Page 36 - npqh NATIONAL POLICY FOR QUALITY IN HEALTHCARE : Bridging Silos, Accelerating Improvements 2022-2026

National Policy for Quality in Healthcare
Bridging Silos, Accelerating Improvements

Clinical Practice Guideline Improvement in Clinical Care
Year Introduced: 1992

» In April 2001, CPG development came under purview of Malaysia Health Technology
Assessment Section (MaHTAS), Medical Development Division, MoH.
» In the past five years (2016-2020) a total of 16 CPG (7 new CPG and 9 updated
CPG) were approved to be published and implemented. These include various
specialty/discipline; cancer, mental health, infectious disease, gastrohepatology,
respiratory, orthopaedics, rheumatology, nephrology, dermatology, haematology,
endocrinology, ophthalmology and otorhinolaryngology.
» Six CPG related manuscripts were published in local and international journal in
2017-2021.
» Various types of implementation strategies were developed (2016-2020) namely
Quick Reference (n=14), training module and training of core trainers at national
level (n=11) and launching of new references (n=14).

Peri-Operative Mortality Review (POMR) Improvement in Clinical Care
Year Introduced: 1992

» After the POMR was introduced in 1992, the POMR reporting rate was being monitored

since then, and in 2015 it has been one of the indicators for Global Surgery 2030.
» The reporting by hospital through vPOMR.
» Training Module has also been developed for the purpose of Hospital Training in

POMR.
Client Charter Improvement in Clinical Care
Year Introduced: 1993

» This initiative monitors 15 MOH’s Piagam Pelanggan Teras (Core Client Charter) in 2

core categories.
» In ensuring client satisfaction with the service delivered (Jan-Dec 2020):

- 100% of customer complaints are given early feedback within 1 working day
from the date the complaint is received
- 91.96% clients were seen by a medical officer within 90 minutes (TPC Data)
- 96.95% prescriptions are dispensed within 30 minutes
- 83.14% patients are called to be seen by a dental officer within 30 minutes
- 91.96% medical reports prepared within the stipulated time
- 98.30% patients satisfied with the dental service delivered
» In ensuring application and approval of various services are processed and completed

within the stipulated time frame from the date the complete application form is
received which meets the application and legal requirements (Jan-Dec 2020):
- 100% achievement for multi-service application process and approval;
Pharmacist Registration Certificate, Private Dental Clinic Registration, Fumigation
License (Lesen Pewasapan), Midwife Board Examination Results, HACCP Audit
Report Results and Health Promotion Services
- 93.19% achievement for Nurse Registration Certificate issued within 14 working
days
- 93.75% for Packaged Drinking Water and Natural Mineral Water License issued
within 5 working days
- 89.01% License for Radiation Apparatus / Radioactive Materials (New and
Renewed) issued within 7 working days
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