Page 40 - npqh NATIONAL POLICY FOR QUALITY IN HEALTHCARE : Bridging Silos, Accelerating Improvements 2022-2026

National Policy for Quality in Healthcare
Bridging Silos, Accelerating Improvements

Incident Reporting & Learning System for MOH Reducing Harm
Hospitals
Year Introduced: 1999

» Incident Reporting is the first Patient Safety activity implemented in MOH. Following

an incident report, investigation need to be conducted to find contributing factors and
root cause. Then, actions need to be taken to prevent similar incident from happening.
» In 2018, a new IR system (IR 2.0) using online reporting e-IR and simpler work process

has been introduced. Reporting of incident does not need approval from superior, in
fact it can be done by any staff and goes directly to Ministry. With this new system,
more reporting of incidents is seen compared to the manual system.
» Emphasis was also given on the importance of Root Cause Analysis and Action as well

as effective Risk Reduction Strategies.
» Actions are taken at both ministry and facility level. At ministry level, new policies,

programmes, promotional and educational activities are among the action taken.
» Root Cause Analysis (RCA) training started in 2007 as an investigation tool following

an Incident Reporting. It was further enhanced to RCA2 (Root Cause Analysis and
Action) in 2018 to emphasize the importance of taking effective Risk Reduction
Strategies.
» Main aim of RCA is to identify main contributing factors to incident, take effective

action to prevent similar incident from happening.
Infection Prevention and Control Reducing Harm
Year Introduced: 2001
» Infection Prevention and Control was introduced mainly to prevent and control

spread of infection in healthcare facility. This is because healthcare associated remain
one of the main patient safety issues across the globe.
» “Clean Care Safer Care” initiative is one of the Malaysian Patient Safety Goals with the

target of at least 75% hand hygiene compliance during each audit.
» Based on 2015/2016 WHO Hand Hygiene Self-Assessment Framework Survey,

Malaysia showed the highest participation among 91 participating countries, with
150 hospitals on board.
» Malaysia also achieved the highest score when audited by the Joint External Evaluation

team of International Health Regulation.
» Nursing Post Basic Training on Infection Control was upgraded to Advance Diploma

with the 5 moments of hand hygiene & hand hygiene compliance audit included.
» Policies and Procedures on Infection Prevention and Control, 3 Edition was
rd
successfully updated and published in 2019.
» Hand Hygiene Train the Trainer Course was conducted in 2017 and 2019 which was

facilitated by University of Geneva and attended by MOH, Private and University
Hospitals. 140 auditors have been qualified as Hand Hygiene Auditor.
» Annual Infection Control seminar is held in conjuction with World Hand Hygiene Day.

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