Page 38 - npqh NATIONAL POLICY FOR QUALITY IN HEALTHCARE : Bridging Silos, Accelerating Improvements 2022-2026

National Policy for Quality in Healthcare
Bridging Silos, Accelerating Improvements

Wound Care Programme Improvement in Clinical Care
Year Introduced: 2009

» In 2011, Director General Circular on the Guidelines for the Establishment of Wound
Care Team in MOH Hospitals was released.
» Wound Care Quick Reference, 1 Edition was developed in 2019.
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» As of 2020, 113 MOH hospitals have established wound care team (MOH Action
Plan 2016-2020) and RM 5 million has been dedicated for wound care programme
annually.

Pain Free Programme Improvement in Clinical Care
Year Introduced: 2011

» This Programme encompasses of Pain as the 5 Vital Sign (P5VS) and Pain Free
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Hospital (PFH).
» This initiative also involved the Dental Programme, Public Health Programme and

Pharmacy.
» P5VS is being implemented at all government hospitals and selected Health Clinics

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throughout Malaysia. As of 1 January 2021, Pain as 5 Vital Sign (P5VS) and Pain
Management, initiative entered its third phase of implementation at all government
dental clinics at all districts/states nationwide.
» At the end of 2020, 32 hospitals were awarded Pain Free Hospital Certification.

National Operating Room Nursing Audit (NORNA) Improvement in Clinical Care
Year Introduced: 2012

» Four elements are monitored under NORNA; (i) Receiving patient at the reception

area (ii) Scrubbing, gloving and gowning (iii) sponges, sharps and instruments
count and (iv) care of patient at the recovery bay. Based on data from 2016-2020, all
elements showed achievement that were slightly lower against target with almost
similar percentage every year from 2016-2020.
Cluster Hospital Improvement in Clinical Care
Year Introduced: 2014

» The Cluster Hospital initiative began its pilot project implementation in 2014 with 3
Cluster Hospitals. Subsequently, in 2016, the Cluster Hospital Policy Framework and
Guidelines were revised. From 2016-2020, MOH decided for a nationwide expansion
of this initiative in phases to include all suitable MOH hospitals. In 2018 the Hospital
Cluster Administrative Guideline was published to support the program.
» 2014-2015 : 3 pilot cluster hospitals involving 11 hospitals
» 2016 : 3 new cluster hospitals involving 11 hospitals
» 2017 : 4 new cluster hospitals involving 15 hospitals
» 2018 : 3 new cluster hospitals involving 11 hospitals
» 2019 : 12 new cluster hospitals involving 44 hospitals
» 2020 : 17 new cluster hospitals involving 47 hospitals
» From 2021-2025, the aim is to strengthen the initiative to ensure its sustainability by
internalising the cluster hospital initiative among the State Health Departments and
the Ministry of Health Headquarters.

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