Overview

Performance Indicators

Medical & Dental Advisory Committee

Nursing Advisory Council

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 2018 (July 2017 to June 2018):

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Accident & Emergency

Indicator MSQH Benchmark
Waiting time relative to triage category- Red zone
seen immediately
100%
Waiting time relative to triage category – Yellow zone
seen within 30 minutes
≥85%
Waiting time relative to triage category- Green zone
seen within 90 minutes
≥85%
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Cathlab

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%
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Housekeeping

Indicator MSQH Benchmark
Customer satisfaction feedback survey 80% satisfaction
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Infection Control

Indicator 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%
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Internal Medicine

Indicator MSQH Benchmark
Percentage of patients passed away due to Dengue 0%
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Labour Delivery Services

Indicator 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%
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Occupational Therapy

Indicator MSQH Benchmark
Percentage of stroke patients with improvement of activities of daily living (ADL) independence after ADL intervention >75%
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Operating Suite Services

Indicator MSQH Benchmark
Rate of compliance to Safe Surgery Saves Lives (SSSL) practice 100%
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Pathology

Indicator MSQH Benchmark
Laboratory Turnaround Time (TAT) for urgent Full Blood Count within 45 minutes > 90%
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Pharmacy

Indicator 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
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Physiotherapy

Indicator MSQH Benchmark
Incidence of Burns sustained during delivery of Electrotherapeutic Modalities or Thermal Agents 0%
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Radiology

Indicator MSQH Benchmark
Perfect, Good, Moderate, Inadequate (PGMI) audits for mammography > 97% for Perfect, Good & Moderate
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Surgical Disciplines

Indicator 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 2018 – June 2020)

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 Koh Eng Thye

Chairman

Dr Sevellaraja N. Supermaniam

Deputy Chairman

Head of MDAC Sub-Committee / Member

Dr Sevellaraja N. Supermaniam

Head of Operating Theatre, ICU and Critical Care

Dr Ng Chek Siung

Head of Blood Bank and Tissue Review

Dr Teng Teck Lin

Head of Continuing Medical Education

Dr Yip Sek Onn

Drugs and Therapeutics

Dr Hah Moon Heng

Head of Hospital Infection Control

Dr Hayani Binti Abdul Wahid

Head of Medical Records

Dr Ruben Raj A/L Theyventhiran

Head of Mortality and Morbidity Review

Dr Choy Khai Chew

Member

Dr Noorddin Bin Younus

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