By Assoc. Prof. Dr. Kadar Marikar Chief Executive Officer
MSQH Development and implementation of Dental Clinics Accreditation Program Patient safety Impact of Accreditation Development of Dental Clinic Standards Dental Clinic Standards
The national accreditation body for Healthcare facilities and services in Malaysia Registered with Registrar of Societies 1997 (ROS 470) as a legal entity An outcome of smart partnership between MOH, APHM and MMA Non governmental and non profit organisation Accreditation is voluntary Implementation Hospital accreditation since end of 1999, Medical Clinic (2011), Dialysis centre (2013) Conducted over 400 Hospital surveys, 12 medical clinics, 4 dialysis centres (stand alone)
SMART PARTNERSHIP Sealing of Commitment A Memorandum of Understanding was signed on 1 st October 1999 (at the 7 th Annual National Healthcare Conference & Exhibition organised by APHM) between the MOH, APHM and MMA with MSQH to enhance and strengthen their collaboration and support towards the success of the Healthcare Accreditation programme . Witnessed by the Minister of Health Malaysia. Active Participation of the Public, Private Sectors & Professional Organizations
FROM: THE DIRECTOR GENERAL OF HEALTH MALAYSIA
The internationally recognised accreditation organisation for the promotion and improvement of quality and safety in healthcare
Advocate, educating and monitoring continuous quality improvement and patient safety in healthcare.
Educational- Peer Review Creating Quality Culture Continuous Quality Improvement Enhancing Patient Safety
Safety culture Integrity Professionalism Patient and people centred Teamwork
Ethical Principles Confidentiality No Conflict of Interest
ROLE OF MSQH Development and Assessment of Compliance to Standards for Accreditation of Healthcare Facilities and Services in Malaysia ▪ Hospitals (Public & Private) ▪ Ambulatory Care Services-Medical Clinics (Public & Private) ▪ Maternity Homes ▪ Nursing Homes ▪ Dental Services ▪ Haemodialysis Services ▪ etc.
Conduct Accreditation Activities with an emphasis on; - Safe facilities/structures - Safe providers - Safe work process and working environment - Patient focus services - SAFE OUTCOMES Quality of Life (Vision for Health)
WHY ACCREDITATION IN MALAYSIA Wide variation in the standards of services between public and private healthcare providers. To ensure the right person doing the right things right with the right process and equipment, in the right (safe) environment to the right patient with the right (good) outcome. Achieving optimum results from available resources Accreditation helps to establish common national standards.
ACCREDITATION OF HEALTHCARE ORGANISATIONS “Accreditation refers to the procedure by which MSQH offers formal recognition to healthcare organisations (facility and service providers) found to meet substantial level of compliance and competence as outline in the relevant MSQH standards.”
“ Accreditation is a self-assessment and external peer review process used by healthcare organisation to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system ” ISQua definition : Federation Operating Rules 1998
PROCESS STRUCTURE OUTCOME (What is the result of (What are the things (What do you do what you do with that you have) With these things ) these things that you have)
ORGANISATIONAL CULTURE & LEADERSHIP VALUES MEDICAL STAFF FOCUS FOCUS ON ON SAFETY ACCESSIBILITY PATIENT PROCESS COMPETENCY COMPETENCY QUALITY EFFICIENCY PATIENT CENTERED EFFECTIVENESS APPROPRIATENESS CONTINUOUS QUALITY IMPROVEMENT ENHANCED QUALITY OF LIFE
Patient safety is an outcome of safe health care process. While patient safety is the ultimate goal, it is a safer health care environment in the course of the process of patient care which ultimately determines safety. Safety is one dimension of the broader construct of culture, which includes aspects of organisational and clinical culture eg. related to specialities and professions. Communication is vital to patient safety in many ways: thus supporting mutual understanding across cultures is essential in the general development of patient safety.
RESOURCES CODE OF CONDUCT / ETHICS ACCREDITATION EVIDENCE BASED MEDICINE AWARD CUSTOMER SATISFACTION QUALITY OF CARE DENTAL CLINIC STANDARDS HUMAN FACILITIES & ACCESS TO PRACTICE RESOURCE CARE EQUIPMENT SAFETY ETHICS GOVERNANCE QIA P S O DOCUMENTATION EVIDENCE OF PRACTICE
THE SURVEYORS THE SURVEYORS External Peer Review Consist of Senior Practicing Dental Practitioners. SURVEYOR Knowledge Expertise Objective Impartiality Diplomacy Tact Communication Skills Report writing
Development of Malaysian Dental Clinics Accreditation Standards
The term Dental Clinics for the purpose of these standards refer to all dental clinics registered under the Private Healthcare Facilities and Services Act 1998 and public sector dental clinics. The term ‘services’ includes consultations, investigations, treatment and referrals.
DEFINITION OF ACCREDITATION “ Accreditation is a self-assessment and external peer review process used by healthcare organization to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system” ISQua definition : Federation Operating Rules 1998
DEMONSTRATE ACCOUNTABILITY Tool to Demonstrate Accreditation = Accountability
No. Name Organisation Dr. Elise Monerasinghe Cawangan Perundangan dan Penguatkuasaan, Bahagian 1. Kesihatan Pergigian, Kementerian Kesihatan Malaysia Dr Savithri a/p N.Vengadasalam Cawangan Akreditasi & Globalisasi, Bahagian Kesihatan 2. Pergigian, Kementerian Kesihatan Malaysia Dr. Norashikin Mustapha Yahya Cawangan Akreditasi & Globalisasi, Bahagian Kesihatan 3. Pergigian, Kementerian Kesihatan Malaysia Dr. Sharifah Tahirah Al-Junid Malaysian Association of Oral and Maxillofacial 4. Surgeons (MAOMS) Dr. Ganasalingam a/l Sockalingam Malaysian Association of Paediatric Dentistry(MAPD) 5. Dr. Noraini Nun Nahar bt Yunus Malaysian Association of Paediatric Dentistry(MAPD) 6. Col. Dr. Shalene Kereshanan Malaysian Association of Orthodontists (MAO) 7. Brig. Gen. Datin Dr. Roza Anon Mohd Bahagian Kesihatan Pergigian, Angkatan Tentera 8. Ramlee Malaysia, Kementerian Pertahanan Malaysia Dr. R. Vijendran Malaysian Private Dental Practitioners' Association 9. (MPDPA) Dr. Chow Kai Foo / Persatuan Doktor Pergigian Malaysia (MDA) 10. Dr. Rani Panadam Dr. Rathna Vaithilingam / Malaysian Society of Periodontology (MSP) 11. Dr. Sharifuddin Dr Tan Boon Tik Malaysian Endodontic Society (MES) 12. Dr. Kadar Marikar Malaysian Society for Quality In Health 13 Noramiza bt Md.Nasir Malaysian Society for Quality In Health 14
TERMS OF REFERENCE OF DENTAL CLINICS COMMITEE 1. Identify and request related professional organization or other related authorities that should provide inputs in the development of the Dental Clinics Standards. 2. Select the members of the working group for the development of the Dental Clinic Standards and on-going review and improvement of the standards and its process 3. Provide direction for the scope and development of the Dental Clinic Standards and its process. 4. Endorse the standards and the processes for implementation. 5. Identify, train, select and appoint the surveyors for the Dental Clinic Accreditation Program.
TERMS OF REFERENCE cont; 6. To develop the Dental Clinic Standards based on agreed principles, philosophy, values and needs of the Malaysian Population. 7. To develop the process (policies & procedures) of implementation of the Dental Clinic Standards based on agreed ISQua Accreditation Federation Council principles and philosophy with reference to the Private Health Care Facilities and Service Act 1998 and Regulations 2006. 8. Conduct pilot testing of the applications of the Dental Clinic Standards and its processes in identified facilities; finalize them and forward to the MSQH committee for approval and national implementation.
ACTIVITIES CONDUCTED Dental Standards from the following countries were reviewed; 1. United Kingdom (UKAS) 2. Australia (Australian Commission on Safety and Quality in Healthcare – NSQHS Standards Guide for Dental Practices and Services). *MOH Oral Health Division checklist
EFFORTS TOWARDS DEVELOPING STANDARDS FOR DENTAL CLINICS Meeting Date Outcome 1st Meeting 5th April 2013 Initial 2nd Meeting 3rd December 2014 Draft 1 3rd Meeting 29th January 2015 Draft 2 4th Meeting 23rd February 2015 Draft 3 5th Meeting 12th March 2015 Draft 4 6th Meeting 9th April 2015 Draft 5 7th Meeting 18th May 2015 Draft 6 8th Meeting 15th June 2015 Final Draft 9th Meeting 6th August 2015 Feedback from public 9 th September 2015 Launching of standards 10 th Meeting 4th December 2015 Operational Policies *Small group 16th December 2015 weightage & scoring 11 th meeting 24th March 2016 Operational Policies 12 th meeting 27 th April 2016 Pilot Test
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