Clinical Indicators

Below achievements are for July 2014 to June 2015 (FY2015)

Standards were compared against Malaysian Productivity Corporation (MPC), http://www.mpc.gov.my/home/index.php and Malaysian Patient Safety Goals (MPSG), http://patientsafety.moh.gov.my/

Patient Safety

Description  Standard  Achieved
Rate of Patient Falls in a year per 1000 inpatient admission

<0.49%

0.26%
Remarks
Our nurses give their utmost attention to patient at risk for falls and undertake every precaution to prevent falls.

 

Prevention of Infection

Description                     Standard  Achieved
Rate of MRSA cases per hundred patient admissions ≤ 0.4% 0%
Remarks
MRSA is bacteria that is resistant to almost all antibiotics. Thus, MRSA infections could result in a longer length of stay in the hospital. In order to minimize the risk of MRSA cases, our healthcare providers practice a high standard of infection control.

 

Laboratory

Description                     Standard  Achieved
Lab result Turn Around Time < 2 hours >85% 89%
Remarks
The timeliness and early reporting of laboratory test results contributes to the early diagnosis of a patient’s condition, and is especially for the reporting of critical test results. This has also allowed our Health Screening Centre to provide reports within the same day.

 

Accident & Emergency

Description                     Standard  Achieved
Unplanned return of patients seen at A&E within 24 hours for similar complaint / illness <0.5% 0.01%
Remarks
An unplanned and unexpected return to the A&E within 24 hours for the treatment of the same condition that was treated earlier on reflect less than optimal patient management. Outpatients seeking treatment in the MMC A&E are fully assessed, investigated and treated before discharged.

 

Cardiac Care

Description                     Standard  Achieved
Rate of “Normal” Diagnostic Angiogram <40%* 20.8%
Remarks
Chest pain can be one of the symptoms of Coronary Artery Disease. Coronary Angiogram is a diagnostic procedure to diagnose and treat heart and blood vessel conditions. “Normal” findings from a coronary angiogram will indicate no stenosis of the coronary arteries. This indicator measures clinical effectiveness.

*Benchmark from Accreditation for Cardiovascular Excellence (ACE) CathPCI

 

Endoscopy Unit

Description                     Standard  Achieved
Post Endoscopy Complications ≤1% 0%
Remarks
Endoscopy procedures are generally safe. However, on occasions, complications could arise. Complications include, but are not limited to, abdominal distension, discomfort and internal bleeding may be encountered post endoscopy.

 

Operation Theatre

Description                     Standard  Achieved
Rate of unscheduled return to Operating Theatre within 48 hours of operation <0.32% 0.03%
Remarks
An unscheduled return to the operating theatre is an indication of unexpected complication(s) following surgery. MMC maintains a very low incidence

 

Urology

Description                     Standard  Achieved
Incidence of patient having blood clots within 24 hours post operation surgery following performance of transurethral resection of the prostate (TURP). <5% 0%
Remarks
TURP is a procedure performed by urologists to relieve the symptoms of an enlarged prostate. Massive bleeding following TURP may require readmission to OT to remove blood clots.

 

Intensive Care Unit

Description                     Standard  Achieved

1) Ventilator Associated Pneumonia Rate (per 1000 ventilator days)*

<16.7% 0%
Remarks
Ventilator Associated Pneumonia (VAP) may develop in patients after 48 hours of endotracheal intubation and mechanical ventilation. MMC has achieved low incidence of VAP through attentive care for our patients.

2) Readmission within 24 hours after transfer out of ICU

<1.0% 0.3%
Remarks
Readmission into ICU is an indication that the patient was not stable enough to have been discharged to the wards. Patients are carefully assessed before discharge to general wards.

 

Medical Ward

Description                     Standard  Achieved
Incidence of pressure sores in non-ambulatory patients <3% 0%
Remarks
Patients confined to bed rest are prone to pressure sores due to a prolonged period being in an unchanged position. It is always a challenge for our healthcare team to aim for zero incidences of pressure sores in non-ambulatory patients.

 

Dietetics and Nutrition

Description                     Standard  Achieved
Percentage of inpatients referral on critical cases attended to by dietitian within 30 minutes. ≥95% 100%
Remarks
A nutritious diet is important for the early recovery of a patient. Our Dieticians are committed to attend to their patients in the shortest time possible, so as to be able to provide dietary counseling and information to them and to ensure they have a healthy and balanced diet to complement their treatment in the hospital.

 

Fertility Centre

Description                     Standard  Achieved
Pregnancy Rate

  • In Vitro Fertilisation (IVF)
  • Intra Cytoplasmic Sperm Injection (ICSI)
  • Frozen Embryo Transfer (FET)
>25%
>25%
>20%
100%
52.7%
34.2%
Remarks
Our Fertility Centre has consistently obtained more than good results in the different techniques of Assisted Reproductive Techniques (ART), comparable to the standards achieved in regional hospitals. This has made our Fertility Centre a top choice for couples who wish to start a family.