced ultrasound
examination
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly

Indicator 08 : Turnaround time of ≤ 2 working days for final report of special
radiological examination done on inpatients
Rationale :
● For a radiological examination to have any impact on patient management, it should be
available to the clinician in a timely manner.
1. Turnaround time:
The time taken between completion of the examination to the availability of report (not including
public holidays and weekend).
2. Final Report:
Reports that have been verified by a radiologist.
3. Special Radiological Examinations:
All contrast examinations, CT, MRI, Ultrasound, Mammograms and Angiograms
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All special radiological examinations performed on inpatients
Cases done when the resident radiologist is not available in the
hospital
Numerator
Denominator
:
:
Number of special radiological examinations performed on
inpatients reported within ( ≤ ) 2 working days
Total number of special radiological examinations
performed on inpatients
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≤ 97%
Monthly

Indicator 09 : Turnaround time of ≤ 14 days for final report of special
radiological examination done on outpatients
Rationale :
● For a radiological examination to have any impact on patient management, it
should be available to the clinician in a timely manner.
1. Turnaround time:
The time taken between completion of the examination to the availability of report (not including
public holidays and weekend).
2. Final Report:
Reports that have been verified by a radiologist.
3. Special Radiological Examinations:
All contrast examinations, CT, MRI, Ultrasound, Mammograms and Angiograms
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All special radiological examinations performed on out patients.
NA
Numerator
Denominator
:
:
Number of special radiological examinations performed on
inpatients reported within ( ≤ ) 14 working days
Total number of special radiological examinations
performed on outpatients
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≤ 90%
Monthly

Indicator 10 : Percentage of patients developed significant contrast media
extravasation following CT examination with intravenous (IV)
contrast media
Rationale :
● CT with intravenous (IV) contrast media is a commonly performed procedure in the
Department of Radiology.
● Contrast extravasation is a known complication which occurs more frequently with power
injection. It may also occur with hand injections.
● Large volumes (usually ˃ 50 mls) of contrast media are known to induce significant tissue
damage. However smaller volumes may also have adverse outcomes especially in
paediatric patients.
● Contrast media are known to induce significant tissue damage such as:
a) Skin ulceration
b) Soft tissue necrosis
c) Compartment syndrome
● The incidence of contrast media extravasation should be kept to the minimum.
1. Contrast media extravasation:
Contrast leaks into the tissue around the vein where the intravenous needle is inserted.
2. Significant contrast media extravasation:
Volume of ˃ 50mls which necessitate referral to the primary team or volumes not more than 50mls
but requiring referral to the primary team.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All CT examinations performed involving intravenous (IV) contrast
media.
1. Patients with comorbidity that prone to have extravasation
2. History of receiving chemotherapy/Radiotherapy
3. Intravenous Drugs Users (IVDU)
4. Age ˃ 60 years old
5. Emaciated patients
6. Oedematous patients
Numerator
Denominator
:
:
Number of patients developed significant contrast media
extravasation following CT examination with intravenous
(IV) contrast media
Total number of patients undergo CT examination with
intravenous (IV) contrast media
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 1%
Monthly

SERVICE STANDARD 14: RADIOLOGY/DIAGNOSTIC IMAGING SERVICES
(Facility without Radiologist)
1. Percentage of accurate interpretation of x-rays films by
medical officers as reported by radiologist [in reference to
indicator (i)]
Monthly
2. Percentage of radiographic errors, i.e. wrong marker,
use of primary markers, wrong site x-rayed, wrong
patient x-rayed
< 5 %
Monthly

Indicator 01 : Percentage of accurate interpretation of x-rays films by medical
officers as reported by radiologist [in reference to indicator
(i)]
Rationale :
● In hospitals without a resident radiologist, this indicator reflects the accuracy of the
interpretation of the x-ray films by medical officers with reference to the films reported by
radiologist.
● For radiological examination to have an impact on patient management, the films/images
should be accurately interpreted.
A Radiological Report:
A Radiological Report Is a clinical document that provides interpretation to any radiological
films/images by a radiologist. The only person who is privileged to prepare and document a
radiology report is a qualified physician (radiologist) who has been granted specific clinical
privileges in that hospital or clinical settings. It is an official medical document that provides
description and interpretation for any officially requested radiological exam.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All x-rays films sent to the radiologist for reporting
NA
Numerator
Denominator
:
:
Number of radiological reports (for X- rays films sent for
reporting) from the Radiologist that corresponds to the
Medial Officers findings
Total number of X-ray films sent to the Radiologist for
reporting
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 02 : Percentage of radiographic errors, i.e. wrong marker, use of
primary markers, wrong site x-rayed, wrong patient x-rayed
Rationale :
● There is a need for adequate quality control in performing Radiological examinations to
ensure the effectiveness of the Radiological Services.
● This indicator is a reflection of the many processes carried out in an imaging department.
In a conventional imaging department this indicator has great relevance as it reflects on
all the processes namely radiographic techniques, performance of x- ray machines, film
processing and storage of films. It also takes into account instances when the radiological
examination was not performed according to what was requested by the referring doctor.
Radiological Examination Errors:
Errors in performing Radiological Examinations that include a repeat of plain x-rays and all
contrast examinations and ultrasound due to wrong marker or use of primary marker, wrong part
or wrong view, wrong site or wrong patient.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All radiological examinations that had to be repeated due to the Wrong
Part or Wrong View being taken by the radiographer
NA
Numerator
Denominator
:
:
Number of radiological examinations/ imaging that had to
be repeated due to wrong part, wrong view, wrong site or
wrong patient X-rayed
Total number of radiological examinations/imaging done in
the same period
X 100 %
Target
Data Collection
Comments/Review
:
:
:
< 5%
Monthly

SERVICE STANDARD 15: PATHOLOGY SERVICES
Frequency
1. Timeliness of urgent requests Monthly
2. Rejection Rate of specimens <1%
3. Notification of critical results. Monthly

Indicator 01 : Timeliness of results of urgent requests
Rationale :
● One of the objectives of a medical laboratory is to provide timely laboratory results for the
management of medical emergency to ensure timeliness of urgent requests.
● Timeliness of the services is the capability of the laboratory providing fast results.
● A fast laboratory turnaround time (LTAT) is desirable and is one of the indicators of
efficient laboratory services
● This indicator measures the clinical effectiveness of care and is expected to reflect the
time taken for urgent and normal request for tests and the corresponding results to
institute the appropriate care.
1. Laboratory Turnaround Time (LTAT):
Refers to the time the specimen is received in the laboratory to the time the test results is validated
and dispatched or available in the system. This should be within the agreed target time and
quality objective of the service for urgent requests.
2. Urgent Request:
Refers to urgent requests for laboratory tests made for immediate management of patients or
emergency cases
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All requests made for laboratory tests and samples sent that are
labelled as urgent.
1. Request for non- urgent laboratory tests
2. Request not for immediate management of patients
3. Laborayory tests done at POCT site
Numerator
Denominator
:
:
Number of urgent requests made for laboratory tests and
complied to the timeliness of results for the corresponding
period
Total number of urgent requests made for laboratory tests
for the corresponding period
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly

Indicator 02 : Rejection Rate of Specimens
Rationale :
● There is a need for validity and reliability in performing laboratory testing of specimens to
ensure appropriate patient care and effectiveness of the Pathology Services.
● This indicator and has great relevance as it reflects on the processes of collection of
specimens and transportation, techniques of testing, performance of machines and
processing to obtain accurate and reliable results to provide effective patient care. It also
takes into account instances when the specimen was not obtained as per technical
instruction for the specific specimen.
Specimens rejected by the laboratory and testing needing to be repeated.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All testing done for in-patients and the testing is done within the same
admission.
NA
Numerator
Denominator
:
:
Total number of specimens rejected
Total number of specimens sent for testing in the same
period
X 100 %
Target
Data Collection
Comments/Review
:
:
:
< 1%
Monthly

Indicator 03 : Notification of critical laboratory tests results
Rationale :
● Active communication of critical results is part of overall responsibilities of patient care
in clinical pathology service. Requestor has a responsibility to ensure contact details are
clear. Individual laboratory must define their pathway for critical result reporting and
define a failsafe system
● This is in line with the Malaysian Patient Safety Goal No. 8 which requires critical result
to be notified within 30 minutes when is ready to be reported. Failure of timely
communication and follow up of critical laboratory values (results) can lead to errors and
increased morbidity and mortality.
● It is important to ensure timely critical result communication between the laboratory and
the clinician for safe patient care.
Reference: Technical Specifications Key Performance indicators (KPIs) Clinical
Services, Medical Programme Version 4.0 2016.
1. Critical Result: Test result or value that falls outside the critical limits or the presence of any
unexpected abnormal findings which may cause imminent danger to the patient and/or
require immediate medical attention.
2. Critical Limit: Boundaries of low and high laboratory test results beyond which may cause
imminent danger to the patient and /or require immediate medical attention.
3. Result Verification: Means results analysed, confirmed and ready to be reported.
4. Notification: Any mode of communication e.g. telephone, SMS. All communication must be
documented. The notification is timely as agreed/stated in the service objectives of the
laboratory.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All notification of critical results of laboratory tests done as per stated
Reference Standards for the corresponding period including Point of
Care Testing (POCT)
NA
Numerator
Denominator
:
:
Number of timely notification of critical results for all
laboratory tests done in the Facility including POCT results
for the corresponding period
Total number of laboratory tests done in the Facility
including POCT for the corresponding period
X 100 %

Target
Data Collection
Comments/Review
:
:
:
Monthly

SERVICE STANDARD 16: BLOOD TRANSFUSION SERVICES
Frequency
1. Cross- Match Transfusion Ratio ≤ 2.0 Monthly
2. Expiry rates of different blood components
-red cell: ≤ 2.5%
-platelet concentrates: ≤ 15%
-apheresis (platelet or plasma): 0%
red cell: ≤ 5%
platelet concentrates:
≤ 15%
apheresis (platelet or
plasma): 0%
Monthly
3.
Number of adverse events in donors
(adverse donor reactions and
seroconversion)
0 Monthly
4. Number of Adverse Events in patients [near
misses, transfusion errors (incorrect blood
component transfused), transfusion reactions,
transfusion transmitted infections)
0 Monthly

Indicator 01 : Cross- Match Transfusion Ratio
Rationale:
● Cross-match transfusion ratio is an indicator of appropriateness of blood ordering. A ratio
of more than 2.5 reflects excessive ordering of blood cross matching tests, thus imposing
inventory problems for blood banks, an increase in workload, cost and wastage.
● This indicator is intended to assist in the enhancement of the cost efficiency of cross-
matching process, avoid unnecessary additional workload on laboratory personnel and
results in better management of blood stocks.
● This indicator has great relevance on the judicial use of blood and blood products which
carries high risks when not administered appropriately as well as assesses the
performance of the Blood Transfusion Services.
1. Cross- Match:
A compatibility test carried out on patient’s serum with donor red blood cells before blood is
transfused.
2. Transfusion:
The infusion of crossed- matched whole blood or red blood cell concentrates to the patient.
3. Cross - match transfusion ratio:
A ratio of the number of red blood cell units crossed matched to the number of red blood cell units
transfused.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All units of packed red blood cells that are cross-matched in the blood
bank for potential transfusion.
Safe Group O blood given without cross match in an emergency
situation.
Numerator
Denominator
:
:
Number of red cell units cross - matched
Number of red cell units transfused
Remarks:
CT Ratio is Total number of units cross matched : Total
number of units transfused
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 2.0%
Monthly
-

Indicator 02 : Expiry rates of different blood components:
● red cell: ≤ 5%
● platelet concentrates: ≤ 15%
● apheresis (platelet or plasma): 0%
Rationale:
● Utilization of donated blood can be fully optimized by preparing blood components from
the collected whole blood.
● This indicator reflects safety precautions and standards on the use of blood and blood
products which can be life threatening when not administered appropriately.
● This indicator reflects the increasing expectations of safety standards in the blood
transfusion services
Blood Components:
Therapeutic components of blood (red cell, white cell, platelets, plasma) that can be prepared by
centrifugation, filtration and freezing using conventional blood bank methodology.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All units of blood components prepared/kept in the blood bank
NA
1. Red cell blood component
Numerator
Denominator
:
:
Number of expired units of red cell blood component
Total number of units of red cell blood component
prepared/available
X 100%
2. Platelet concentrates
Numerator
Denominator
:
:
Number of expired units of platelet concentrates blood
component
Total number of units of platelet blood component
prepared/available
X 100%
3. Apheresis (platelet or plasma)
Numerator
Denominator
:
:
Number of expired units of Apheresis (platelet or plasma)
Total number of units of Apheresis (platelet or plasma)
prepared/available
X 100%

Target
Data Collection
Comments/Review
:
:
:
Red cell: ≤ 5%
Platelet concentrates: ≤ 15%
Apheresis (platelet or plasma): 0%
Monthly
-

Indicator 03 : Number of adverse events in donors (adverse donor reactions
and seroconversion)
Rationale:
● Regular voluntary non- remunerated blood donors are safer source of blood for transfusion
as they have lower risk of carrying any agents of blood borne infection.
● Donor safety is of paramount importance during blood donation sessions and is assured,
in so far as it can be, by donor selection guidelines, SOPs, adequately trained staff and
appropriate facilities. Despite these measures, various adverse events and reactions can
and do occur during and after blood donation. These complications can be a negative
experience for donors. Hence Blood Centres have a duty of care to minimise the risks to
donors.
● This indicator reflects the effectiveness of care of blood donors and the increasing
expectations of safety standards and cost.
1. Regular Blood Donors:
Qualified blood donors who have donated their blood at a minimum frequency of 2 times within
two years in the same blood centre.
2. Adverse Events/Adverse reactions in Donors:
Refers to any unintended response in donor from complications related to blood donation. The
complications are grouped into two main categories: those with predominantly local symptoms
and those with predominantly generalized symptoms. The most common systemic adverse
events were fatigue, vasovagal symptoms and nausea and vomiting. The most common arm
findings were bruise arm soreness and haematoma. The more serious complications are specific
to aphaeresis donations, e.g. citrate reactions, haemolysis, air emboli, allergic reactions to
ethylene oxide used in the sterilization of the harness, and thrombocytopenia and protein
deficiency from excessive platelet or plasma donations respectively .
Ref: Manual on Adverse events and reactions during blood donation- EU definition.
A surveillance program on blood donor reactions needs to be established especially on
seroconversion.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of blood donors (e.g. new, regular, relapsed)
Deferred donor due to temporary and permanent deferral.
Numerator
Denominator
:
:
Number of cases of adverse events in donors reported in
a given period of time
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

Indicator 04 : Number of Adverse Events in patients [near misses, transfusion
errors (incorrect blood component transfused), transfusion
reactions, transfuse transmitted infections)
Rationale:
● Blood transfusion is a complex process which involves several personnel in the blood
bank and clinical departments. Transfusion error can occur at any phase of the transfusion
chain. It can be divided into 3 phases:
i. Incidence of sampling and labelling error (clinical departments)
ii. Incidence of laboratory error
iii. Incidence of administrative error
● Adverse events related to blood transfusion reflects safety precautions on the use of blood
and blood products which can be life threatening and contribute to patient morbidity and
mortality when not administered appropriately. Incidences of adverse events related to
blood transfusion i.e. near misses, transfusion errors (incorrect blood component
transfused), transfusion reactions, transfuse transmitted infections) must be monitored for
the purpose of implementing corrective and preventive measures.
● This indicator reflects the clinical effectiveness of care and increasing expectations of
safety standards and cost. Patients and family members have high expectations of safety
and quality of blood.
Adverse Events related to Blood Transfusion
i. Any untoward occurrence associated with the collection, testing, processing, storage and
distribution, of blood and blood components that might lead to death or life-threatening,
disabling or incapacitating conditions for patients or which results in, or prolong
hospitalization or morbidity.
ii. Outcomes that are not intended or desired to occur as a result of transfusion of blood and
blood products that include transfusion errors, transfusion reactions and transfusion
transmitted infections. Transfusion errors can arise from mislabeling sample tubes,
mislabeling blood packs, donor grouping, patient ABO typing compatibility testing and
transcription errors.
Ref: Manual on Adverse events and reactions during blood donation- EU definition.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients transfused with blood and blood products
NA
Sentinel Event

Numerator
Denominator
:
:
Number of incidences of blood transfusion related adverse
events in patients for the corresponding period
Target
Data Collection
Comments/Review
:
:
:
0
Monthly
-

SERVICE STANDARD 17: REHABILITATION MEDICINE SERVICES
There is tracking and trending of specific performance indicators which include
but not limited to at least two (2) of the following indicators:
Frequency
1. Percentage of patients with waiting time of 60
minutes to see the doctor at the Rehabilitation
Medicine Outpatient Clinic (Two or more
registration areas involved)
≤ 90% Monthly
2. Percentage of patients with waiting time of 90
minutes to see the doctor at the Rehabilitation
Medicine Outpatient Clinic (Only one
registration area involved)
≤ 90%
Monthly
3. Percentage of patients with established
interdisciplinary rehabilitation plan within ≤ 5
working days of admission
≤ 90% Monthly
4. Percentage of falls and near-falls in
Rehabilitation Medicine Outpatient Clinic
≤ 2% of
monthly
attendance
Monthly
5. Percentage of inpatients with functional
measure assessment upon admission and
prior to cessation of patient rehabilitation
programme
≥ 90% Monthly

Indicator 01 : Percentage of patients with waiting time of 60 minutes to see the
doctor at the Rehabilitation Medicine Outpatient Clinic (Two or
more registration areas involved)
Rationale:
involved in some hospitals/ departments, some clinical departments have opted for
monitoring of registration from department counter, as any process prior to that appears
out of the clinical department’s control. Thus, due to involvement of 2 or more counters
within the hospital, for monitoring of clinical services KPI, the target of waiting time is for
less than 60 minutes within the department. This is applicable only if patient is being
registered at another counter within the same hospital (e.g. at hospital’s main outpatient/
ACC complex registration counter) prior to the clinical department counter.
1. Two or more registration areas involved:
If registration of patient is first done at hospital’s main outpatient/ ACC complex registration
counter with payment collection, following which the patient needs to re-register at the respective
clinical department counter.
2. Waiting time:
(whichever is later) till the time the patient is first seen by the doctor, which is beginning of a
consultation.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All outpatients of Rehabilitation Medicine Outpatient Clinic.
seeing the doctors (e.g. blood taking or imaging.
Numerator
Denominator
:
:
minutes to see the doctor at the Rehabilitation Medicine
Outpatient Clinic
X 100%

Target
Data Collection
Comments/Review
:
:
:
≤ 90%
Monthly
-

Indicator 02 : Percentage of patients with waiting time of ≤ 90 minutes to see
the doctor at the Rehabilitation Medicine Outpatient Clinic (Only
one registration area involved)
Rationale:
involved in some hospitals/ departments, some clinical departments have opted for
monitoring of registration from department counter, as any process prior to that appears
out of the clinical department’s control. Thus, due to involvement of 2 or more counters
within the hospital, for monitoring of clinical services KPI, the target of waiting time is for
less than 60 minutes within the department. This is applicable only if patient is being
registered at another counter within the same hospital (e.g. at hospital’s main outpatient/
ACC complex registration counter) prior to the clinical department counter.
Waiting time:
(whichever is later) till the time the patient is first seen by the doctor, which is beginning of a
consultation.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All outpatients of Rehabilitation Medicine Outpatient Clinic.
seeing the doctors (e.g. blood taking or imaging).
Numerator
Denominator
:
:
minutes to see the doctor at the Rehabilitation Medicine
Outpatient Clinic
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 90%
Monthly
-

Indicator 03 : Percentage of patients with established interdisciplinary
Rehabilitation Plan within ≤ 5 working days of admission
Rationale:
● In Rehabilitation Medicine, the Rehabilitation Plan for inpatient care requires a
documented and agreed plan that specifies goals, interventions and time frame
established via interdisciplinary consultation.
● This indicator reflects Timely Access of Care and Patient Centeredness
1. Rehabilitation Medicine:
May be defined as the multi- and interdisciplinary management of a person's functioning and
health. Rehabilitation medicine defines itself with respect to concepts of functioning, disability and
health. Assessment and intervention management rely on these concepts may use the WHO
International Classification of Functioning, Disability, and Health (ICF) Model of Functioning and
Disability and therefore facilitates multidisciplinary responsibility and coordination of interventions.
2. Rehabilitation Plan:
Documented evidence of consultation, communication between the disciplines involved in the
rehabilitation plan.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All referral/admission for inpatient rehabilitation care.
All inpatients for rehabilitation care with length of stay of less than
Seven working days of admission.
Numerator
Denominator
:
:
Number of in-patients established interdisciplinary
rehabilitation plan within ≤ 5 working days of admission
Total number of patients admitted/ referred for in-patient
rehabilitation care during the specified period of time
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 90%
Monthly
-

Indicator 04 : Percentage of falls and near-falls in Rehabilitation Medicine
Outpatient Clinic
Rationale:
● To ensure patients’ safety starting from the registration in clinic until completion of the
clinic session as falls/ near-falls are preventable and has multifactorial cause which
includes intrinsic and modifiable extrinsic factor.
A fall is defined as:
An event that result in a person coming to rest in advertently on the ground or floor or other lower
level, with or without injury
A near-fall is defined as:
A slip, trip, stumble or loss of balance such that the individual starts to fall but either able to
recover (witnessed or unwitnessed) and remains upright because their balance recovery
mechanisms were activated and/or caught by staff/other persons, or they were eased to the
ground or floor or other lower level, by staff/other persons (e.g. could not stop or prevent falling
to the ground, floor or lower surface).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patient who experience fall and near-fall in the Rehabilitation
Medicine Specialist Clinic area from the time of registration at the
clinic untill completion of the clinic session
NA
Numerator
Denominator
:
:
Number of falls and near-falls in the Rehabilitation Medicine
Specialist Clinic area
Number of patients attending Rehabilitation Medicine
Specialist Clinic in a month.
X 100%
Target
Data Collection
Comments/Review
:
:
:
≤ 2 % of monthly attendance
Monthly
Ref: Technical Specifications Key Performance Indicators (KPI)
Clinical Services, Medical Programme MOH, 2019

Indicator 05 : Percentage of inpatients with functional measure assessment
upon admission and prior to cessation of patient rehabilitation
programme
Rationale:
● Rehabilitation Medicine prioritizes function as the objective of service delivery.
● The use of objective measure of function enables assessment of this and subsequent
audit of clinical effectiveness o service delivery in adequate discharge planning and
minimization of risk of readmission.
Functional Measure Assessment:
Documented evidence of assessment including functional scales e.g. Modified Barthel Index
(BMI), Spinal Cord Independence Measure (SCIM), Functional Independence Measure (FIM),
Modified Rankin Scale (MRS), Functional Capacity etc.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All inpatients referral/admission for inpatient rehabilitation care.
1. Patients who have an unplanned cessation of inpatient
rehabilitation care.
2. All inpatients for rehabilitation care with length of stay of less than
7 days of admission
Numerator
Denominator
:
:
Number of inpatients with functional measure assessment
prior to cessation of inpatient rehabilitation care
Total number of inpatients who ceased an inpatient
rehabilitation care during the specified period
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly

SERVICE STANDARD 17A: PHYSIOTHERAPY SERVICES
Frequency
1. Burns Incidence incurred with the administration of
Electrotherapeutic Modalities or Thermal Agents
Sentinel
Event
Monthly
2.
Patient with musculoskeletal condition reported a
reduction in pain scale (VAS) in each
physiotherapy session (minimum of 3 sessions)
within 2 months
80% Monthly
3. Percentage of inpatient referrals seen by the
physiotherapist within 24 hours
90%
Monthly
4. Rate of positive outcomes from cases referred for
chest physiotherapy by Intensive Care Unit
75%
Monthly
5.
Improvement in Modified Rivermead Mobility
Index (MRMI) score within 6 months of
physiotherapy intervention for newly referred
Stroke patient
80% Monthly

Indicator 01 : Incidence of Burns sustained during delivery of
electrotherapeutic modalities or thermal agents (sentinel event)
Rationale:
● Burns should not occur if a model of good care is followed. The emphasis is on prevention
because safety of patients is of utmost importance during the delivery of heat therapy.
● This indicator reflects Safety and Clinical Effectiveness.
1. Burns:
Tissue damage following the application of electrotherapeutic modalities and thermal agents
resulting in excessive/latent redness and pain or blistering of skin over the area treated
2. Electro-therapeutic Modalities:
Short wave Diathermy, Microwave Diathermy, Infra-Red Ray
3. Thermal Agents:
Hot packs, Paraffin wax baths
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patient undergoing treatment with the use of electro therapeutic
modalities or thermal agents
NA
Sentinel Event
Numerator
Denominator
:
:
Number of incidences of burns sustained during delivery of
electrotherapeutic modalities or thermal agents
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

Indicator 02 : Patient with musculoskeletal condition reported a reduction in
pain scale (VAS) in each physiotherapy session (minimum of 3
sessions) within 2 months
Rationale:
This indicator was selected because of clinical effectiveness:
● To enhance the effectiveness of physiotherapy treatment management.
● To provide prompt and efficient physiotherapy service and prevent complications
Musculoskeletal condition: Condition related to hard tissue and soft tissue such as bone,
muscle, ligaments and tendon.
Visual Analogue Scale (VAS): pain measurement scale
Reduction in Pain Scale: Patient experienced a reduction in pain based on VAS pain scale (at
least 1 numeric number) after receiving physiotherapy treatment. Comparison between pre and
post treatment.
Physiotherapy session: All physiotherapy treatment that’s related to pain management.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All newly referred musculoskeletal outpatient.
2. Patients that comply to the first three appointments given.
1. Patient didn’t suffer for pain, VAS = 0 during the first assessment.
2. Defaulter patient, patient fail to attend physiotherapy session.
Numerator
Denominator
:
:
Number of patients showed a reduction in pain scale for 3
sessions of physiotherapy treatment
Total number of musculoskeletal patients suffered for pain
that’s referred to Physiotherapy
X 100%
Target
Data Collection
Comments/Review
:
:
:
80%
Monthly

Indicator 03 : Percentage of inpatient referrals seen on time (≤ 24 hours) by
the physiotherapist
Rationale:
● To improve patients and clients satisfaction.
● To prevent complications.
1. In-patients:
Patients who are admitted in the ward.
2. Working Days:
Physiotherapy services are available on weekdays i.e. Mondays to Friday or Sunday to Thursday
(according to individual states)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All inpatients referred during working days
All inpatients referred during weekends and public holidays
Numerator
Denominator
:
:
Number of inpatients receiving intervention by
physiotherapist within 24 working hours
Total number of inpatients referred for Physiotherapy
Services
X 100%
Target
Data Collection
Comments/Review
:
:
:
90%
Monthly

Indicator 04 : Rate of positive outcomes from cases referred for chest
physiotherapy by Intensive Care Unit
Rationale:
1. Chest Physiotherapy
Chest physiotherapy is the term for a group of designed treatments to improve respiratory
efficiency, promote expansion of the lungs, strengthen respiratory muscles and eliminate
secretions from the chest. The chest physiotherapy treatments are generally performed by
physiotherapists. The purpose of chest physiotherapy is to help patients breathe more freely and
to get more oxygen into the body. Chest physiotherapy includes postural drainage, chest
percussion, chest vibration, positioning, breathing exercises, coughing and suctioning is
necessary.
2. Positive Outcome for chest physiotherapy
Clearance of secretions and improved respiratory efficiency is the goal of chest physiotherapy.
Positive Outcome of cases refers to an improvement in respiratory function and cough ability.
The patient is considered to be responding positively to chest physiotherapy
if some, but not necessarily all of these changes occur:
- decreased volume of secretions
- changes in breath sounds
- improved vital signs
- increased oxygen in the blood as measured by arterial blood gas values
- patient reports of eased breathing
Reference: The Free Dictionary By Farlex
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All adult patients admitted to ICU and referred for chest physiotherapy
1. Myocardial instability:
a. Sytolic BP (<90mmHg)
b. Heart Rate (>140/min)
c. Evidence of acute myocardiac ischemic last 24 hours
d. Dysrhythmia requiring new anti-dysrhythmic agents last 24
hours
2. Increased ICP ˃20mmHg
3. Aneurysm
4. Un-stabilized head injury
5. Recent spinal injury/surgery ( less than 24 hours)
6. Acute haemorrhage ie APO (Acute Pulmonary Oedema)
7. Pulmonary Embolism before anti - coagulant drugs
8. Active Pulmonary Tuberculosis before anti Tuberculosis drug

Numerator
Denominator
:
:
Number of patients achieve positive outcomes from
physiotherapy intervention
Total number of patients in ICU referred for Chest
Physiotherapy
X 100%
Target
Data Collection
Comments/Review
:
:
:
75%
Monthly
References:
1. Chelsea Critical Care Physical Assessment Tool (CPax) 2010
2. MOH Early Mobility Programme 2013
3. KKM Care Protocol Critically Ill Adults 2003
4. Physiotherapy for Respiratory and Cardiac Problem 1995

Indicator 05 : Improvement in Modified Rivermead Mobility Index (MRMI) score
within 6 months of physiotherapy intervention for newly referred
Stroke patient
Rationale:
Newly referred Stroke patient: Newly referred stroke patient with current attack of Cerebral
Vascular accident within 6 months
Improvement in Modified Rivermead Mobility Index: An improvement in functional ability of a
stroke patient based on Modified Rivermead Mobility Index after 6 months of physiotherapy
interventions.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All newly referred adult stroke patient
i. Defaulter
ii. Cognitive impairment
iii. Lack of family support
iv. Patient suffered for progressive neurological disease
Numerator
Denominator
:
:
Number of patients showed an improvement of at least 1
score (11.7%) in Modified Rivermead Mobility Index after
6 months of physiotherapy interventions.
Total number of newly referred adult stroke patients
X 100%
Target
Data Collection
Comments/Review
:
:
:
80%
Monthly

SERVICE STANDARD 17B: OCCUPATIONAL THERAPY SERVICES
Frequency
1. Percentage of stroke patients with
improvement of activities of daily living
(ADL) independence after 3 months of
Occupational Therapy interventions
≥ 75% 3 Monthly
2
Percentage of patients with hand and
upper limb injury who have attained a full
score in prehension patterns within 3
months of Occupational Therapy
interventions
≥ 85% 3 Monthly
3
Percentage of patients with developmental
disabilities who improve in at least one
component of development after 6 months
of Occupational Therapy interventions
> 80% 6 Monthly

Indicator 01 : Percentage of stroke patients with improvement of activities of
daily living (ADL) independence after 3 months of Occupational
Therapy interventions
Rationale :
● The rate at which independence level is achieved varies between hospitals. The rate
needs to be standardized
● There is strong evidence to show that there is significant improvement after ADL
intervention among the stroke patients
1. Stroke:
Stroke or cerebro-vascular accident (CVA) is the sudden onset of neurological deficit brought
about by vascular injury to the brain. The most typical manifestation of CVA is hemi paresis or
hemiplegia (mild weakness or complete paralysis respectively) of the body OPPOSITE to the side
of CVA
2. Activities of Daily Living (ADL):
Activities related to grooming, bathing, toilet, dressing, feeding, transfer/wheelchair, bowel
control, urinary control, walking and climbing stairs.
3. Modified Barthel ADL Index:
The Modified Barthel ADL Index (MBI) is an international assessment instrument for ADL that is
designed to record what a patient does; not what he could achieve and is aimed at recording the
degree of independence. (Shah, S 1989).
Modified Barthel ADL Index is an assessment of Personal hygiene, bathing self, feeding, toileting,
climbing stairs, dressing, bowel control, bladder control, ambulation, wheelchair and transfer from
chair/ bed.
Score of MBI from: The International standard of dependency level is shown as follow:
0 - 24 indicates total dependence on others in ADL.
25 - 49 indicates severe dependency
50 - 74 indicates moderate dependency
75 - 90 indicates mild dependency
91 - 99 indicate minimal dependency.
(Shah, S. and Cooper B. 1995)
Cohort Period: data for this indicator is collected for a period of 3 months upon referral.
Treatment session can be delivered in the ward, in the Occupational Therapy Department or in
the patient’s home/place of stay.

Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All stroke patients referred for Occupational Therapy.
2. Age 18 years old and above.
1. Stroke patients with MBI score of 91 and above.
2. Stroke occurring after brain injury or brain tumour
3. Recurrent stroke during cohort period.
4. Patient who did not turn up for three consecutive appointments.
5. Patient without good social support
Numerator
Denominator
:
:
The total number of STROKE patients who have improved
a minimum of one level of dependency in MBI within 3
months of intervention.
The total number of STROKE patients referred to
Occupational Therapy (fulfill inclusion criteria)
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 75%
3 Monthly
-

Indicator 02 : Percentage of patients with hand and upper limb injury who
have attained a full score in prehension patterns within 3
months of Occupational Therapy interventions
Rationale :
● This indicator measures the effectiveness of occupational therapy treatment for cases of
hand and upper limb injuries treated in hospital through the measurement of hand
prehension scores. There is strong evidence to show that there is significant
improvement in hand function after Occupational Therapy interventions among the
patients with hand injuries.
Hand prehension is defined as the ability of the hand to hold an object between two surfaces of
the hand through 7 forms as follows:
1. Hook: such as holding a handbag holder or bucket handle
2. Lateral: like holding a key
3. Tip Pinch (Tip to Tip): like holding a needle
4. Pad Pinch: like holding a 20-cent coin
5. Tripod Pinch: like holding a pencil or pen
6. Cylindrical: such as holding a cylindrical object such as a can of drinking water
7. Spherical: holding a spherical object such as a tennis ball
(Edward, Buckland, McCoy-Powlen, 2002)
Hand prehension ability means a full score against a score of 7/7 for all hand prehension abilities.
In cases where injuries occur to both hands, scores are taken on the hand that gets the highest
score only.
Hand injuries mean all injuries that occur to the area located from shoulder level to the fingertips
including burn injuries.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. New diagnosis of hand and upper limb injuries.
2. Patients who scored a hand prehension ability score of less than
7/7 during the initial assessment.
3. Patients aged 4 years and above.
1. Patients with complete brachial plexus nerve injury.
2. Patients with amputation of the entire thumb (from the level of the
Metacarpophalangeal (MCP) joint) and amputation of 3 fingers
(from the level of the MCP joint and below).
3. Hand injury due to excessive or repetitive or degenerative
movements such as Carpal Tunnel Syndrome, Trigger Finger, De
Quarvain’s Tenosynovitis, and others.
4. Patients who absent for 3 consecutive treatment sessions.
Numerator
Denominator
:
:
The total number of patients who achieved a full score of
hand prehension ability within 3 months of interventions
The total number of patients with hand injuries referred to
Occupational Therapy (fulfill inclusion criteria)
X 100%

Target
Data Collection
Comments/Review
:
:
:
≥ 85%
3 Monthly
-

Indicator 03 : Percentage of patients with developmental disabilities who
improve in at least one component of development after 6
months of Occupational Therapy interventions
Rationale :
● Children with development disabilities is commonly seen in occupational therapy setting.
● The rate of developmental improvements among children with developmental disabilities
is vary between facilities. Thus, rate needs to be standardized. There is strong evidence
in improvement of development component among children with developmental
disabilities after occupational therapy intervention.
● This indicator reflects Clinical Effectiveness and Efficiency.
1. Developmental disabilities: any of various conditions (such as autism spectrum
disorder, cerebral palsy, intellectual disability, blindness, or fragile X syndrome) that
usually become apparent during infancy or childhood and are marked by delayed
development or functional limitations especially in learning, language, communication,
cognition, behaviour, socialization, or mobility.
2. Denver Development Screening Test II (Denver II): Is a screening tools that measure
4 component of children development
i. Personal-social
ii. Fine motor-adaptive
iii. Language
iv. Gross motor
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients with developmental delay below 5 years old.
Children with severe epilepsy.
Numerator
Denominator
:
:
Total number of patients with developmental disabilities
who improve in at least one component of development
after 6 months of Occupational Therapy interventions
Total number of patients referred with developmental
disabilities
X 100%
Target
Data Collection
Comments/Review
:
:
:
> 80%
6 Monthly
-

SERVICE STANDARD 17C: DIETETIC SERVICES
There tracking and trending of specific performance indicators which include but not
Frequency
1. Percentage of in-patient referrals seen on time
(24 hours) by the Dietician
≥ 85% Monthly
2. Percentage of out-patient referrals seen by the
Dietician within the stipulated time by the
Dietetic Services and approved by the Facility
≥ 85% Monthly
3. Energy intake at least 70% of recommendation
within 5 days of enteral nutrition initiation
among patients in the ward
≥ 80%
Monthly

Indicator 01 : Percentage of in-patient referrals seen on time (24 hours) by the
Dietician
Rationale:
● Dietary consultation and nutrition support services are an integral part of total patient care.
The high rate of referrals and limited manpower pose a challenge to the dietician in striving
to deliver the services within acceptable time frame; to ensure the provision of appropriate
nutrition intervention.
● This indicator reflects Timely Access and Patient Centeredness
Seen on Time/Timely Response:
In- patient referrals should be seen within the same day of receiving of referral cases on working
days, and for cases referred after 1.00 pm, the patient should be seen before 1.00 pm the
following working day.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patient requiring nutritional intervention:
i. Tube feeding
ii. Combination of tube feeding and parenteral
iii. Oral liquid Diet only
iv. Combination of oral and parenteral nutrition
v. Patient with poor oral intake (intake less than half of food served)
i. Patient referred for dietician consultation only
ii. Patient referred but discharged without being seen by dietician
iii. Patient referred but passed away before being seen by dietician
Numerator
Denominator
:
:
Number of in-patients requiring intervention and seen by
dietician within 24 hours of referral
Total number of in-patients requiring intervention and seen
by dietician
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
Monthly

Indicator 02 : Percentage of out-patient referrals seen by the Dietician within
the stipulated time by the Dietetic Services and approved by the
Facility
Rationale:
● Dietary consultation and nutrition support services are an integral part of total patient care.
The high rate of referrals and limited manpower pose a challenge to the dietician in striving
to deliver the services within acceptable time frame; to ensure the provision of appropriate
nutrition intervention.
● This indicator reflects Timely Access and Patient Centeredness
1. Seen within the stipulated Time:
Out-patient cases referred for intervention by Dietician should be seen within the stipulated time
upon receiving of referrals on working days.
2. Stipulated time:
Refers to the agreed time/duration as specified by the Facility within which appointments are
given for out-patient referrals to the dietician.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients requiring dietary consultation
i. Patient referred for urgent dietary intervention
ii. Patient referred but discharged without being seen by dietician
iii. Patient referred but passed away before being seen by dietician
Numerator
Denominator
:
:
Number of outpatient referrals seen by the Dietician within
the stipulated time
Total number of out-patients referred to the dietician
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
Monthly

Indicator 03 : Energy intake at least 70% of recommendation within 5 days of
enteral nutrition initiation among patients in the ward
Rationale:
● Nutritional support is an integral part of total patient care. Patients requiring enteral
nutrition are ill patients who are unable to take oral feedings due to their health status or
provided as a temporary measure in post- surgery to ensure the provision of appropriate
nutritional intervention.
● This indicator reflects Clinical Efficiency and Patient Centeredness.
1. Enteral Nutrition:
Enteral nutrition is provided where a patient is fed via an enteral tube. There are several different
methods of enteral tube feeding, but most short term tube fed enteral nutrition should be given
via a nasogastric tube. Patients for enteral feeding include those with swallowing disorders, such
as motor neurone disease, multiple sclerosis, those with physical obstruction to swallowing, such
as oesophageal tumours, those unable to ingest food, such as head injury or stroke patients
among others.
2. Energy Intake:
Energy intake is the total number of calories taken in daily whether ingested or by parenteral
routes. Energy is provided by food and drink. It comes from the fat, carbohydrate and protein the
diet contains. Energy requirements vary from one individual to the next, depending on factors
such as age, sex, body composition and physical activity level.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients in the Facility /Hospital requiring parental nutrition
NA
Numerator
Denominator
:
:
Number of patients receiving parental nutrition having
achieved 70% of the recommended energy intake within 5
days of initiation
Total number of patients on parental nutrition during the
specified period
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
Monthly

SERVICE STANDARD 17D: SPEECH-LANGUAGE THERAPY SERVICES
Frequency
1. Percentage of new cases outpatient referrals
given appointment within 90 days
(waiting time between the date patient
presents to request for appointment and
the initial appointment given within 90 days)
≥ 85% Monthly
2. Percentage of inpatient referrals of swallowing
and feeding difficulties responded within 3
working days.
≥ 85% Monthly
3. Percentage of patient satisfaction towards
patient education in therapy
≥ 80% 6 Monthly

Indicator 01 : Percentage of new cases outpatient referrals given appointment
within 90 days
Rationale:
● Speech- Language Pathology Services consultation and support services are an integral
part of total rehabilitative care. The provision of appropriate intervention should be within
the acceptable time frame.
● Patient–centred services must give priority to prompt attention to patient needs by
reducing the waiting times for consultation. This indicator reflects Timely Access and
Patient Centredness.
Waiting Time for new appointment:
Waiting time between the date patient presents to request for appointment and the initial
appointment given within 90 days of referral. Time of receiving referral documentation to time of
initial appointment given on working days.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All new outpatients referred to Speech Pathologist for consultation or
management
NA
Numerator
Denominator
:
:
Number of new outpatient cases given appointment to the
Speech – Language Therapist within 90 days of referral
Total number of new outpatient referrals received by
Speech-Language Therapist for initial appointment
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
Monthly

Indicator 02 : Percentage of inpatient referrals of swallowing and feeding
difficulties responded within 3 working days
Rationale:
● Speech- Language Therapy Services consultation and support services are an integral
part of total rehabilitative care and the treatment plan is usually a long term process. The
provision of appropriate intervention should be within the acceptable time frame.
● Patients with swallowing and feeding difficulties must be given priority to prompt attention
to meet patient’s nutritional needs and general wellbeing.
● This indicator reflects Timely Access and Patient Centredness.
1. Swallowing and Feeding Difficulties:
Eating and swallowing problems, known as dysphagia, occur in many medical conditions and can
occur both in adults and children. The main risks associated with swallowing problems are:
● Choking or asphyxiation: When food blocks the airway, preventing breathing. Also
when food or liquid enter the airway below the level of the vocal cords.
● Aspiration pneumonia: If food or liquid enter the lungs it can cause a lung infection.
● Dehydration: Not drinking enough fluids is bad for health and can lead to problems such
as constipation.
● Malnutrition: Lack of nourishment leads to poor health and harms the body’s ability to
fight infection.
Feeding disorders in children include problems gathering food and getting ready to suck, chew,
or swallow it. For example, a child who cannot pick up food and get it to her mouth or cannot
completely close her lips to keep food from falling out of her mouth may have a feeding disorder.
2. Waiting Time for Speech Therapist Response:
Time between the date the inpatient is referred to the Speech Language Therapist to initial
contact/examination within 3 working days.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All in-patients referred to Speech – Language Therapist for
management of swallowing and feeding difficulties.
NA
Numerator
Denominator
:
:
Number of in-patients referred and responded within 3 days
by Speech Therapist for swallowing & feeding difficulties
Total number of in-patients referred to Speech Therapist for
swallowing & feeding difficulties
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
Monthly

Indicator 03 : Percentage of patient satisfaction towards patient education in
therapy
Rationale:
● Speech- Language Pathology Services consultation and support services are an integral
part of total rehabilitative care.
meeting patient needs from registration for out-patient care to care and treatment.
1. Patient Satisfaction Survey:
Patient satisfaction is a measure of the extent to which a patient is content with the health care
which they received from their health care provider.
2. Patient Education Therapy:
Patient education is an individualized, systematic, structured process to assess and impart
knowledge or develop a skill in order to effect a change in behavior. The goal is to increase
comprehension and participation in the self-management of health care needs. The
patient/family/significant others play an active part in the process. Patient education is an
important component of care in both inpatient and ambulatory settings. Patient/family education
is an interdisciplinary and collaborative process designed to meet the needs of the individual
patient throughout the continuum of care.
Ref: UTMB Handbook of Operating Procedures : Policy 9.3.4 Patient/Family Education
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All out-patients attending patient education therapy
In- patient satisfaction survey
Numerator
Denominator
:
:
Number of outpatients given patient education therapy with
≥ 80% satisfaction level
Total number of outpatients given patient education therapy
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 80% patient satisfaction level
6 Monthly

SERVICE STANDARD 17E: AUDIOLOGY SERVICES
There is tracking and trending of specific performance indicators which include but are
not limited to at least two (2) of the following indicators:
Frequency
1. Percentage of new cases given an
appointment in audiology clinic following a
referral within 45 days
≥ 85% 6 Monthly
2.
Percentage of patients received hearing aid
provision following diagnosis of hearing loss
within 8 weeks.
≥ 90% 6 Monthly
3.
Percentage of patients showing improved
hearing ability within 3 months after hearing
aid fitting.
≥ 85% 6 Monthly

Indicator 01 : Percentage of new cases given an appointment in audiology
clinic following a referral within 45 days
Rationale:
• Audiology services are an integral part of total rehabilitative care. The high rate of referrals
poses a challenge to an audiologist to deliver the appropriate intervention within an
acceptable time frame.
• Patient-centered services must give prioritize patient needs by reducing the waiting times
for consultation. This indicator reflects Timely Access and Patient Centredness.
Waiting Time for a new appointment:
1. New case- cases of seeking assessment/ treatment for the first time
2. Referral- cases referred either through phone call or at clinic counter
3. Within 45 days- the difference between the date of receiving the referral and the date of
appointment given is not more than 45 days (including weekends and public holidays).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All new cases are referred to the audiologist for assessment or
intervention.
1. Patients request an appointment date of more than 45 days due to
specific reasons (e.g: health problems, financial constraints, logistic
issues)
2. Patients unstable to undergo a hearing assessment or intervention
within 45 days
3. Neonates/ infants referred from a neonatal hearing screening
program in the same hospital
Numerator
Denominator
:
:
Number of new cases given an appointment within 45 days
of referral
Total number of new cases given audiology appointment
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
6 Monthly

Indicator 02 : Percentage of patients who received hearing aid provision
following diagnosis of hearing loss within 8 weeks.
Rationale:
• Patients with hearing loss should start early intervention. The time interval between
diagnosis of hearing loss until the patients received hearing aid (HA) provision reflects
on patients focused care
• A delay in HA trial would delay the time of HA prescription and HA fitting which may lead
to the deterioration of patients quality of life
• Patient-centered care must align with patient-centered goals in a timely manner (the
right care is provided at the right time).
Waiting time for hearing aid provision:
1. A hearing aid- is a battery-powered electronic device designed to amplify sound and to
improve hearing. A hearing aid includes air conduction (ACHA) and/ or BCHA (bone
conduction)
2. Hearing aid provision- a process involving HA trial and HA prescription (for an adult) and
hearing aid prescription only (for pediatric)
3. Diagnosis of hearing loss- confirmed the presence of hearing loss (peripheral and central).
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All new patients required a hearing aid
1. Patient not keen on hearing aid
2. Patients request an appointment date of more than 8 weeks due to
specific reasons (e.g: health problems, financial constraints, logistic
issues)
3. Patient covered by PERKESO & MAKNA
Numerator
Denominator
:
:
Number of patients received hearing aid provision within 8
weeks
Total number of patients received hearing aid provision
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
6 Monthly

Indicator 03 : Percentage of patients showing improved hearing ability within 3
months after hearing aid fitting.
Rationale:
• Audiologists provide aural rehabilitation (AR) services to help the patient meet maximum
success in listening and communication after hearing aid fitting. There are several
domains of hearing aid outcome that can be measured, including benefit, satisfaction,
residual activity and participation
restrictions, and quality of life.
• This indicator, named the Client Oriented Scale of Improvement (COSI) aims to measure
the benefit of hearing aid usage.
• COSI is recommended as the most useful clinical measure of rehabilitation outcomes as
its focus on patients’ individual needs in specific situations.
1. Degree of change- obtaining BETTER or MUCH BETTER outcome after hearing aid fitting.
Only first ranked needs are considered for this indicator assessment.
2. Hearing aid fitting- involved all the processes from hearing aid orientation to counselling of
hearing aid usage
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All outpatients aged 19 yo and above
2. New and experienced hearing aid user
3. Using a hearing aid in one or both ears.
4. Cases with hearing loss only
5. Cases with air conduction and bone conduction hearing aid
1. COSI assessment is done after 3 months from fitting’s date.
2. Patient with chronic middle ear problems
3. Patients with cognitive impairment, unable to understand speech,
or using sign language
Numerator
Denominator
:
:
Number of patients obtaining BETTER or MUCH BETTER
outcome within 3 months after hearing aid fitting
Number of patients using hearing aids
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
6 Monthly

SERVICE STANDARD 17F: OPTOMETRY SERVICES
Frequency
1. Percentage of keratoconus cases with
increased levels of contact lens complications
within 4 months of RGP contact lens delivery.
≤ 20%
6 monthly
2. Optometrist involvement at least 2 outreach
programmes in current year.
100% yearly
3. New cases achieving best corrected visual
acuity 6/6 after refraction.
≥ 85% 6 monthly
4.
Percentage of new patients that were given
appointment for refraction procedure within ≤ 6
weeks in Optometry Clinic without
Ophthalmologist.
≥ 80% 6 monthly
5.
Percentage of new patients that were given
appointment for diabetic retinopathy screening
within ≤ 6 weeks in Optometry Clinic at Klinik
Kesihatan.
≥ 80% 6 monthly
6. Waiting time to see optometrist ≤ 60 minutes ≥ 80% 6 monthly

Indicator 01 : Percentage of keratoconus cases with increased levels of
contact lens complications within 4 months of RGP contact lens
delivery.
Rationale:
1. RGP contact lens wear could preserve optimal vision for keratoconus patients. However
patients need to comply with contact lens care and ensure eye safety.
2. To reduce visual morbidity among RGP contact lens wearers.
3. A reflection of the clinical process in management of keratoconus patients.
1. Keratoconus: Ocular disorder characterized by progressive thinning and changes in the
shape of the corneas which can cause blurry or distorted vision, sensitivity to light
(photophobia), and other visual problems.
2. Time 4 months: Is calculated from the date of contact lens delivery to the patient (± 2 weeks).
3. RGP contact lenses: All types of RGP contact lenses such as Rose K2, Rose K XL, Rose K
NC, Igel K, Rose K2 PG, As LUNA (SEED) etc.
4. Increased level of complications (from normal/mild to moderate or worse) within 4 months after
RGP contact lenses delivery.
5. Complications of RGP contact lenses wear (Reference: Efron Grading Scales For Contact
Lens Complication):
a) Conjunctival redness
b) Limbal redness
c) Corneal neovascularization
d) Epithelial microcysts
e) Corneal edema
f) Corneal staining
g) Conjunctival staining
h) Papillary conjunctivitis
i) Blepharitis
j) Meibomian gland dysfunction
k) Superior limbic keratoconjunctivitis
l) Corneal infiltrates
m) Corneal ulcer
n) Endothelial polymegathism
o) Endothelial blebs
p) Corneal distortion
6. Those patients referred to other hospitals for follow - up, the respective hospital has to report
the aftercare outcome. (The patient is a denominator for the hospital who conducted the
contact lens delivery).

Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All keratoconus patients who received RGP during contact lens
delivery.
Patients default aftercare appointment within 4 months + 2 weeks
from the date of contact lens delivery.
Numerator
Denominator
:
:
Number of keratoconus cases with increased levels of
contact lens complications within 4 months of RGP
contact lens delivery
Total number of RGP contact lens delivery for
keratoconus cases
Target
Data Collection
Comments/Review
:
:
:
≤ 20%
6 Monthly
-

Indicator 02 : Optometrist involvement at least 2 outreach programmes in
current year.
Rationale:
1. To provide eye care for the community.
2. To facilitate patient access to Optometry services.
3. To promote eye care awareness.
4. To ensure all Optometrist participates in outreach programmes.
Outreach services: All outreach activities conducted outside of the place of duty (clinic) and
must get approval from the Hospital Director/Head of Department.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All outreach activities involving the Ophthalmology Department or
Optometry Unit.
1. Optometrist who is on leave for more than 6 months in a current
year.
2. Optometrist who has medical problems with medical consent.
Customer Centeredness
Numerator
Denominator
:
:
Number of Optometrist who involved in at least 2 outreach
programmes in a current year
Number of Optometrist who involved in outreach
programmes
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Yearly
-

Indicator 03 : New cases achieving best corrected visual acuity 6/6 after
refraction.
Rationale:
1. Refraction is a procedure to determine the refractive error status. (Pemeriksaan Optometri
Asas in the Standard Operating Procedures).
2. This indicator is implemented to measure the quality of the procedure which is performed
by the Optometrist to ensure that patients with refractive errors achieved 6/6 best
corrected visual acuity with appropriate prescription.
3. 6/6 vision means normal vision for optimum quality of life. However, there are several
factors that contribute 6/6 vision not achieved after refraction such as ocular diseases that
can only be detected by conducting a full eye examination.
1. New cases: Patients who are referred for the first-time refraction.
2. 6/6: The ability to see clearly 5 minutes of arc sized letters at a distance of 6 meters.
3. Refractive assessment includes objective and subjective refraction.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. New case referred for refraction.
2. Habitual vision before refraction was ≤ 6/10.
3. Vision is measured using a Snellen chart or equivalent (Smart
chart or projector chart).
4. Vision with a pinhole improved at least ≥ 6/10.
1. Patients who are unable to respond subjectively.
2. Patients aged <7 years in the current year.
3. Medico-legal patients.
4. Suspected of having amblyopia.
5. Patients with ocular diseases.
Outcome Based Process Indicator
Numerator
Denominator
:
:
Number of new cases achieving 6/6 visual acuity after
refraction for each eye.
Number of new cases achieving vision ≥ 6/10 with a
pinhole.
Target
Data Collection
Comments/Review
:
:
:
≥ 85%
6 Monthly
-

Indicator 04 : Percentage of new patients that were given appointment for
refraction procedure within ≤ 6 weeks in Optometry Clinic
without Ophthalmologist.
Rationale:
Patient care should be given priority by reducing the waiting time to get an appointment for
refraction in line with patient centred services (Reference Circular of the Director General of
Health Malaysia No. 6/2004).
New patient: New referral for refraction.
Within ≤ 6 weeks: Time taken from the date of getting an appointment until the appointment date
for refraction.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All new cases who get a refraction appointment date.
1. Patients request a later appointment date.
2. Defaulted patient.
Numerator
Denominator
:
:
Number of new cases given the refraction appointment ≤ 6
weeks at the Optometry Clinic.
Number of new cases get an appointment for refraction at
the Optometry Clinic.
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
6 Monthly
-

Indicator 05 : Percentage of new patients that were given appointment for
diabetic retinopathy screening within ≤ 6 weeks in Optometry
Clinic at Klinik Kesihatan.
Rationale:
1. Prevention of blindness at the early stages due to complications of diabetes mellitus can
reduce the cost of a patient's treatment.
2. Patient’s care should be given priority by reducing waiting time to get an appointment for
diabetic retinopathy screening.
New patient: New referral for diabetic retinopathy screening.
Within ≤ 6 weeks: Time taken from the date of getting an appointment to the date of the
appointment of diabetic retinopathy screening is given to patients.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. New cases referred for diabetic retinopathy screening.
2. Patient's visual acuity must be 6/12 or better.
1. Patients request a later appointment date.
2. Defaulted patients.
Numerator
Denominator
:
:
Number of new cases given appointment for diabetic
retinopathy screening ≤ 6 weeks at the Optometry Clinic at
Klinik Kesihatan.
Number of new cases referred for diabetic retinopathy
screening at the Optometry Clinic at Klinik Kesihatan.
X 100
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
6 Monthly
-

Indicator 06 : Waiting time to see Optometrist within 60 minutes.
Rationale:
To ensure the waiting time to get Optometry services is in line with the General Circular Director
of Health Malaysia No. 6/2004.
Waiting time ≤ 60 minutes: The time calculated from the patient's file/card arrives at the
optometrist's room until the patient is called for refraction.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients were referred for refraction.
NA
Numerator
Denominator
:
:
Number of patients seen by Optometrist for refraction with
waiting time ≤ 60 minutes
Number of patients seen by an Optometrist for refraction
X100
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
6 Monthly
-

SERVICE STANDARD 17G: HEALTH EDUCATION SERVICES
Frequency
1. Number of patients received behavioural
needs assessment (cognitive, affective &
psychomotor) prior to health education
intervention
Monthly
2. Percentage of successful quit smoking after 6
months from setting Quit Date 35%
6 Monthly
3. Percentage of patient referrals seen within
two (2) weeks
80% Monthly
4. Percentage of successful clients to reduce
bodyweight (weight management program) 10% Yearly

Indicator 01 : Number of patients received behavioural needs assessment
(cognitive, affective & psychomotor) prior to health education
intervention.
Rationale:
● Behavioural needs assessment prior to Health Education Intervention should be
conducted to assess the change in the cognitive, affective and psychomotor behaviour
of the clients after Health Education intervention which also measures the effectiveness
of Health Education.
● Health Education is aimed to educate and encourage patients and community to
comply with the treatment regime and maintaining their wellbeing.
● Including weight management, quit smoking, organ donation and others
1. Behavioural Needs Assessment
The practice of health education involves three major program-planning activities: needs
assessment, program development, and evaluation. Behavioral needs assessment is a method
used in the field of psychology to observe, describe, explain, predict and sometimes correct
behavior. Behavioral needs assessment can be useful in clinical, educational and corporate
settings. Clients receiving behavioral health education are assessed on their knowledge, attitude
and practices.
2. Health Education Intervention:
Various techniques/activities aimed at change in the cognitive, affective and psychomotor
behaviour of the clients/patients.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients receiving health education intervention
NA
Numerator
Denominator
:
:
Number of patients received behavioural needs
assessment prior to Health Education Intervention
Target
Data Collection
Comments/Review
:
:
:
Monthly
-

Indicator 02 : Percentage of successful quit smoking after 6 months from
setting Quit Date
Rationale:
● Smoking has been shown to be hazardous to health and is a risk for many diseases
such as cancers and cardiovascular diseases. In the National Health and Morbidity
Survey (NHMS) conducted in 2006, it was found that 22.5% of Malaysians aged 18 and
over were smokers. Therefore, the Ministry of Health has taken the initiative to continue
the Say No to Smoking Campaign that was held on a large scale nationally, initiated in
2004.
● This is in line with the commitments that have been affirmed by the Ministry of Health
Malaysia in the 64th World Health Assembly in May 2011 that is by targeting 60% of
patients with cardiovascular disease or at high risk of developing the disease to quit
smoking within 6 months of enrolling in a Quit Smoking Clinic organized by the Ministry
of Health.
1. Quit Smoking intervention:
Patients admitted to Ministry of Health Hospitals that have Quit Smoking Clinic Service and
have enrolled in the Quit Smoking Program.
2. Post Intervention:
Patients enrolled in the Quit Smoking Program and have ceased smoking.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Patients enrolled in the Quit Smoking Program in Ministry of Health
Hospitals that have Quit Smoking Clinic Service.
NA
Numerator
Denominator
:
:
Number of persons who quit smoking within 6
months of enrolling in the Quit Smoking Clinic
Total number of persons who smoke who attended the
Quit Smoking Clinic
X 100%
Target
Data Collection
Comments/Review
:
:
:
35%
6 Monthly
-

Indicator 03 : Percentage of patient referrals seen within two (2) weeks
Rationale:
● Patient Centered services must give priority to prompt attention to patient needs by
reducing waiting times for consultation.
● This indicator reflects the effectiveness of the service.
Patient Referrals:
Time taken from the date of referral received to the date seen by the Health Education Officer
within two (2) weeks.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients referred to the Health Education Officer for
consultation/health education
NA
Numerator
Denominator
:
:
Number of patients seen by the Health Education Officer
within 2 weeks of referral
Total number of patients referred to the Health Officer
X 100%
Target
Data Collection
Comments/Review
:
:
:
80%
Monthly
-

Indicator 04 : Percentage of successful clients to reduce bodyweight (weight
management program)
Rationale:
● This indicator reflects the effectiveness of the service.
At least 10% of the participants managed to lose weight.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Participants aged 18 years and above and have a BMI> 25kg -
34.9kg
2. Agree and are interested in participating in the intervention
3. Do not have chronic health problems such as heart disease,
diabetes, hypertension and others
1. Have high risk factors for CAD, pulmonary artery coronary artery
disease and metabolic syndrome
2. Pregnancy
3. Has a permanent disability that can interfere with movement
Numerator
Denominator
:
:
At least 10% of the participants managed to lose weight
The total number of participants remained until the end of
the intervention
X 100%
Target
Data Collection
Comments/Review
:
:
:
10%
Yearly
-

SERVICE STANDARD 17H: MEDICAL SOCIAL SERVICES
Frequency
1. Percentage of early response time taken
within two (2) working days from the date
of referral
95% 3 Monthly
2. Percentage of cases referred to the referral
agencies within seven (7) working days
after social intervention complete
80% 3 Monthly

Indicator 01 : Percentage of early response time taken within two (2) working
days from the date of reference
Rationale:
1. Patient-centered services must give priority to prompt attention to patient needs. It is the
aim of the MOH to reduce the waiting times to a minimum in line with the Circular of the
Director-General of Health Malaysia No. 6/2004-Steps to reduce The Waiting Time in
MOH Facilities
Patient referred for Medical Social services received intervention within 2 working days
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. Malaysian citizen
2. All patients who referred to JKSP
3. Non Malaysian citizen which is involving social legislation and
disaster cases only for support therapy assistance only
1. Non Malaysian citizen
2. weekend or on public holidays not included
Numerator
Denominator
:
:
Total no of patients who received Medical Social Worker’s
initial intervention within 2 working days
Total no patients referred for Medical Social Worker’s
intervention
X 100%
Target
Data Collection
Comments/Review
:
:
:
95%
Once in three months
-

Indicator 02 : Percentage of cases referred to the referral agencies within
seven (7) working days after social intervention complete
Rationale:
● To enable patient to going through the treatment and rehabilitation process accordingly
in order to enhance their quality of life and help them to restore their social functioning in
community in line to limitation caused by the disease.
● This indicator reflects the effectiveness of the service and poses a challenge to the
Social Medical Worker to deliver the services within the acceptable time frame.
1. Reference agencies include government or non-government agencies.
a) Ministry of Health Malaysia (Tabung Bantuan Perubatan)
b) Department of Social Welfare
c) Royal Malaysian Police
d) Islamic Religious Department/ Islamic Religious Council / Zakat Board
e) Legal Aid Department
f) State Education Department
g) Embassy
h) National Registration Department
i) Immigration Department
j) Jabatan Kemajuan Orang Asli (JAKOA)
k) National Cancer Council (MAKNA)
l) Tabung Kebajikan Perubatan Malaysia (TKPM)
m) National Welfare Foundation (YKN)
n) And other reference agencies
2. Social intervention: A method used to provide assistance to the community (individuals,
group, communities) that used in the practice of social work to improve the functionality of
individuals either through investigation/ home visits/ supporting documents/ inter-agency
discussions.
3. Seven (7) working days excluding weekend and public holidays.
4. Practical assistance intervention: Involving the aspects of financial assistance
(purchasing medical equipment and medicines, funding treatment costs or general
assistance), institutional placement and tracing patient’s family. These practical
assistances are also provided for acute and chronic illness patients.
5. The support therapy intervention: Involving a consultation, emotional support and
crisis interventions including domestic violence cases, unmarried mothers, child abuse
and neglect, sexual crimes and other related cases including acute and chronic illness
patients.

Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All patients who qualify and meet the criteria should be referred to
the relevant agency
2. Inpatient and outpatient
3. Malaysia citizen
4. Non-citizen involved in social legislation and disaster cases for
support therapy assistance cases only
5. High-risk neglected baby cases for non-citizen
1. Patients who are not eligible and do not meet criteria related
agency
2. Non Malaysian citizen
Numerator
Denominator
:
:
Number of patients referred to the agencies within seven
(7) days after the social intervention had completed
The number of patients who need to be referred to
agencies after the social intervention had completed
X 100%
Target
Data Collection
Comments/Review
:
:
:
80%
Once in three months
-

STANDARD 17I: PSYCHOLOGY COUNSELLING SERVICES
Frequency
1. Percentage of new case given counselling
psychology services within 3 working days
70% Monthly
2. Percentage of clients achieved their
counselling goal
70%
Monthly

Indicator 01 : Percentage of new case given counselling psychology services
within 3 working days
Rationale:
● This indicator reflects access to Psychology Counseling Services and being effectively
discharged from the programme, which poses a challenge to the Psychology Counsellor
to deliver the services effectively.
1. Counseling Psychology: is general practice and health service provider specialty in
professional psychology. It focuses on how people function both personally and in their
relationships at all ages. Counseling psychology addresses the emotional, social, school,
work and physical health concern people may have at difference stages in their lives, focusing
on typical life stresses and issues in which people may struggle as individual and as a part of
family, group and organization.
2. Counseling Psychology Services: help people with physical, emotional and mental health
to improve their sense of well-being and alleviate feelings of distress. The scope of counseling
psychology practice shall be provided by Psychology Officer (Counseling) appointed by
Government of Malaysia
There are 2 types of Psychology Officers (Counseling) appointed by government of Malaysia:
1. Psychology Officer (Counselling) who registered with the Malaysian Board of Counselor (Act
580)
2. Psychology Officer (Counselling) who are not registered with the Malaysian Board of
Counselor (Act 580)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All clients registered for Counseling Psychology services.
1. Clients whom unable to communicate verbal and nonverbal.
2. Clients with severe cognitive impairment.
3. Clients whom are not cooperative.
4. Unreacheable clients after 3 times attempts.
5. Clients who refuse counseling psychology services.
Numerator
Denominator
:
:
Number of new case given counseling psychology services
Total number of cases registered for counseling psychology
services during the study period
X 100%
Target
Data Collection
Comments/Review
:
:
:
70% of new case given counseling psychology services within 3
working days
Monthly

Indicator 02 : Percentage of clients achieved their counseling goal
Rationale:
● This indicator reflects access to care for further management and effectiveness of the
service which poses a challenge to the Psychology Counsellor to make prompt and timely
referrals.
1. Psychology Services:
Psychology Services help people with physical, emotional and mental health to improve their
sense of well-being and alleviate feelings of distress. The scope of counseling psychology
practice shall be provided by Psychology Officer (Counseling) appointed by Government of
Malaysia.
6. Counseling Goal:
Clients who achieved at least score 2 in SMARTGOAL tool.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All clients registered for Counseling Psychology services.
1. Clients whom unable to communicate verbal and nonverbal.
2. Clients with severe cognitive impairment.
3. Clients whom are not cooperative.
4. Unreacheable clients after 3 times attempts.
5. Clients who refuse counseling psychology services.
Numerator
Denominator
:
:
Total clients who achieved counseling goal at least score 2
Total number of cases registered for counseling psychology
services during the study period
X 100%
Target
Data Collection
Comments/Review
:
:
:
70% of total clients to achieve at least score 2 in SMARTGOAL
Monthly

SERVICE STANDARD 17J: CLINICAL PSYCHOLOGY SERVICES
There is safety tracking and trending of specific performance indicators which include
Frequency
1. Percentage of Relapse Cases Sentinel
event
6 Monthly
2. Percentage of Psychological Assessment
Completed within 30 working days 85%
6 Monthly
3. Percentage of new patient referred for
psychotherapy session receiving first session
within 60 working days
80% 6 Monthly

Indicator 01 : Percentage of Relapse Cases
Rationale:
● The Clinical Psychology Services shall be provided only by trained and qualified Clinical
Psychologists to outpatients, inpatients in an efficient and effective and caring manner
and shall be coordinated with other relevant clinical services in accordance with accepted
standards of practice.
● This indicator reflects clinical effectiveness and poses a challenge to the Clinical
Psychologist in striving to deliver the services effectively.
1. Clinical Psychology Services:
Clinical Psychology Services offer psychotherapy to reduce psychological distress (mental
illness), augment and promote psychological well-being and quality of life. The services are part
of a multidisciplinary team for psychological readjustment and restoration to psychological fitness.
2. Relapse of Case:
Clinical Psychology Services require extended case monitoring of the status of clients, providing
support, and accelerating re-entry into treatment in the event of impending or actual relapse. This
is accomplished through the efforts with contacts with the client and significant other members of
the family and health care providers.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients successfully discharged from the Clinical Psychology
Services having achieved restoration of psychological fitness.
NA
Sentinel Event
Numerator
Denominator
:
:
Number of patients having acquired psychological fitness
and successfully discharged from the Clinical Psychology
Services and relapsed
Total number of patients having acquired psychological
fitness and successfully discharged from the Clinical
Psychology Services
X 100%
Target
Data Collection
Comments/Review
:
:
:
0
6 Monthly

Indicator 02 : Percentage of Psychological Assessment Completed within 30
working days
Rationale:
● Psychological Assessment is the basis for clinical psychology service delivery.
● The use of psychological assessment requires a documented plan for subsequent audit
of clinical effectiveness of service delivery.
1. Psychological Assessment:
Psychological assessment is a process of testing that uses a combination of techniques to help
arrive at some hypotheses about a person and their behavior, personality and capabilities.
Psychological assessment is the extensive purview of psychologists who use assessment tools
to better understand what may be causing behavioral, emotional, or cognitive symptoms. Simply
by observing a person’s behavior during various structured and unstructured tasks, having them
and those who know them answer questions on psychological tests, and/or meeting with the
person directly, a psychologist can help identify underlying causes and develop a plan for
assisting them.
2. Psychological Assessment Completed within 30 working days:
Time taken from the date of referral to the Clinical Psychologist for consultation and treatment to
the date of completion of the psychological assessment of the same patient. The waiting time
refers to time between the dates the patient is seen by the Clinical Psychologist to the date of
completion of the psychological assessment within 30 working days.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All patients referred to the Clinical Psychologist for consultation and
treatment.
NA
Numerator
Denominator
:
:
Number of patients who had Psychological Assessment
completed within 30 working days
Total number of patients referred to the Clinical
Psychologist for consultation
X 100%
Target
Data Collection
Comments/Review
:
:
:
85%
6 Monthly

Indicator 03 : Percentage of new patient referred for psychotherapy session
receiving first session within 60 working days
Rationale:
● Psychotherapy is another main service in clinical psychology field.
● Clinical psychology clinic receives a significant amount of referrals for psychotherapy
cases.
1. Psychotherapy session:
Psychological intervention session for psychiatric disorders, administered as part of treatment
plan in managing psychiatric illnesses. It is usually administered in a form of talk therapy, as a
way to help patients in managing their symptoms, restoring functions, and increasing their well-
being.
2. New patient referred for psychotherapy session receives first session within 60
working days:
New patient is defined as a new case referred to Clinical Psychology Clinic. Patient will receive
his / her first appointment for psychotherapy session within 60 working days, from the date of
the referral received at clinic.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
● All cases referred to Clinical Psychology Clinic for psychotherapy
session.
● The Clinical Psychology Clinic offers psychotherapy service.
● Patient defaults / refuses to attend first session of psychotherapy.
● Clinical Psychology Clinic rejects a referral for psychotherapy for a
specific reason.
● Patient is not reachable via clinic’s communication platform, hence
he / she is not informed with psychotherapy first appointment date.
● Patient requests a specific date for first appointment, which
exceeding 60 working days.
Numerator
Denominator
:
:
Number of patients who have attended first psychotherapy
session within 60 working days.
Number of patients who have attended first psychotherapy
session in a specific month.
X 100%
Target
Data Collection
Comments/Review
:
:
:
80%
6 Monthly

SERVICE STANDARD 18: PHARMACY SERVICES
Frequency
1. Percentage of Prescription Error 0 Monthly
2. Percentage of Dispensing Error 0 Monthly
3. Average time for a prescription to be
dispensed from time received at counter to
time medication given to patient
≥ 95%
prescription
dispensed
within 30
minutes
Monthly
4. Number and value of expired drugs at end of
month over a specified period
0 Monthly

Indicator 01 : Percentage of Prescription Error
Rationale:
● Medication Error is a significant problem in hospitals and has an impact on the safety of
patients. The large amount of medications used as well as the availability of new and
potent medicines requires further enhancement on the awareness on medication safety.
It is a serious adverse event where there is much pain and suffering or
temporary/permanent disability.
● It is an indicator of the delivery of safe patient care in the hospital.
1. Medication Error:
A medication error is any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the healthcare professional, patient
or consumer. Such an event may be related to professional practices, healthcare products,
procedures and systems including prescribing, order communication, product labelling,
packaging and nomenclature, compounding, dispensing, distribution, administration, education,
monitoring and use. Medication errors may be committed by both inexperienced and experienced
personnel like doctors, pharmacists, dentists and other healthcare provider, patients,
manufacturers, caregivers and others.
2. Prescribing Error:
Incorrect drug product selection (based on indications, contraindications, known allergies,
existing drug therapy, and other factors), dose, dosage form, quantity, route of administration,
concentration, rate of administration, or instructions for use of a drug product ordered or
authorized by physician (or other legitimate prescriber); illegible prescriptions or medication
orders that lead to errors.
(Reference: Guideline on Medication Error Reporting Ministry of Health Malaysia)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All prescriptions made out for patients (in-Patient and Out- Patients)
NA
Numerator
Denominator
:
:
Number of prescription errors (out-patients and in-patients)
Total number of prescriptions (outpatients and Inpatients)
written by doctors
X 100%
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

Indicator 02 : Percentage of Dispensing Error
Rationale:
● Medication Error is a significant problem in hospitals and has an impact on the safety of
patients. The large amount of medications used as well as the availability of new and potent
medicines requires further enhancement on the awareness on medication safety. It is a
serious adverse event where there is much pain and suffering or temporary/permanent
disability.
● It is an indicator of the delivery of safe patient care in the hospital.
1. Medication Error:
A medication error is any preventable event that may cause or lead to inappropriate medication
use or patient harm while the medication is in the control of the healthcare professional, patient
or consumer. Such an event may be related to professional practices, healthcare products,
procedures and systems including prescribing, order communication, product labelling,
packaging and nomenclature, compounding, dispensing, distribution, administration, education,
monitoring and use. Medication errors may be committed by both inexperienced and experienced
personnel like doctors, pharmacists, dentists and other healthcare provider, patients,
manufacturers, caregivers and others.
2. Dispensing Error:
● Dispensing or administration to the patient of medication not authorised by a legitimate
prescriber.
● Dispensing or administration to the patient of a dose that is greater than or less than the
amount ordered by the prescriber or administration of multiple doses to the patient, i.e. one
or more dosage units in addition to those that were ordered.
● Dispensing or administration to the patient of a drug product in a different dosage form than
that ordered by the prescriber.
● Dispensing or administration of a drug that has expired or for which the physical or chemical
dosage-form integrity has been compromised.
(Reference: Guideline on Medication Error Reporting Ministry of Health Malaysia)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All prescriptions made out for patients (in-Patient and Out- Patients)
NA
Numerator
Denominator
:
:
Number of dispensing errors (out-patients and in-patients)
Total number of prescriptions dispensed (outpatients and
Inpatients)
X 100%
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

Indicator 03 : Average time for a prescription to be dispensed from time
received at counter to time medication given to patient
Rationale:
● Promptness of service is one criteria of quality care. Patient centred service must give
priority to reducing waiting time for dispensing. This indicator reflects access and patient
centeredness.
● Long waiting time can adversely affect patient satisfaction
Definition of Term:
1. Waiting Time:
Time when a prescription is received at the pharmacy counter to the time the medication (s) is
dispensed to the patient.
2. Dispense:
Process of delivering medication to the patient
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All prescriptions received from the Outpatient Pharmacy Department
/Specialist Clinic/Follow up Clinic
NA
Numerator
Denominator
:
:
Total cumulative time taken to dispense all prescriptions
received for the day from the time of receiving the first
prescription to the time of the last dispensing
Total number of prescriptions (outpatients) received for the
day
Target
Data Collection
Comments/Review
:
:
:
≥ 95% prescription dispensed within 30 minutes
Monthly

Indicator 04 : Number and value of expired drugs at end of month over a
specified period
Rationale:
● To ensure good quality and safe medicines are available and accessible in a system that
uses resources effectively for enhancement of the pharmaceutical services with better use
of medicines and reduced wastage.
● To reflect the efficiency of the pharmaceutical services.
Definition of Term:
Value of Expired Drugs:
The cost of the drugs at the time of purchase.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All expired drugs in stock at the end of the month over a specified
period.
NA
Number and Value (cost)
Numerator
Denominator
:
:
Total number and value (cost) of expired drugs (all types of
medications- oral, parental etc.) at the end of each month
over a specified period.
Target
Data Collection
Comments/Review
:
:
:
0
Monthly

SERVICE STANDARD 19: CENTRAL STERILE SUPPLY SERVICES (CSSS)
Frequency
1. Percentage of sterile instrument sets rejected < 5% Monthly
2. Percentage of incidents reported monthly that
have had Root Cause Analysis (RCA) done
and action taken to prevent recurrence
100% Monthly
3. Internal Customer feedback > 80% 6 monthly
4.
Leak testing for rigid container system to
ensure sterility
100% Quarterly

Indicator 01 : Percentage of sterile instrument sets rejected
Rationale:
● The Central Sterile Supply Services responsibility is to provide centralized sterilizing
services and sterile supplies for all areas within the Facility that use sterile instruments,
dressings, linen and other items to effectively prevent and control the incidence of
Healthcare Acquired Infection (HAI).
● This indicator reflects the efficiency of the Central Sterile Supply Services.
Definition of Term:
Reject of sterile instruments:
The major role of the CSSS is disinfection, sterilization and reprocessing service and thermal
decontamination for products not able to be sterilized. Occasions of reject sterile instruments sets
could cause disruptions in surgical procedures and cost for the facility due to:
● Breech in the integrity of sterility
● Incomplete sets
● Use of poor packaging material
● etc.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Reject instrument sets per batch from all areas (OT, wards, clinics) of
the facility at the end of the day over a specified period.
NA
Numerator
Denominator
:
:
Total number of reject sterile instrument sets in a month
Total number of instrument sets sterilized in a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 5%
Monthly

Indicator 02 : Percentage of incidents reported monthly that have had Root
Cause Analysis (RCA) done and action taken to prevent
recurrence.
Rationale:
● Knowledge of how to prevent harm to patients and staff during care is the most important
knowledge in the field of patient safety. One of the best practices for patient safety is to
establish a “No Blame, Reporting Culture by initiating an Incident Reporting and Learning
System.
1. Incidents:
Mishaps, near misses and hazards that have a likely hood of recurring if risk management
strategies are not institutionalised. Example: incomplete sets, breach of sterility, staff injury,
mechanical failure/malfunction of autoclaves etc.
2. Root Cause Analysis (RCA)
Root Cause Analysis is a structured investigation that aims to identify the true cause of a problem
and the actions necessary to eliminate it.
(Bjorn Andersen and Tom Fagerhaug. Root Cause Analysis: Simplified Tools and Techniques.
McGraw- Hill, 2000)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of incidents needing RCA reported and documented
NA
Numerator
Denominator
:
:
Number of incidents reported and where Root Cause
Analysis is done and actions taken in the month
Total number of incidents reported in the month
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly

Indicator 03 : Internal Customer feedback
Rationale:
● This indicator reflects the efficiency of the Central Sterile Supply Services
● Customer satisfaction survey is a measure of providing exemplary service requires the
consistent delivery of safe, high-quality products and services.
● To obtain feedback from the end-user pertaining to the services of CSS provided to help
the department to improve their services.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Customer who participate in customer satisfaction survey
NA
Numerator
Denominator
:
:
Number of participating customers who indicated they were
satisfied in the customer survey within > 80% satisfaction
level
Total number of customers who participate in the customer
satisfaction survey
X 100%
Target
Data Collection
Comments/Review
:
:
:
> 80% customer satisfaction level
6 monthly

Indicator 04 : Leak testing for rigid container system to ensure sterility
Rationale:
Healthcare Acquired Infection.
● This indicator reflects sterilization achieved post all instruments set that has been
sterilized in a container for OT use.
● Check the condition of containers used for sterilization that is effective to maintain
sterility of product post sterilisation
Leak testing is the process of checking the containers used for leaks (a defect). Leak testing can
be achieved using various leak detection methods and is employed to test for defects in the
container casing seal which if it is broken or eroded will compromise the sterilisation of the
instruments.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All containers used for instruments sterilisation
NA
Numerator
Denominator
:
:
Number of containers found with leak
Number of containers tested
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Quarterly

SERVICE STANDARD 20: HOUSEKEEPING SERVICES
Frequency
1. Trend of performance score during in-
house inspection/joint inspection
80% with
minimum
score of 3
Monthly
2. Customer satisfaction feedback survey 80%
satisfaction
6 Monthly

Indicator 01 : Trend of performance score during in-house inspection/joint
inspection
Rationale:
● The Housekeeping Services are an integral part of the hospital support services to ensure
a clean environment in the hospital and is crucial in the prevention and control of
● This indicator measures the quality of the performance of Housekeeping Services.
Regular trending of the performance of the service examines the weakness and shortfalls
in the overall improvement of the Housekeeping Services.
1. Trending of Performance Score:
During the periodic in-house/joint inspection of the performance of the house keeping services,
staff of the hospital/outsourced services contractor conducts an objective assessment using set
criteria and scoring on the performance of the cleansing service for each area of the facility. These
scores are to be trended as per achievement for each area of the facility for a specific period.
2. Performance Score:
1 = Poor
2 = Fair
3 = Good
4 = Excellent
5 = Non-Applicable
(Source: Technical Requirements Performance Indicators, Ministry of Health Hospital Support
Services)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All the areas in the facility to be included i.e. wards, critical care
areas, operating theatre, Emergency Department etc.
NA
Process Based Indicator
Numerator
Denominator
:
:
Performance trend showing 80% with minimum score of 3
for cleansing service in all areas of the Facility
Target
Data Collection
Comments/Review
:
:
:
80% with minimum score of 3
Monthly
-

Indicator 02 : Customer satisfaction feedback survey
Rationale:
● The Housekeeping Services are an integral part of the hospital support services to ensure
a clean environment in the hospital and is crucial in the prevention and control of
Healthcare Acquired Infection (HAI) and mishaps may occur in the cleansing service
meeting patient needs on cleanliness of the environment and comfort of the patient.
Patient satisfaction survey is a measure of the extent to which a patient (inpatient and
outpatient) is content with the cleanliness of the environment/facilities of the Healthcare Facility
and the level of patient comfort.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All out-patients and inpatients
NA
Numerator
Denominator
:
:
Number of patient satisfaction surveys done every six (6)
months with 80% satisfaction level
Target
Data Collection
Comments/Review
:
:
:
80% satisfaction level
6 Monthly
-

SERVICE STANDARD 21: LINEN SERVICES
Frequency
1. Percentage of Linen Shortfall 2 % Monthly
2. Linen Rejection Rate < 2 % Monthly
3. Percentage of incidents reported monthly that
have had Root Cause Analysis (RCA) done
and action taken to prevent recurrence
100% Monthly
4. Internal customer satisfaction survey 80%
satisfaction
6 monthly

Indicator 01 : Percentage of Linen Shortfall
Rationale:
● A reliable laundry service is of utmost importance to healthcare facilities. In healthcare
facilities, patients expect linen to be changed daily. An adequate supply of clean linen that
is sufficient for the comfort and safety of the patient thus becomes essential.
● The Linen Service is an integral part of the hospital support services to ensure clean Linen
and Laundry Services in hospitals and is crucial in the prevention and control of
● Laundry and linen service plays a very important role in maintaining and safeguarding the
health and hygiene of both the inpatient and medical staff.
1. Hospital Linen
The term ‘hospital linen’ includes all textiles used in the hospital including mattress, pillow covers,
blankets, bed sheets, towels, screens, curtains, doctors/staff coats, theatre cloth etc. The hospital
uses these materials in different areas like Operation Theatre, wards, outpatient departments and
office areas.
2. Linen Services
Linen Services include the supply and delivery of clean linen and the collection and washing of
dirty and soiled linen which may be provided from within the Facility or outsourced where linen
shortfalls are likely to occur.
3. Shortfall in Linen Services:
Target per bed weight (e.g., 5.34 kg) versus Actual Received (4.85 kg/Bed) or par level as is the
current practice in hospitals.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of linen used in the Healthcare Facility i.e., patient’s linen,
bed covers, linen for drapes and procedures etc.
NA
Numerator
Denominator
:
:
Total quantity of Linen by types (bed sheet, patients
pyjamas, bedcovers etc) and par levels actually supplied to
the Facility in a month
Total quantity of Linen by types (bed sheet, patients
pyjamas, bedcovers, etc.) and par levels agreed to be
supplied to the Facility in a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
2%
Monthly
-

Indicator 02 : Linen Rejection Rate
Rationale:
● A reliable laundry service is of utmost importance to healthcare facilities. In healthcare
facilities, patients expect linen to be changed daily. An adequate supply of clean linen that
is sufficient for the comfort and safety of the patient thus becomes essential.
● The Linen Service is an integral part of the hospital support services to ensure clean Linen
and Laundry Services in hospitals and is crucial in the prevention and control of
● Laundry and linen service plays a very important role in maintaining and safeguarding the
health and hygiene of both the patients and medical staff.
1. Hospital Linen:
The term ‘hospital linen’ includes all textiles used in the hospital including mattress, pillow covers,
blankets, bed sheets, towels, screens, curtains, doctors/staff coats, theatre cloth etc. The hospital
uses these materials in different areas like Operation Theatre, wards, outpatient departments and
office areas.
2. Linen Rejection:
Washed linen upon delivery maybe rejected by the facility for various reasons i.e., odour, torn,
stained, torn etc.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of washed hospital linen upon delivery that does not comply
with the set standards of clean linen
NA
Numerator
Denominator
:
:
Total quantity of Linen by weight and types (bed sheet,
patients pyjamas, bed covers etc.) rejected by the Facility
in a month
Total quantity of Linen by weight and types (bed sheet,
patients pyjamas, bedcovers etc.) supplied to the Facility in
a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
< 2%
Monthly
-

Indicator 03 : Percentage of incidents reported monthly that have had Root
Cause Analysis (RCA) done and action taken to prevent
recurrence.
Rationale:
● Knowledge of how to prevent harm to patients and staff during care is the most important
knowledge in the field of patient safety. One of the best practices for patient safety is to
establish a “No Blame, Reporting Culture by initiating an Incident Reporting and Learning
System.
● The Linen Service is an integral part of the hospital support services to ensure clean linen
and laundry services in hospitals and is crucial in the prevention and control of Healthcare
Acquired Infection (HAI).
1. Linen Services:
Linen Services include the supply and delivery of clean linen and the collection and washing of
dirty and soiled linen which may be provided from within the Facility or outsourced where incidents
of mishaps i.e., injury, linen shortfalls etc are likely to occur.
2. Incidents:
Mishaps, near misses and hazards i.e., injury due to unclear Standard Operating Procedures that
have a likely hood of recurring if risk management strategies are not institutionalised.
3. Root Cause Analysis (RCA):
Root Cause Analysis is a structured investigation that aims to identify the true cause of a problem
and the actions necessary to eliminate it?
(Bjorn Andersen and Tom Fagerhaug. Root Cause Analysis: Simplified Tools and Techniques.
McGraw- Hill, 2000)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All types of incidents needing RCA reported and documented within
a specified period
NA
Numerator
Denominator
:
:
Total number of incidents reported for which Root Causes
Analysis is done and actions taken in a month.
Total number of incidents reported in a month
X 100%
Target
Data Collection
Comments/Review
:
:
:
100%
Monthly
-

Indicator 04 : Internal Customer satisfaction survey
Rationale:
● The Linen Service is an integral part of the hospital support services to ensure clean linen
and laundry services in hospitals and is crucial in the prevention and control of Healthcare
Acquired Infection (HAI).
● Customer satisfaction survey is one of the tools that can be used in recognizing areas for
improvement in the linen services provided.
1. Facility’s Internal Customer:
Internal Customer refers to the Facility’s staff involved in the handling of Linen and Laundry
Services including representatives of the Facility’s Management i.e., liaison staff, ward staff etc.
2. Satisfaction Survey:
Internal customer satisfaction survey is a measure of the extent to which the Facility’s
management/ staff is satisfied with the Linen and Laundry Services in particular the cleanliness
and adequacy of patients’ garments, linen used for beddings, towels etc. The survey is referring
to a Customer Satisfaction Survey Questionnaire.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All staff/clients handling the Facility’s Linen and Laundry Services and
participates in the Internal Customer Satisfaction Survey
NA
Numerator
Denominator
:
:
Number of participating Internal Customers indicating they
were “satisfied” in the customer satisfaction survey
Total number of Internal Customers who participated in
the Customer Satisfaction Survey
X 100%
Target
Data Collection
Comments/Review
:
:
:
80% satisfaction level
6 Monthly
-

SERVICE STANDARD 22: FOOD SERVICES
Frequency
1. Percentage of ready to serve food tested
negative for pathogenic microorganism as per
schedule
100% 3 Monthly
2. Occurrence of physical contamination of food
served to patients
Sentinel
Event
Monthly
3. Client Food Satisfaction survey ˃ 85%
satisfaction
6 Monthly

Indicator 01 : Percentage of ready to serve food tested negative for
pathogenic microorganism as per schedule
Rationale:
● This indicator reflects the safety of the Healthcare Facility’s Food Services for in-patients’
consumption.
● There should be no occurrences of samples of ready to serve food being tested positive
for pathogenic micro-organism if high quality food preparation, handling and transport are
implemented or adhered to.
1. Ready to serve food:
Ready to eat/serve food means food (cooked and freshly cut) that is in a form that is edible without
additional preparation to achieve food safety. Foods which are ready to be taken for sampling
under strict sanitary and food quality standards and tested for pathogenic microorganism.
2. Food testing for microorganism:
Microbiology testing is a crucial requirement across many food industries worldwide where
products, processes and human health are at risk of being negatively affected by the presence
and breeding of micro-organisms such as specific pathogens, bacteria, yeast and moulds. Food
testing for microorganism is important to determine the safety and quality of food.
3. As per schedule:
Samples (6-10) of ready to be served food (cooked and freshly cut) for in-Patients taken for testing
for microorganism over every three (3) months
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Samples (6-10) of ready to be served food (cooked and freshly cut)
for In-Patient Food Services (that include outsourced or in-house
kitchen) are taken for sampling every three (3) months
NA
Numerator
Denominator
:
:
Number of samples of ready to serve food (cooked and
freshly cut) for in-patients tested negative for
pathogenic micro-organism
Total number of samples (6-10) of ready to serve food
(cooked and freshly cut) for in-patients tested for
pathogenic micro-organism
Target
Data Collection
Comments/Review
:
:
:
100%
3 monthly
-

Indicator 02 : Occurrence of physical contamination of food served to patients
Rationale:
● This indicator reflects the safety of the Food and Dietary Services for patient’s
consumption.
● There should be no occurrences of food contamination if high quality food preparation,
handling and transport are implemented or adhered to.
Contaminated Food:
Presence of materials that are not normally found in food served/prepared for inpatients (that
include outsourced and in-house kitchen)
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Food prepared for all inpatients/on call staff
Micro-organisms and toxic chemicals.
Sentinel Event
Numerator
Denominator
:
:
Number of Occurrences of Physical Contamination of Food
during the study period
Target
Data Collection
Comments/Review
:
:
:
Sentinel Event
Monthly
-

Indicator 03 : Client Food Satisfaction survey
Rationale:
● It is the hospital’s responsibility to provide high quality food services for the patients to
support in the treatment and recovery of the patient’s health during admission at the
hospital. Hence standards of food quality should be implemented and adhered to.
● This survey is a proxy measurement of Patient- Centred Services and Client Satisfaction
level on the Food Services.
● Client satisfaction survey is one of the tools that can be used in recognizing areas for
improvement in the Food Services.
1. Hospital Client:
Refers to all inpatients provided Food Services during their course of admission in the Hospital
2. Food Satisfaction Survey
Client food satisfaction survey is a measure of the extent to which an in-patient is content with
the Food Services in particular in meeting the patient’s nutritional requirements and dietary needs.
The survey is referring to a Customer Satisfaction Survey Questionnaire.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All inpatients in all wards/ units of the Facility
NA
Numerator
Denominator
:
:
Numbers of Client Food Satisfaction Survey Feedback
with 80% satisfaction level
Total number of clients that participated in the Client Food
Satisfaction Survey
X 100 %
Target
Data Collection
Comments/Review
:
:
:
˃ 85% satisfaction level
6 Monthly
-

SERVICE STANDARD 23: FORENSIC MEDICINE SERVICES
There are including tracking and trending of specific performance indicators which
include but not limited to at least two (2) of the following indicators:
Frequency
1. Turnaround time of ≤ 3 hours for releasing
bodies (non-police cases) to the next of
kin/claimant after body registration.
≥ 80% Monthly
2. Percentage of bodies released to the right
next of kin/claimant
≥ 99%
(sentinel
event needs
to be
investigated
immediately)
Monthly
3. Percentage of completion of post-mortem
report for non-complicated cases from the date
of post-mortem within twelve (12) weeks
≥ 80% Monthly
Note:
Non-complicated cases refer to accidents, suicides and natural deaths which are
routine police cases subjected to forensic post-mortem examination.

Indicator 01 : Turnaround time of ≤ 3 hours for releasing bodies (non-police
cases) to the next of kin/claimant after body registration.
Rationale:
● This indicator reflects the timeliness for the release of bodies for non- medico-legal cases
and client centeredness of care in the Mortuary Service. There is a need to hasten the
release of bodies of non - medico- legal cases for cultural and religious reasons.
Non- Medico-legal cases:
There is no issue of Polis 61 order for post-mortem.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Bodies of all cases requiring no post-mortem
NA
Numerator
Denominator
:
:
Number of bodies released (non-medico-legal cases) to
next of kin/claimant within 3 hours from the time bodies
were received in the mortuary
Total number of bodies received (non-medico-legal cases)
in the mortuary during the month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
Monthly
-

Indicator 02 : Percentage of bodies released to the right next of kin/claimant
Rationale:
● This indicator reflects the efficiency of the Mortuary Service. The release of wrong bodies
to the next of kin/claimant can turn out to be traumatic for the family as well as a medico-
legal issue and an embarrassment to the facility.
Definition of Term:
Release of Correct Bodies:
Refers to the release of correct bodies (correct identity of the deceased) or to the correct party
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All bodies received at the mortuary
NA
Numerator
Denominator
:
:
Number of bodies released to the right next of
kin/claimant
Total number of bodies received in the mortuary during the
month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 99% (sentinel event needs to be investigated immediately)
Monthly
-

Indicator 03 : Percentage of completion of post-mortem report for non-
complicated cases from the date of post-mortem within twelve
(12) weeks
Rationale:
● This indicator reflects the efficiency of the Forensic Services and timeliness for post-
mortem reports for non-complicated cases.
1. Post-mortem Report:
A detailed clinical report of a postmortem examination of a cadaver. An autopsy also known as
a post-mortem examination is a highly specialized surgical procedure that consists of a thorough
examination of a corpse by dissection to determine the cause and manner of death and to
evaluate any disease or injury that may be present.
2. Non-Complicated Cases:
Non-complicated cases refer to accidents, suicides and natural deaths which are routine police
cases subjected to forensic post-mortem examination.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All non- complicated cases requiring post-mortem
NA
Numerator
Denominator
:
:
Number of post-mortem reports completed within twelve
(12) weeks from date of post-mortem for non- complicated
cases
Total number of post-mortems performed for non –
complicated cases within the month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 80%
Monthly
-

SERVICE STANDARD 23A: MORTUARY SERVICES
Frequency
1. Turnaround time of ≤ 3 hours for releasing
bodies (non-police cases) to the next of
kin/claimant after body registration.
≥ 80% Monthly
2. Percentage of correct bodies released to the
right next of kin/claimant
≥ 99%
(sentinel
event needs
to be
investigated
immediately)
Monthly
3. Percentage of completion of post-mortem
report for non-complicated cases from the date
of post-mortem within twelve (12) weeks
≥ 99%
(sentinel
event needs
to be
investigated
immediately)
Monthly
Note:
Non-complicated cases refer to accidents, suicides and natural deaths which are
routine police cases subjected to forensic post-mortem examination

Indicator 02 : Percentage of bodies released to the right next of kin/claimant
Rationale:
● This indicator reflects the efficiency of the Mortuary Service. The release of wrong bodies
to the next of kin/claimant can turn out to be traumatic for the family as well as a medico-
legal issue and an embarrassment to the facility.
Definition of Term:
Release of Correct Bodies:
Refers to the release of correct bodies (correct identity of the deceased) or to the correct party
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All bodies received at the mortuary
NA
Numerator
Denominator
:
:
Number of bodies released to the next of kin/claimant
Total number of bodies received in the mortuary during the
month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly
-

Indicator 03 : Percentage of completion of post-mortem report for non-
complicated cases from the date of post-mortem within twelve
(12) weeks
Rationale:
● This indicator reflects the efficiency of the Forensic Services and timeliness for post-
mortem reports for non-complicated cases.
1. Post –mortem Report:
A detailed clinical report of a postmortem examination of a cadaver. An autopsy also known as
a post-mortem examination is a highly specialized surgical procedure that consists of a thorough
examination of a corpse by dissection to determine the cause and manner of death and to
evaluate any disease or injury that may be present.
2. Non-Complicated Cases:
Non-complicated cases refer to accidents, suicides and natural deaths which are routine police
cases subjected to forensic post-mortem examination.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All non-complicated cases requiring post-mortem
NA
Numerator
Denominator
:
:
Number of post-mortem reports completed within twelve
(12) weeks from date of post-mortem for non- complicated
cases
Total number of post-mortems performed for non-
complicated cases within the month
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Monthly
-

SERVICE STANDARD 25: MEDICAL ASSISTANT SERVICES
There is tracking and trending of the following specific performance indicators for the
service:
FREQUENCY
1. Number of fire drill that has been carried out by the
hospital in the corresponding year:
a. Fire Drill at hospital level: Once a year
b. Tabletop Exercise at hospital level: Twice a year
(Once in 6 month)
a) Once a
year
b) Once in 6
months
Annually
6 monthly
2. Dispatch and Ambulance Preparedness of Primary
Responses
≥90%
3. Percentage of Medical Assistants in Emergency
Services trained in Advanced Life Support (ALS)
Non-specialist
hospital: ≥30%
Specialist
hospital: ≥50%)
4. Percentage of Medical Assistants with post basic
qualification and advance training in relevant
disciplines.
≥ 40% (for
staff with at
least 3 years
working
experience)
5. Peak Flow Rate (PEFR) Implementation for Asthma
Patients in Asthma Bay by Medical Assistant (AMO)
>80% number
of all asthma
patients with
Pre and Post
PEFR treated
in Asthma Bay

Indicator 01 : Number of Fire Drills that have been carried out by the hospital in
the corresponding year:
a. Fire Drill at hospital level: Once a year
b. Tabletop Exercise at hospital level: Twice a year (Once in 6
months)
Rationale:
Fire drills are essential in any workplace or public building for practicing what to do in the event
of a fire (Terry Penney, 2016). Not only do they ensure that all staff, customers and visitors in the
premise understand what they need to do in case of fire, but they also help to test how effective
the fire evacuation plan is and to improve certain aspects of the fire provisions.
Fire Drill: A practice of the emergency procedures to be used in case of fire. Fire Drill with multiple
Agencies: Fire Drill that involves Fire & Rescue Department or/and other agencies (e.g., St John
Ambulance/ Red Crescent) with the hospital staff/ personnel.
Tabletop exercise: A meeting to discuss a simulated emergency situation. Members of the team/
hospital review and discuss the actions they would take in a particular emergency, testing their
emergency plan in an informal, low stress environment. Tabletop exercises are used to clarify
roles and responsibilities and to identify additional campus mitigation and preparedness needs.
The exercise should result in action plans for continued improvement of the emergency plans.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All hospital building.
NA
Numerator
Denominator
:
:
1. Number of Fire Drill that has been carried out in the
corresponding year.
2. Number of Tabletop Exercise that has been carried out
in the corresponding year.
1. Total number of Fire Drill that has been planned in the
corresponding year
2. Total number of Tabletop Exercise that has been
planned in the corresponding year.
X 100 %
Target
Data Collection
Comments/Review
:
:
:
100%
6 Monthly
-

Indicator 02 : Dispatch and Ambulance Preparedness for Primary Responses
within 5 minutes. (Target: ≥90%)
Rationale:
1. Delay in ambulance turnout time may contribute to increased morbidity and mortality.
2. The aim is to reduce the ambulance turnout time and ensuring an appropriate ambulance
response in order to improve pre-hospital care.
Ambulance preparedness: Appropriate ambulance that is capable of providing basic emergency
medical and trauma care.
Ambulance dispatch: The mobilization of ambulance to the designated destination after the
activation call is terminated.
Primary response: Initial response and care by emergency medical services (by an ambulance
services).
Within (≤) 5 minutes: Time taken from the ambulance call was terminated/ completed to the
dispatch of the ambulance from the hospital to the scene.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
NA
1. Request for inter-hospital transfer.
2. Patient transportation.
3. Secondary response.
4. Mass casualty incident.
5. Non-emergency cases.
6. Diverted calls to other agencies.
Numerator
Denominator
:
:
Number of ambulance preparedness and dispatch for
primary response within (≤) 5 minutes
Total number of ambulance calls
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 90%
Monthly
-

Indicator 03 : Percentage of Medical Assistants in Emergency Services trained
in Advanced Life Support (ALS) (Target: Non-specialist hospital:
≥30% Specialist hospital: ≥50%)
Rationale:
Advanced Trauma and Life Support (ALS) skills (as stipulated in the Malaysian Trauma Life
Support and Advanced Trauma Life Support (MTLS/ALS/PALS) training programmes) is an
important skill for all health personnel to possess and is an important element of Continuing
Professional Development, which is a vital aspect of professionalism for Medical Assistants in the
Emergency and Trauma Services to provide resuscitation for patients presenting life threatening
conditions, hence improving the quality and safety of care provided. The use of defibrillator and
other devices to resuscitate a patient who has collapsed is permissible only to those who are
trained in MTLS/ALS/PALS.
Advanced Life Support: Advanced Life Support (ALS) is a set of life-saving protocols and skills
that extend Basic Life Support to further support the circulation and provide an open airway and
adequate ventilation (breathing).
Advanced Life Support Training: ALS Training is a standardized
national/international course teaching evidence-based resuscitation guidelines and skills to
healthcare professionals. ALS includes procedures and skills that extend Basic Life Support
(BLS) to further stabilize the patient.
Life Threatening Condition: The four conditions considered immediately life threatening in
an emergency situation are: Unconsciousness. No breathing or difficulty breathing. No pulse. The
following are signs and symptoms of life-threatening emergencies: Respiratory distress or
cessation of breathing. Severe chest pains. Shock. Uncontrolled bleeding.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Medical Assistants who is working in the Emergency and Trauma
Services for more than 24 months.
1. Medical Assistants who are transferred- in to the Emergency and
Trauma Services for less than 24 months.
2. Medical Assistants who are currently working in the Emergency
and Trauma Services for less than 24 months.
Rate Based Structural Indicator
Numerator
Denominator
:
:
Number of eligible Medical Assistants in the Emergency
and Trauma Services trained in Advanced Life Support
(ALS)
Total Number of eligible Medical Assistants in the
Emergency and Trauma Services
X 100 %
Target
Data Collection
Comments/Review
:
:
:
Non-specialist hospital: ≥30%
Specialist hospital: ≥50%
6 Monthly
-

Indicator 04 : Percentage of Medical Assistants with post basic qualification
and advance training in relevant disciplines.
Target: ≥ 50% (for staff with at least 3 years working experience)
Rationale:
Post basic qualification is an important element of Continuous Professional Development which
is a formal education. Therefore, continuous updating of the Medical Assistants in the respective
disciplines/fields will ensure the current/latest management of patient care is being practiced.
Post Basic Qualification: This qualification/certification usually signifies that one has attained
a basic level of higher education knowledge and competence in a particular field or occupation
and are capable of applying such knowledge and competence in an occupation or role in the
workplace. Post basic qualification may be obtained at baccalaureate level or as an extension of
the diploma holder in specific disciplines of health care/other fields.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All Medical Assistants with at least 3 years working experience and
working in any discipline in the hospital/facility.
All Medical Assistants with less than 3 years working experience and
employed in the hospital/facility.
Rate Based Structural Indicator
Numerator
Denominator
:
:
Number of eligible Medical Assistants with post basic
qualification and advance training in relevant disciplines.
Total Number of eligible Medical Assistants in the Facility
with at least 3 years working experience
X 100 %
Target
Data Collection
Comments/Review
:
:
:
≥ 40% (for staff with at least 3 years working experience)
6 Monthly
-

Indicator 05 : Peak Flow Rate (PEFR) Implementation for Asthma Patients in
Asthma Bay by Medical Assistant (AMO)
Rationale:
1. Asthmatic condition is assessed by PEFR procedure before and after treatment.
2. The aim is to manage Asthma patients according to severity of asthma and priority of
treatment.
3. To ensure all AMOs are compliant to Standard Operating Procedure (SOP) in management
of Asthma (Refer to Emergency Care SOP for AMOs)
4. PEFR as a crucial indicator in managing Asthma concurrent with current SOP and Clinical
Practice Guidelines (refer to CPG- Management of Asthma - MOH/P/PAK/354.17(GU)
5. AMO Clinical Audit in Asthma Care (2016-2017). Findings: Poor practice of pre and post
PEFR among AMOs.
PEFR: Peak Expiratory Flow Rate
PEFR before treatment: Reading of Peak Flow Meter Device on patient before treatment is
given
PEFR after treatment: Reading of Peak Flow Meter Device on patient after treatment is given
Asthma Category: 3 categories of asthma condition: Mild, Moderate and Severe Asthma
Priority of treatment: Asthma treatment are given according to the severity of asthma
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All mild asthma patients with Pre and Post PEFR treated in Asthma
Bay.
1. Patient refusal/uncooperative
2. Moderate & Severe Asthma
3. Unable to perform PEFR (patient factor and poor technique)
4. Patients with other lung conditions including congenital lung
diseases in children or infants, foreign body and cardiovascular
pathology that mimic asthma conditions
Numerator
Denominator
:
:
Number of all asthma patients with Pre and Post PEFR
treated in Asthma Bay.
Total number of asthma patients treated in Asthma Bay.
X 100 %
Target
Data Collection
Comments/Review
:
:
:
>80% number of all asthma patients with Pre and Post PEFR treated
in Asthma Bay
Monthly
Mild Asthma } Refer to Clinical Practice Guidelines
Moderate Asthma } (MOH/P/PAK/354.17(GU)
Severe Asthma }

SERVICE STANDARD 26: CLINICAL RESEARCH CENTRE SERVICES
Frequency
1. Number of trainings conducted per year Minimum
2 per year
Yearly
2. Number of publications per year Minimum
2 per year
Monthly

Indicator 01 : Number of trainings conducted per year
Rationale:
This indicator was selected as a generic indicator because:
• Staff knowledge, competency and skills acquired to conduct studies related to clinical
practices enable the Health Facility to share on best practices in the industry. Training in
Clinical Research is an important element in continuing education for staff development
in clinical research and practices.
• The Hospital’s Clinical Research Centre must undertake the responsibility to conduct
Clinical Research Training for its own staff and for the Ministry of Health where required.
• Training in Clinical Research will be an early exposure and encouragement for staff to be
involved in research
Training in Clinical Research:
Refers to continuing education/training program designed to educate an individual and give him
or her further skills or knowledge on Clinical Research to be applied in his or her line of work.
These programs are intended to educate persons on new advancements, or to build upon a
person's expertise in a given field.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All training conducted in the Facility in relation to Clinical Research in
a year
NA
Clinical Effectiveness and Quality Improvement
Numerator
Denominator
:
:
Total number of training courses on Clinical Research
conducted in the Facility in a year
Target
Data Collection
Comments/Review
:
:
:
Minimum 2 per year
Yearly

Indicator 02 : Number of publications per year
Rationale:
• The Hospital’s Clinical Research Centre must undertake the responsibility to publish
Clinical Research studies conducted by the staff to share on their experiences and best
practices in the industry. Publication on Clinical Research is an important element in
continuing education for staff development.
• Publications on Clinical Research will be an early exposure and encouragement for staff
to be involved in research
Publications on Clinical Research:
Studies with significant results more likely to lead to a greater number of publications
and presentations and to be published in journals with a high citation impact factor.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
All publications on Clinical Research studies undertaken by the
Facility’s Clinical Research Centre
NA
Clinical Effectiveness and Quality Improvement
Numerator
Denominator
:
:
Number of publications on Clinical Research undertaken
the Facility’s Clinical Research Centre in a year
Target
Data Collection
Comments/Review
:
:
:
Minimum 2 per year
Yearly

SERVICE STANDARD 27: DECEASED ORGAN & TISSUE DONATION AND PROMOTION
SERVICES
Frequency
1. Percentage of Potential Donor Detection
≥ 2% Monthly
2. Update of new organ and tissue donor
pledger registration into National Transplant
Resource Centre(NTRC) database within 3
working days
≥ 70% Monthly

Indicator 01 : Percentage of Potential Donor Detection
Rationale:
• Detecting potential donor is the first and crucial step in the deceased donation activity. It
should be carried out actively by donor coordinators in the hospital, in which each potential
donor should be referred to the National Transplant Resource Centre (NTRC).
• Identifying potential donors will create an opportunity for donor coordinators to plan and
carry out family approach for organ and tissue donation and possibly convert potential
donors to actual donors.
Potential Donor:
a) A person whose circulatory functions have ceased and resuscitative measures are not to
be attempted of continued, OR,
b) A person whose clinical condition is suspected to fulfil brain death criteria.
Actual Donor: A consented eligible donor in which an incision was made for the purpose of
organ or tissue donation or at least one (1) organ or tissue was procured for the purpose of
transplantation.
Brain Death: Irreversible cessation of all functions of the brain including the brain stem.
Critical Care Areas: An organised system for the provision of care to critically ill patients that
provide intensive and specialised medical and nursing care, and enhanced capacity for
monitoring and multiple modalities of physiological organ support to sustain life during a period of
life-threatening organ system insufficiency i.e. Intensive Care Units (ICU), Cardiac Care Units
(CCU), High Dependency Wards (HDW) and Emergency departments.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
1. All deaths which include brain death and cardiac death.
2. In critical care areas and/or mortuary.
1. Other wards not mentioned in the above, including medical,
geriatric, psychiatry, orthopaedics, rehabilitation, gynaecology,
maternity and paediatric wards.
2. Operating theatres.
Numerator
Denominator
:
:
Total number of potential donors
Total number of deaths in the hospital
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥ 2%
Monthly

Indicator 02 : Update of new organ and tissue donor pledger registration into
National Transplant Resource Centre (NTRC) database within 3
working days
Rationale:
This indicator was selected as a generic indicator because:
• The National Transplant Resource Centre (NTRC) has provided a database for the
registry of pledgers. This database is accessible to officers in charge of promotion of
activity of deceased organ and tissue donation in the country.
• With multiple campaigns held in many modalities, the number of new pledgers can be
overwhelming. To avoid any delay in updating the donor pledger database, this database
should be updated within 3 working days.
New Registration: New registration of organ and tissue donor pledger received via exhibitions,
web, social media and telephone.
Organ donation pledge: An individual who agrees to pledge as organ and tissue donor
Within 3 working days: A period of 3 working days from the time the completed registration form
is received.
Inclusion Criteria
Exclusion Criteria
Type of Indicator
:
:
:
Completed donor pledger registration form.
1. Information in registration in the donor pledge form is not
completed.
2. Parents /guardians of individuals under the age of 18 years who
do not allow to pledge as an organ and tissue donor.
Numerator
Denominator
:
:
Total number of updated new registration of organ and
tissue donation pledgers into the main database within 3
working days
Total number of updated new registration of organ and
tissue donation pledgers into the main database
X 100%
Target
Data Collection
Comments/Review
:
:
:
≥70%
Monthly

00. MSQH Performance Indicators - 6th Edition Complete Set of Performance Indicators .pdf

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