Page 43 - npqh NATIONAL POLICY FOR QUALITY IN HEALTHCARE : Bridging Silos, Accelerating Improvements 2022-2026

National Policy for Quality in Healthcare
Bridging Silos, Accelerating Improvements

Corporate Culture System Environment
Year Introduced: 1990

» MOH invented corporate culture since 1990 with three core elements of caring,
professionalism and teamwork.
» Corporate culture trainings in the MOH are conducted every year, however the
number was reducing since 2018 – 2020 (2086, 2074 & 926).
» Besides trainings, every month, an infographic poster on different theme of the three

elements will be circulated to all staff through email and physical posters as a strategy
to continuously remind the staff about this culture.
» Corporate Culture Short Video Competition was held from 1 October 2019 to 29
October 2019 as another means for staff to appreciate the culture and present it in
the form of video.
Hospital Accreditation System Environment
Year Introduced: 1998
» By the end of 2020, there were 71 out of 145 MOH hospitals with valid accreditation

status by Malaysian Society for Quality in Health.
» A total of 6 Training of Trainers (TOT) courses for the 5 Edition Accreditation MSQH
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Standard have been conducted nationwide to enhance the awareness and facilitate
the implementation of accreditation standards at the healthcare facilities.
» MOH also involved in giving awareness and training of accreditation standards to

Malaysian Armed Forces hospitals and university hospitals.
» 6 Edition Accreditation Standard will be implemented in 2022.
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Performance Surveillance in Healthcare System Environment
Year Introduced: 2005

» Performance surveillance is one of the quality tools designed to assess quality of
healthcare. The Key Performance Indicators (KPI) are selected based on global/
national priority areas and the impact to the population.
» Different sets of indicators are formulated to measure performance of specific groups:

- Technical Performance Monitoring KPIs for high level leaders (Director General
of Health, Deputy Director General of Health, Director of Division and State Health
Director) started in 2015
- Clinical Service KPIs developed in 2014 and is used to monitor the performance
of the clinical services.
- Hospital Performance Indicator for Accountability began in 2014 and is used to
monitor the hospitals management.
- Clinical Performance Verification Form was implemented in 2016 with main
objective is to identify the workload or output of clinicians.
Training and Supervision of Workforce - CPD System Environment
Year Introduced: CPD in 2007

» Workplace training and supervision are ongoing processes.
» Annual trainings, including those related to Quality Improvement Initiatives, are part
of the Continuous Professional Development (CPD), which is planned at the start of
the year or at the end of the previous year and linked to the Pelan Operasi Latihan
(POL) or Training Operational Plan for budgeting purposes.

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