Assoc. Prof. Dr. Kadar Marikar Chief Executive Officer MSQH - - PowerPoint PPT Presentation
By Assoc. Prof. Dr. Kadar Marikar Chief Executive Officer MSQH Development and implementation of Dental Clinics Accreditation Program Patient safety Impact of Accreditation Development of Dental Clinic Standards Dental
By
Chief Executive Officer
MSQH Development and implementation of Dental
Clinics Accreditation Program
Patient safety Impact of Accreditation Development of Dental Clinic Standards Dental Clinic Standards
The national accreditation body for Healthcare
facilities and services in Malaysia
Registered with Registrar of Societies 1997
(ROS 470) as a legal entity
An outcome of smart partnership between
MOH, APHM and MMA
Non governmental and non profit organisation Accreditation is voluntary Implementation Hospital accreditation since
end of 1999, Medical Clinic (2011), Dialysis centre (2013)
Conducted over 400 Hospital surveys, 12
medical clinics, 4 dialysis centres (stand alone)
Sealing of Commitment
A Memorandum of Understanding was signed on 1st October 1999 (at the 7th Annual National Healthcare Conference & Exhibition organised by APHM) between the MOH, APHM and MMA with MSQH to enhance and strengthen their collaboration and support towards the success of the Healthcare Accreditation programme. Witnessed by the Minister of Health
Malaysia.
Active Participation of the Public, Private Sectors & Professional Organizations
FROM: THE DIRECTOR GENERAL OF HEALTH MALAYSIA
The internationally recognised accreditation
improvement of quality and safety in healthcare
Advocate, educating and monitoring continuous quality improvement and patient safety in healthcare.
Development and Assessment of Compliance to Standards for Accreditation of Healthcare Facilities and Services in Malaysia ▪Hospitals (Public & Private) ▪Ambulatory Care Services-Medical Clinics (Public & Private) ▪Maternity Homes ▪Nursing Homes ▪Dental Services ▪Haemodialysis Services ▪etc.
Conduct Accreditation Activities with an emphasis on;
Quality of Life (Vision for Health)
Wide variation in the standards of services
between public and private healthcare providers.
To ensure the right person doing the right things
right with the right process and equipment, in the right (safe) environment to the right patient with the right (good) outcome.
Achieving optimum results from available
resources
Accreditation helps to establish common national standards.
ACCREDITATION OF HEALTHCARE ORGANISATIONS “Accreditation refers to the procedure by which MSQH offers formal recognition to healthcare
found to meet substantial level of compliance and competence as outline in the relevant MSQH standards.”
“Accreditation is a self-assessment and external peer review process used by healthcare organisation to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system”
ISQua definition : Federation Operating Rules 1998
(What are the things that you have) (What do you do With these things) (What is the result of what you do with these things that you have)
ENHANCED QUALITY OF LIFE
MEDICAL STAFF LEADERSHIP ORGANISATIONAL CULTURE & VALUES FOCUS ON PATIENT FOCUS ON PROCESS
QUALITY
SAFETY COMPETENCY
APPROPRIATENESS
EFFICIENCY ACCESSIBILITY
CONTINUOUS QUALITY IMPROVEMENT
COMPETENCY PATIENT CENTERED EFFECTIVENESS
Patient safety is an outcome of safe health care process. While patient safety is the ultimate goal, it is a safer health
care environment in the course of the process of patient care which ultimately determines safety.
Safety is one dimension of the broader construct of culture,
which includes aspects of organisational and clinical culture
Communication is vital to patient safety in many ways: thus
supporting mutual understanding across cultures is essential in the general development of patient safety.
EVIDENCE OF PRACTICE
DOCUMENTATION
ACCREDITATION AWARD
QUALITY OF CARE
RESOURCES CODE OF CONDUCT / ETHICS EVIDENCE BASED MEDICINE CUSTOMER SATISFACTION
DENTAL CLINIC STANDARDS ACCESS TO CARE PRACTICE HUMAN RESOURCE SAFETY ETHICS FACILITIES & EQUIPMENT GOVERNANCE QIA
Consist of Senior Practicing Dental Practitioners.
Knowledge Objective Expertise Impartiality Tact Diplomacy Communication Skills Report writing External Peer Review
The term Dental Clinics for the purpose of
these standards refer to all dental clinics registered under the Private Healthcare Facilities and Services Act 1998 and public sector dental clinics.
The term ‘services’ includes consultations,
investigations, treatment and referrals.
“Accreditation is a self-assessment and external peer review process used by healthcare
performance in relation to established standards and to implement ways to continuously improve the healthcare system” ISQua definition : Federation Operating Rules 1998
No. Name Organisation 1.
Cawangan Perundangan dan Penguatkuasaan, Bahagian Kesihatan Pergigian, Kementerian Kesihatan Malaysia 2. Dr Savithri a/p N.Vengadasalam Cawangan Akreditasi & Globalisasi, Bahagian Kesihatan Pergigian, Kementerian Kesihatan Malaysia 3.
Cawangan Akreditasi & Globalisasi, Bahagian Kesihatan Pergigian, Kementerian Kesihatan Malaysia 4.
Malaysian Association of Oral and Maxillofacial Surgeons (MAOMS) 5.
Malaysian Association of Paediatric Dentistry(MAPD) 6.
Malaysian Association of Paediatric Dentistry(MAPD) 7.
Malaysian Association of Orthodontists (MAO) 8.
Ramlee Bahagian Kesihatan Pergigian, Angkatan Tentera Malaysia, Kementerian Pertahanan Malaysia 9.
Malaysian Private Dental Practitioners' Association (MPDPA) 10.
Persatuan Doktor Pergigian Malaysia (MDA) 11.
Malaysian Society of Periodontology (MSP) 12. Dr Tan Boon Tik Malaysian Endodontic Society (MES) 13
Malaysian Society for Quality In Health 14 Noramiza bt Md.Nasir Malaysian Society for Quality In Health
TERMS OF REFERENCE OF DENTAL CLINICS COMMITEE
related authorities that should provide inputs in the development of the Dental Clinics Standards.
the Dental Clinic Standards and on-going review and improvement
Clinic Standards and its process.
Accreditation Program.
TERMS OF REFERENCE cont;
philosophy, values and needs of the Malaysian Population.
the Dental Clinic Standards based on agreed ISQua Accreditation Federation Council principles and philosophy with reference to the Private Health Care Facilities and Service Act 1998 and Regulations 2006.
and its processes in identified facilities; finalize them and forward to the MSQH committee for approval and national implementation.
ACTIVITIES CONDUCTED
Dental Standards from the following countries were reviewed;
Quality in Healthcare – NSQHS Standards Guide for Dental Practices and Services). *MOH Oral Health Division checklist
EFFORTS TOWARDS DEVELOPING STANDARDS FOR DENTAL CLINICS
Meeting Date Outcome 1st Meeting 5th April 2013 Initial 2nd Meeting 3rd December 2014 Draft 1 3rd Meeting 29th January 2015 Draft 2 4th Meeting 23rd February 2015 Draft 3 5th Meeting 12th March 2015 Draft 4 6th Meeting 9th April 2015 Draft 5 7th Meeting 18th May 2015 Draft 6 8th Meeting 15th June 2015 Final Draft 9th Meeting 6th August 2015 Feedback from public 9th September 2015 Launching of standards 10th Meeting 4th December 2015 Operational Policies *Small group 16th December 2015 weightage & scoring 11th meeting 24th March 2016 Operational Policies 12th meeting 27th April 2016 Pilot Test
Meeting Date Outcome 12th meeting 24th June 2016 Operational Policies and process *Small group 19th July 2016 Sedation in Dental clinic 28th July 2016 Pilot Test 2 13th meeting 11th August 2016 Findings of Pilot Tests 14th meeting 7th October 2016 Finalization of sedation criteria 15th meeting 27th October 2016 Meeting for training for councilors and surveyors 16th meeting 23rd November 2016 Meeting for training for councilors and surveyors 28th November 2016 Training for councilors and surveyors (26 participants) 17th meeting 7th April 2017 Identify surveyors for Dental Clinic Accreditation Survey 18th meeting 20th July 2017 Meeting for training of Dental Clinic Accreditation Programme
Focus of the Standards are on the following areas of concern.
Standard 1: ACCESS TO CARE Standard 2: FACILITIES AND EQUIPMENT Standard 3: HUMAN RESOURCE Standard 4: PRACTICE Addendum: Sedation in Dental Practice Standard 5: SAFETY Standard 6: ETHICS Standard 7: CLINICAL GOVERNANCE Standard 8: QUALITY IMPROVEMENT ACTIVITIES
Advertisement on 11th August 2015
month)
1.PUSAT PERGIGIAN ANGKATAN TENTERA JALAN PADANG TEMBAK : 27 APRIL 2016
MID VALLEY BANGSAR :28 JULY 2016
VOLUNTARY REQUEST
PREPARATION & STANDARDS INTERPRETATION SELF-EVALUATION BY CLINICS SURVEYORS’IDENTIFICATION/APPOINTMENT/CONSENSUS PRE-SURVEY ASSESSMENT
(On site) AGREEMENT ON SURVEY DATES
Preparation towards survey
❑
and Services Act; or
❑
Minimum of 12 months continuous operation.
❑
No existing legal issue or misconduct with court or enforcement.
❑
The Person In Charge (PIC) have no record of any offence by the MDC or in a court of law within the past two (2) years after the
completion of the punishment.
❑
All Dental Practitioners and clinical staff have no record of any
years after the punishment end. The duration of 2 years takes effect from the completion of the punishment.
Councillor 1 Councillor 2 Vote Vote
MSQH Endorsed by DCSC Chairman Final Accreditation Status Conferment of Accreditation Status by President MSQH
DECISION MAKING PROCESS
ACCREDITATION AWARD AN IMPARTIAL PROCESS Clinic Identity Expunged Independent Voting Individual Surveyor Presentation Survey Team Consensus S1 S2 Minimum 3 Endorsement By Chief Surveyor Final Survey Report Survey Team Deliberation assessment Clinic-wide Survey Post Survey
MSQH Secretariat
6 MONTHS TO RECTIFY
FULL (4 YEARS)
RM 3000 (GST 6%) 180 (For 2 dental chairs) = RM 3180 1 year equivalent = RM 3000.00 / 4 years
= RM 750 per year!!!
1 month equivalent = RM 3000.00 / 48 months
= RM 62.50 per month!!
for private clinic (GST 6%) 180 = RM 3180
* Additional fee of RM 1000 per dental chair *Inclusive of surveyors’ transport and accommodation
Submitted at 12th month, 24th month & 36th
month after the survey
Re-visit may be conducted when needs arises
e.g. complaint, report, etc.
Strong leadership support and commitment Implementation of Organisational-wide CQI
Activities
Participation of all staff at all levels Continuous training and measurement of
performance
Certification through Peer review process
Although the accreditation process mainly
focuses on structure, process and continuous quality improvement at its core it is a risk reduction activity.
The underlying principle is that when
healthcare organization meet or surpass the required accreditation standards, then errors and adverse events are less likely to occur.
field
THE TRUE VALUE IS NOT ACCREDITATION ITSELF
Going through the cycle and conducting self
assessment prior to actual survey by the assessors.
This process is an educational exercise for all staff
involved and this institutionalize the quality culture within the organization.
Builds up team work and improves communication Enhancing Accountability among all providers Keeps the organization motivated thus producing
better and safer outcomes.
Accreditation provides
the power to act on recommendations and the tools for quality improvement.
Accreditation recommendation leads to real
changes in the health system, and these changes impact health providers, clients and their families.
The process of accreditation over time, leads to
quality improvement process that strengthen and improve the delivery of service in Dental clinics.
The response to recommendations and the
commitment to implement quality improvement process within an organization, leads to real and positive changes in the delivery of safer health service.