SERVICE STANDARD 1: Governance, Leadership and Direction

Malaysian Hospital Accreditation Programme - Survey Questionnaires 4th Edition January 2013

SERVICE STANDARD 1: Governance, Leadership and Direction

Standard No. Survey Item HospitalSurveyor

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1.1 ORGANISATION AND MANAGEMENT

1.1.1The Governing Body adopts a governing framework thatconstituted the internal legislation that will fit the particularneeds and circumstances of the Facility.These may becalled Hospital By-Laws and Medical Staff By-Laws, whichinclude Rules and Regulations, Termsof Reference,Policies, Resolutions or other similar terms and theygovern the actions of the Board and management of theFacility. The governing framework isessential for thegovernance of the Facility.

1.1.1.1The

Governing Body ensures that the Vision and Mission

statements, goals, objectives andvalues are identified anddocumented; and these reflect the Facility’s roles andaspirations in the community that it serves. These are asfollows:

a)The documented statements of Vision and Mission, goals,objectives and values are what the services want toachieve.

b)Statements reflect the Facility’s roles and aspirations inthe community that it serves.

c)The goals of the service are achieved by the objectives as

stated.

d)The goals and objectives are consistent with professionalstandards, guidelines and relevant legislation.

e)Statements are monitored, reviewed and revised asrequired accordingly.

1.1.1.2The Governing Body reviews the facilities’ objectives regularlyand revises them when necessary.

1.1.1.3The

services provided by the Facilitymeet the needs of the

community and also address Patient and Family Rights.

Service Std 1: Governance, Leadership and Direction Page 1


StandardNo. Survey Item

Hospital Surveyor

Rating Rating1.1.1

.4There is a written governing framework in accordance withstatutory and other legal requirements, e.g. written organisationplan, hospital operating policies, Medical Staff By-Laws etc.Where there are two or more registered medicalpractitioners/dental practitioners in any one specialty in theFacility, a specialised department is organised and establishedwith designated Heads for effective delivery of the clinicalservices.

1.1.1.5

There is a governing framework which include the followingelements, unless otherwise provided for by statute:

a)the Facility has an organisation chart which:

i) provides a clear representation of thestructure, function and reporting relationships of theservices;

ii)is accessible to all staff;

iii) is revised when there is amajor change in any one of thefollowing: organisation plan; functions; reporting relationships; goals and objectives; staffing patterns.

iv) is exhibited in a conspicuous part of the

Facility.

b) relationships between the Governing Body and:

i) any authority superior to it, if such exists; ii) the Person In Charge (PIC) and

other executive staff; iii) all medical practitioners working in the

Facility; iv) nursing and all other healthcare professionals.

c) guidelines for the appointment ofmembers of the Governing Body, itsofficers, committees, thequalifications required of theincumbents and the terms of office.

d) the appointment of the Person InCharge (PIC) is in accordance tothe relevant Acts and Regulationswhich


Standard No.

Survey Item HospitalSurveyor

Rating Ratingstipulate a degree in Medicine and is registered withMalaysian Medical Council (MMC),

at least two (2) years

training in any specialty and at least two (2) yearsexperience in hospital management. (Fourth ScheduleRegulation 12 PHFSA 1998 Regulations 2006). ThePerson In Charge (PIC) ensures the formation ofspecialised departments and appointments of Heads ofDepartments and staff meet the requirements of therelevant Acts, Regulations and By-Laws.

e)documentation of the authority and duties of theGoverning Body, its officers, and committees.

f)documented evidence of delegationof authority to thePerson In Charge (PIC) or other persons; and the right ofthe Governing Body to rescind such delegation;

g)intervals at which reviews of the governing framework arecarried out;

h)specifications of rules and regulations which areapplicable to all staff;

i)governing framework is accessible tostaff of the Facility.

1.1.1.6 There is provision for the establishmentand delineation of thepurpose and function of any auxiliary

organisations, such as St.John’s Ambulance, Red Crescent and others.

1.1.2 The Governing Body ensures that quality services, safepatient care and safe working environment are initiated,facilitated, promoted, and maintained within the Facility.

1.1.2.1The Governing Body has established Organisational QualityPolicies which include but not limited to the following andensures the implementation hospital wide.

a)There is a mechanism established for reportingincidents/accidents and near misses;

b)The Person In Charge (PIC) has copies of reports forincidents/accidents, near misses andrisk assessment ofconsequences of unintended care/treatment;



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c)Investigation and resolution of all complaints are donewithin a stipulated period.

1.1.3There is an appointment of the Person InCharge (PIC) whois a person possessing such qualification, training andexperience as prescribed according to the relevant Acts,Regulations and By-Laws. The Person In Charge (PIC) isresponsible for the organisation, management and controlof the healthcare facility or service towhich a licence orregistration relates and answers to the Governing Body.Clinical staff appointments, credentialing and privilegingare documented. These meet the requirements of therelevant Acts, Regulations and By-Laws.There is a Medical and Dental Advisory Committee toadvise the Governing Body to plan, coordinate, implement,control and improve activities relating to clinical patientcare.

1.1.3.1The Person In Charge (PIC) appointed is in accordance to therelevant Acts and Regulations which include a degree inMedicine and is registered with Malaysian Medical Council(MMC), at least two (2) years training in any specialty and atleast two (2) years experience in hospital management (Fourth

Schedule Regulation 12 PHFSA 1998 Regulations 2006).

1.1.3.2The Person In Charge (PIC) has a letter of appointment whichdelineates the authority, responsibilities and accountabilities ofthe position.

1.1.3.3The Person In Charge (PIC) is responsible for the establishmentof an organisational structure that clearly represents theuniformity of the clinical services and reporting relationshipswhich are documented in the job description. The organisationalstructure reflects the PIC is in charge of clinical services.

1.1.3.4The Governing Body has established the Medical Staff By-Lawswhich include the following policies andprocedures for medicalpractitioners:

a)criteria and process for appointment;


StandardNo. Survey Item HospitalSurveyor

Rating Ratingb)

criteria and process for re-appointment;

c)

delineation of clinical privileges, roles and responsibilities.

1.1.3.5

There is a Medical and Dental Advisory Committee (MDAC)whose members are registered medical anddental practitionersrepresenting all medical and dental practitioners practising in theFacility or service advise the GoverningBody, the licensee andPerson In Charge (PIC) on all aspects relating to medical anddental practices. In the smaller public facilities, the MedicalStaff/Clinical Staff Committee functions as the MDAC. TheMDAC is expected to discharge its dutiesand responsibilitiesthrough subcommittees. The MDAC is chaired by a member ofthe medical practitioners and documents: Appointment of a Chairperson Terms of Reference Committee members Tenure of membership Frequency of meetings

1.1.3.6

The subcommittees of MDAC address at least the followingareas of concern:a)

development and consensus of policies, procedures andstandards of patient care evidence based guidelines;

b)

credentialing and privileging of clinical care providers;

c maintenance of professional

) standards and ethics;d)

safety and quality improvementactivities and riskmanagement;

e)

clinical documentation and medical records;

f)

prevention and control of infection and antibiotic usage;

g)

drug utilisation and medication practices;

h) use of blood and blood products;i)

continuing professional development, training andcontinuing medical education;



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j)facilitation and supervision of research including theethical aspects of research where appropriate.

1.1.3.7There is a Hospital Management Committeewhich meets withsufficient regularity and with an adequate quorum. Minutes arekept and accessible to members. Findings, decisions andresolutions made during meetings are communicated to relevantstaff members of the Facility and to theGoverning Body. Thecommittee has:

Appointment of Chairperson

Terms of Reference Committee members

Tenure of membership

Frequency of meetings

1.1.4Service planning is based on the organisation’s strategicdirection and due consideration of financial factors and theexternal environment. The financial management of theFacility is organised to allow reasonable managementreports to be generated.

1.1.4.1The

Person In Charge (PIC) isresponsible for the efficient

management of the financial resources ofthe Facility and this isdocumented in the job description.

1.1.4.2There

are

external audits carried

outby

anappropriate

lyqualified independent auditor at least on an annual basis andreports are sent to the Governing Body or its representative.

1.1.4.3 There is documented evidence that the Governing Bodyregularly reviews audit reports; andaction is taken on anyrecommendations made by the auditor.

1.1.4.4There is an appropriate programme of internal financial controlimplemented.

1.1.4.5There is

an internal accounting

system,

whichproduces

information reflecting the fiscal experience and the currentfinancial position of the Facility.



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1.1.4.6Policies and procedures for all accounting functions aredocumented and complied with.

1.1.4.7There is an appropriate and effective system of inventory andstock control.

1.1.4.8Minutes of Hospital Management Committeemeetings reflectsbudget development with participation ofappropriate staff.

1.1.4.9There are periodic reports analysing therelationship betweenthe budget and actual expenditure.

1.1.4.10There are comprehensive financial management reports andperiodic reviews as to the accuracyand appropriateness ofthese reports submitted to the GoverningBody.

1.1.4.11 Insurance policies are available for:

a)the protection of the buildings,contents, and otherphysical assets;

b)the protection of the financial assets;

c)professional liability to protect the Facility in respect of theprofessional actions of medical practitioners, paramedicsand other support services staff.

1.1.5The Governing Body ensures that all reasonable action istaken to conform to all applicable government Statutes,Acts, Regulations, By-Laws, Ordinances

and Orders; andtreat all information relating to the affairs of the Facility,patients, and staff in a confidential manner.

1.1.5.1Copies of all relevant Acts, Regulations, By-Laws, Ordinancesand Orders are available and accessible to staff.

1.1.5.2The governing framework, structure, functions, policies andprocedures conform to all applicable government Statutes, Acts,Regulations, By-Laws, Ordinances and Orders.



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1.1.5.3There are signed agreements by the Governing Body, staff andmedical practitioners on preserving confidentiality of all mattersrelating to the Facility.

1.1.6Where external services are used to assist in the operationsof the Facility, these contracted or referral services meetthe MSQH Standards of Accreditation.

1.1.6.1There are

written agreements between the external service

provider and the Facility on the appointment and provision ofexternal services to the Facility, whichinclude the following:

a)The services meet all patient and environmental safetystandards contained in the MSQH Standards ofAccreditation, regardless of where the activities occur, on-site and off-site.

b)There is documentation on the external aspects of theservices which refer to:

i)specification of formal lines ofcommunication andresponsibility between the external source providerand the Facility;

ii)provision of services by personnel appropriatelyqualified to perform their duties;

iii)

adequate pick up and delivery arrangements;

iv)appropriate participation of the external serviceprovider in committees of the

Facility;

v)arrangements for after-hoursand emergencyservices;

vi)quality control of the external services includinginvolvement in safety and quality improvementactivities of the Facility, as appropriate;

vii)

procedures for identifying and rectifying problems inthe delivery of the services;

viii)

adequacy of facilities and equipment for theservices being provided at both the Facility and thesite of the external services;



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personnel provided by the external services whoare bound by the rules and regulations applicable tothe staff of the Facility.



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1.2HUMAN RESOURCE DEVELOPMENT AND MANAGEMENT

1.2.1The Governing Body makes adequate provision for thedelegation of authority to Person In Charge (PIC) to ensurethe achievement of the Facility’s objectives.

1.2.1.1The authority, responsibilities and duties of the Person InCharge (PIC) as delegated by the Governing Body aredocumented in the letter of appointment.

1.2.1.2The Person In Charge (PIC) appointed is in accordance to therelevant Acts and Regulations which include a degree inMedicine and is registered with Malaysian Medical Council(MMC), at least two (2) years training in any specialty and atleast two (2) years experience in hospital management (FourthSchedule Regulation 12 PHFSA 1998 Regulations 2006).

1.2.1.3The Person In Charge (PIC) acts inaccordance with thepolicies, delegated authority, and instructions of the GoverningBody; and is responsible for the organisation, management andcontrol of the Facility.

1.2.1.4The Person In Charge (PIC) attends all meetings of theGoverning Body as evidenced in the minutes of meetings.

1.2.1.5There is documented evidence of performance review of thePerson In Charge (PIC) by the Governing Body.



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1.2.2Appointment, Verification of Credentialsand PrivilegingThe appointment, reappointment and clinical privileges ofmedical practitioners, nursing andother healthcareprofessionals to the healthcare facilityare appropriate tothe complexity of services of the Facility.

1.2.2.1The appointments of staff are made by the Governing Body onthe advice of any delegated authority. For the medicalpractitioners, the Governing Body seeks the advice of theCredentialing and Privileging Committee.The membership ofthe Credentialing and Privileging Committee may includerepresentatives of the Governing Body and regionalrepresentation of medical practitioners.The committee meetsregularly to make recommendations onthe appointment,reappointment, and clinical privileges of each member of thestaff of the facilities. Minutes of meetings are available.

1.2.2.2There are written and dated specific jobdescriptions for all staffwhich include:

a)qualifications, training, experience and

certification

required for the position;

b) lines of authority;c) accountability, functions

and responsibilities;

d)review when required and when there is a major change inany one of the following:

nature and scope of work;

duties and responsibilities;

general and specific accountabilities;

qualifications required and privileges granted;

staffing patterns; Statutory Regulations.



Rating Rating1.2.2

.3The mechanism taken by the Facility in determiningappointments and privileges are documented and adhered tothe following:

a)the written policies and procedures for Appointment,Credentialing and Privileging;

b)the decisions made are objective, fair, and impartial;

c)the granting of reappointments and privileges for aspecified period of time;

d)where appropriate, the granting of

temporary

appointments and privileges for a limited period of timeaccording to a policy approved by theGoverning Body;

e) allocation of appointments and privileges in such a way that

each staff functions within a specified area of competence.

1.2.2.4

The criteria for determining appointments and privileges arespecified, documented and uniformly applied to all applicants,which include:

a)the criteria are designed to assure the medical practitionersand Governing Body that patients willreceive safe andquality care;

b)the criteria include, at least, evidence of currentcompetence, relevant training and/or experience, andcurrent registration with the local professional registration

bodies, e.g. Malaysian Medical Council; other criteria mayapply, e.g. the needs of theFacility;

c)personal recommendations are taken into account whenrecommendations for individual appointments andprivileges are being considered;

d)the relevant department and/or major professional servicesare represented when recommendations for individualappointments and privileges are beingconsidered.


StandardNo.

Survey Item HospitalSurveyor

Rating Rating1.2.2

.5The process for determining appointmentsand granting clinicalprivileges include the following:

a)the applicant’s request;

b)the verification of qualifications submitted by applicants;

c)the verification that relevant staffmembers are registeredwith the relevant national registers (Malaysian MedicalCouncil and other registers for example, Nursing BoardMalaysia, Medical Assistants Board Malaysia etc.);

d)where relevant the staff member has a valid annualpracticing certificate;

e)the staff member is professionally qualified for the positionheld;

f)the assignment of duties and privileges that matches thequalifications and experience thus ensuring that he/she iscapable of carrying out duties and privileges to beaccorded;

g)the resources available in the Facility support the dutiesand privileges.

1.2.2.6

The granting of delineated clinical privileges is given in writingbased on the recommendations of theCredentialing andPrivileging Committee and the following principles:

theassignment

ofduties and

privilegesmatch the

qualifications and experience thus ensuring that he/she iscapable of carrying out duties and privileges to beaccorded;

the resources are available in the Facility to support theduties and privileges.

1.2.2.7

There is documented criteria and procedure for clinicalprivileges, which include:

a) the

specifiedperiod

of time for

the clinicalprivileges

granted;



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b)renewal of clinical privileges based on performance review,records of actual performances (log book), peerrecommendations, continuing medical education, code ofconduct and health status;

c)downgrading of existing clinical privileges;

d) granting of new clinical privileges.

1.2.2.8There is evidence of periodic performance reviews of all staffincluding medical practitioners practicing in the Facilityirrespective whether the period of appointment is specified ornot.

1.2.2.9There is a procedure to address appeals when decisions onclinical privileges and appointments are adverse to theapplicant. This mechanism provides for review of decisionswhen requested by the applicant. The final decision in all casesis taken by the Governing Body and within a fixed period oftime.

1.2.3The Person In Charge (PIC) in order to manage the Facilityprofessionally is ensures that there is an adequate numberof staff appropriately qualified forthe level of servicesprovided.

1.2.3.1The Person In Charge (PIC) is responsible to ensure that anadequate number of appropriately qualified staff are available tomeet the needs of patient care.

1.2.3.2The Person In Charge (PIC) establishes and maintains policiesand practices for staff planning that support safe patient care.These policies are:

a)written and available to all employees;

b)reviewed periodically at least once in three years andrevised as necessary with the date of the most recentreview being incorporated;

c)established to include a procedure for notifying employeesof changes in the policies.


StandardNo. Survey Item Hospital Surveyor

Rating Rating1.2.3

.3The Person In Charge (PIC) maintains accurate, complete andconfidential staff records. These include the following but notlimited to:

a)leave and sickness with documented evidence;

b)results of recent staff appraisal;

c) qualifications held;

d)evidence of current registration;

e) clinical placements;

f)amendments to the employmentcontract;

g)continuing education and training;

h) staff counselling sessions;

i) disciplinary action.

1.2.3.4

There is a written and dated specific job description forindividual staff that sets out responsibilities for the position heldand is regularly reviewed and updated.

1.2.3.5

There is a documented staff appraisal system based on the jobdescription, and the appraisal identifies strengths inperformance and areas for improvement.

1.2.3.6

There is evidence that staff are involved in the appraisal of theirperformance.

1.2.3.7

Staff

appraisal is documented andaccessible to the staff

involved and to authorised personnel only.

1.2.3.8

There are documented procedures for reporting

suggestions

and complaints and these are made known to the staff.



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1.2.4The Governing Body through the Person InCharge (PIC)ensures that staff follow the professional ethics of theirrespective professional bodies.

1.2.4.1There is a mechanism put in place by thePerson In Charge(PIC) for the consideration of ethical issues faced by the Facilityand for implementation of the resulting policies.

1.2.5The Governing Body through the Person InCharge (PIC)ensures that there are continuing education, orientation,and in-service programmes for its members and all the staffin order to improve their knowledgeand skills, therebyimproving the function of the individualservice.

1.2.5.1There is a planned orientation programmefor newly appointedmembers of the Governing Body and Board of Visitors.

1.2.5.2There is a planned orientation programmefor all categories ofnewly appointed staff including medical practitioners. Thisprogramme is appropriate to the size of the Facility andincludes:a) information on the Vision and Mission statements, goals,

objectives and values of the Facilityand each service;

b) explanation of particular dutiesand functions, lines of

authority, areas of responsibility, and methods of obtaining

appropriate resource materials;c) explanation of the expected responses to internal and

external disasters and other contingencies;

d) provision for the acquisition of necessary additional skills;e) explanation of the methods that will be used to evaluate

staff performance.

1.2.5.3There is a planned staff development programme whichprovides in-service and continuing education opportunities for allcategories of staff. The Person In Charge (PIC) wheneverpossible makes resources available to allow implementation ofsuch programmes (this may be done in collaboration with otherorganisations).



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1.2.6Where the Facility has teaching responsibilities to providefor the educational needs of medical undergraduates,postgraduates, nurses and other health professionals, thereis a formal written agreement stating the terms of referenceand the requirements of the teaching needs.

1.2.6.1There are written agreements which include the following:

a) lines of communication;

b)provision of appropriately qualified staff to providesupervision;

c)student activities which should be fully supervised;

d)the faculty staff participating in the teaching/training andpatient care of all categories of students in the Facility arecredentialed and privileged;

e)mechanism for dealing with problems during theteaching/training period;

f)meeting the appropriate Standards ofAccreditation for thatpart of the teaching/training functions and patient carewithin the Facility;

g) Indemnity.



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1.3 POLICIES AND PROCEDURES

1.3.1The Governing Body through the Person InCharge (PIC)ensures that documented and dated policies andprocedures in line with the requirementsof the relevantregulations are available to guide all staff, includingmedical practitioners and locums, patients and visitors inrespect of the operations of the Facility.

1.3.1.1The Person In Charge (PIC) when formulating policies andprocedures take into consideration both external and internalfactors which are relevant to the Facility. These policies are:a)clearly articulated in understandable language;

b)recorded in policy manuals;c)determined only on the basis of adequate information and

consultation;

d)able to guide those making decisions;

e) capable of being implemented;

f)relevant with current Acts, Regulations and By-Laws.

1.3.1.2There is documented evidence that the Person In Charge (PIC)monitors compliance to the written policies.

1.3.1.3Policies and procedures are dated, authorised, signed and

reviewed at least once every three years and revised asrequired, and readily accessible for reference.

1.3.1.4There is evidence of staff acknowledgement that policies andprocedures including new and revised ones are communicatedto all staff.

1.3.1.5All policies and procedures, relevant Acts, Regulations, By-Laws and health related Standing Orders are available andaccessible to staff.



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1.4 FACILITIES AND EQUIPMENT

1.4.1The Governing Body through the Person InCharge (PIC)has the overall responsibility for ensuring the provision ofappropriate facilities and equipment so as to enable theachievement of the objectives of the Facility, in keepingwith its Vision and Mission statements, goals, objectivesand values as well as the relevant Acts,Regulations andBy-Laws.

1.4.1.1The Person In Charge (PIC) ensures the facilities andequipment are adequate and safe forthe level of servicesprovided.

1.4.1.2There is documentation that the Facilityhas a comprehensivemaintenance programme such as predictive maintenance,planned preventive maintenance and calibration activities, toensure the facilities and equipment are in good working order.

1.4.1.3There is a planned programme for upgrading and replacementfor facilities and equipment and evidence of implementation.



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1.5SAFETY AND QUALITY IMPROVEMENT ACTIVITIES

1.5.1The Governing Body through the Person InCharge (PIC)establishes, implements and maintains aneffective safetyand quality improvement plan throughout the Facility asrequired under the relevant Acts, Regulations and By-Laws.This plan refers to planned and systematic safety andquality improvement activities. The safety and qualityimprovement activities include but not limited to Mortalityand Morbidity Reviews, Incident Reporting and GrievanceMechanism.

1.5.1.1There is evidence that the Person In Charge (PIC) has in awritten document assigned responsibilities to appropriateindividuals/committees for safety andquality improvementactivities within the services.

1.5.1.2There are documented plans for systematic safety and qualityimprovement activities that include:

a) Planned activities

b) Data collectionc)Monitoring and evaluation of the performance

d)Action plan for improvement

e) Implementation of action plan

f) Re-evaluation for improvement

1.5.1.3There is documented evidence of implementation of a RiskManagement System as a quality improvement activity withIncident Reporting mechanism that addresses but not limited tothe following World Health Organization (WHO) World Alliancefor Patient Safety:

a) Patient Safety Goals

i) Identify patient correctly.



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ii) Improve effective communication.

iii)Improve the safety of high-alertmedications.

iv)Ensure correct-site, correct-procedure, correct-patient surgery.

v)Reduce the risk of healthcare associated infections.

vi)Reduce the risk of patient harm resulting from fall.

b) Patient Safety Solutions

i)Look-Alike, Sound-Alike Medication Names.

ii) Patient Identification.iii)

Communication During Patient Hand-Overs.

iv)Performance of Correct Procedureat Correct BodySite.

v)Control of Concentrated Electrolyte Solutions.

vi)Assuring Medication Accuracy at Transitions inCare.

vii)

Avoiding Catheter and Tubing Misconnections.

viii) Single Use of Injection Devices.

x)Improved Hand Hygiene to Prevent HealthcareAssociated Infections.

1.5.1.4

There are safety and quality improvementactivities in place thatinclude tracking and trending of specific performance indicatorsnot limited to but at least two (2) of the following:

a) average number of training hours per

employee (Full TimeEquivalent) had attended in a year

b)percentage of patients leaving hospital against medicaladvice relative to all patients hospitalised within a specifiedperiod

c)percentage of incidents/accidents during hospitalisation ofpatients as percentage of all admitted patients

d)average waiting time for patients from registration togetting into a bed (R2B) for Medical, Surgical, Paediatrics,and Obstetrics & Gynaecology wards

1.5.1.5

There is evidence that feedback on results of safety and qualityimprovement activities are regularly communicated to the staff.



Rating Rating1.5.1

.6There is evidence that results of safetyand quality improvementactivities are utilised for improvement of the organisation andmanagement of the Facility.

1.5.1.7

Records on safety and quality improvement activities are keptand confidentiality of staff and patients is preserved.

1.5.1.8

There is documented evidence of safety and qualityimprovement activities that address staff safety, e.g. staff healthscreening, education.


GOVERNANCE, LEADERSHIP AND DIRECTION

HOSPITAL COMMENTSStd. No: __________



SURVEYOR COMMENTSStd. No: __________



SURVEYOR RECOMMENDATIONSStd. No: __________

SERVICE STANDARD 1: Governance, Leadership and Direction

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Transcript of SERVICE STANDARD 1: Governance, Leadership and Direction