Quality Improvement
At Mahkota Medical Centre, we emphasise on providing consistently high quality and safe health care services to our patients and clients. It has been our first priority since the Hospital was established.
Overview
At Mahkota Medical Centre, we focus on providing consistently high quality and safe healthcare services to our patients and clients. It has been our utmost priority since the hospital was established in 1994.
We strive to improve by continuously identifying pain points and bottlenecks in the processes and systems, as well as rethinking on ways to better serve our patients. Once the changes have been implemented, measurements will be taken to check and validate the outcomes of the action plan.
The checking and validation of outcomes is performed both internally and by external auditors. We are pleased to have been accredited by the Malaysia Society for Quality in Health (MSQH) since 2008. In addition, our laboratory has also been awarded the MS ISO 15189 accreditation.
Performance indicators
Based on the following Performance Indicators, we have met and exceeded MSQH’s benchmark standard for Financial Year 2019, 2020 and 2021:
Accident & Emergency
| Performance Indicators | MSQH Benchmark |
| Waiting time relative to triage category: Red zone seen immediately | 100% |
| Waiting time relative to triage category: Green zone seen within 90 minutes | > 85% |
| Waiting time relative to triage category- Green zone seen within 90 minutes | > 85% |
Cathlab
| Performance Indicators | MSQH Benchmark |
| Indicator MSQH Benchmark Major Complication Rates during Percutaneous Coronary Intervention | < 1% |
| Major Complication Rates during Diagnostic Coronary Angiogram | < 1% |
| Electrocardiogram taken within 10 minutes after triaging as possible Acute Coronary Syndrome patients | 100% |
Housekeeping
| Performance Indicators | MSQH Benchmark |
| Customer satisfaction feedback survey | 80% satisfaction |
Infection Control
| Performance Indicators | MSQH Benchmark |
| Percentage of healthcare associated infections | < 5% |
| Number of Resistant Organisms to Antibiotics within a specified period of time | MRSA <0.3% ESBL <0.3% |
Internal Medicine
| Performance Indicators | MSQH Benchmark |
| Percentage of patients passed away due to Dengue | 0% |
Labour Delivery Services
| Performance Indicators | MSQH Benchmark |
| Incidence of massive Post-Partum Haemorrhage (PPH) of total deliveries should be less than 1% (exclusion criteria: placenta previa and adherence placenta) | <1% |
Occupational Therapy
| Performance Indicators | MSQH Benchmark |
| Percentage of stroke patients with improvement of activities of daily living (ADL) independence after ADL intervention | >75% |
Operating Suite Services
| Performance Indicators | MSQH Benchmark |
| Rate of compliance to Safe Surgery Saves Lives (SSSL) practice | 100% |
Pathology
| Performance Indicators | MSQH Benchmark |
| Laboratory Turnaround Time (TAT) for urgent Full Blood Count within 45 minutes | >90% |
Pharmacy
| Performance Indicators | MSQH Benchmark |
| Average time for a prescription to be dispensed from time received at counter to time given to patient | >90% of outpatient prescriptions prepared within 12 minutes |
Physhiotherapy
| Performance Indicators | MSQH Benchmark |
| Incidence of Burns sustained during delivery of Electrotherapeutic Modalities or Thermal Agents | 0% |
Radiology
| Performance Indicators | MSQH Benchmark |
| Perfect, Good, Moderate, Inadequate (PGMI) audits for mammography | > 97% for Perfect, Good & Moderate |
Surgical Disciplines
| Performance Indicators | MSQH Benchmark |
| Percentage of unplanned re-admission within 72 hours of discharge | < 0.5% |
Medical & Dental Advisory Committee
MDAC Composition / Head of Sub-Committee (July 2020 – June 2022)
The doctors at Mahkota are represented in MDAC whose members are elected from the pool of doctors who practice full time in Mahkota. The establishment of MDAC is a regulatory requirement under the Private Healthcare Facilities and Service Act 1998. The MDAC shall have due regard to the safety and interest of patients and maintenance of ethical and professional standards.
Dr Parthiban Navoo
Chairman
Dr Yip Sek Onn
Deputy Chairman
Head of MDAC sub-committee / member
Nursing advisory council
The Nursing Advisory Council functions are to provide leadership and professional guidance for the practice of nursing; facilitate in the development, implementation and evaluation of a strategic plan to support professional nursing practice; promote a positive climate for nursing that includes effective communication mechanisms, partnership with other disciplines and other stakeholders.
Ee Lin Neo
Chairperson
Lee Yee Kew
Member
Lucia Voon
Member
Sally Tan
Member
The Nursing Advisory Council functions are to provide leadership and professional guidance for the practice of nursing; facilitate in the development, implementation and evaluation of a strategic plan to support professional nursing practice; promote a positive climate for nursing that includes effective communication mechanisms, partnership with other disciplines and other stakeholders.
Ee Lin Neo
Chairperson
Lee Yee Kew
Member
Lucia Voon
Member
Sally Tan
Member
International Patient Safety Goals
Joint Commission International established the International Patient Safety Goals (IPSGs) in 2006 to help accredited organizations target critical areas where safety can be improved, such as medication management and reducing the risk of health care–acquired infections (HAIs). All Joint Commission International-accredited organizations are surveyed for compliance with the requirements of the goals as appropriate to the services the organization provides. Mahkota Medical Centre compliance with the International Patient Safety Goals was validated by Joint Commission International in 2020.
Kindly reach out to us if you wish to report a patient safety or quality-of-care concern to JCI:
Click here to report a quality and safety issue