APAKAH AKREDITASI HOSPITAL

Akreditasi adalah alat atau kaedah yang digunakan bagi memantau dan mengukuhkan perlaksanaan ‘good governance’ dan ‘good clinical governance’ dalam memberikan perkhidmatan kesihatan kepada pesakit.

Ia merupakan satu proses ke arah meningkatkan perkhidmatan kesihatan yang optima dengan menggunakan sumber yang sediada.

Ia memberi penekanan dan fokus kepada Penambahbaikan berterusan, mempromosikan serta menyebarkan maklumat berkaitan Keselamatan Pesakit dan Budaya Kualiti bagi sesebuah jabatan atau organisasi.

SIAPA YANG MEMBERI STATUS AKREDITASI

MALAYSIAN SOCIETY FOR QUALITY IN HEALTH ( MSQH – OKT 1997 ).
Telah dilancarkan oleh Ketua Setiausaha Kerajaan pada bulan Mac 1998.
MSQH ( KKM-MMA-APHM )

FAEDAH

Kepuasan Pelanggan ( K )
Kepuasan Kakitangan / Anggotakerja (K)
Perkhidmatan Berkualiti ( P )

SECARA RINGKAS, DIFORMULAKAN SEBAGAI (KKP)

FOKUS / PERKARA UTAMA DALAM PROSES AKREDITASI

  1. Organization and Management
  2. Human Resource Development And Management
  3. Policies And Procedures
  4. Facilities And Equipment
  5. Safety and Performance Improvement Activities
  6. Special Requirements

CARA PENILAIAN AKREDITASI EDISI 5

Rating 1 @ 2 @ 3 @ 4
Rating 1 = Poor/Rendah

( 0 – 39 % ) Rating 2 = Fair/Sederhana
( 40 – 59 %) Rating 3 = Good / Baik
( 60 – 79 % ) Rating 4 = Excellence / Cemerlang
( 80 – 100 % ) Rating LULUS adalah 3 dan 4
Rating GAGAL adalah 1 & 2

Wajib dapat sekurang-kurangnya Rating 3 secara keseluruhan ( terutamanya standard  1- 7 (Hospital Wide Standard ) untuk Pensijilan Penuh 4 Tahun bagi MSQH Edisi 5.

SYARAT LULUS 4 TAHUN PENSIJILAN AKREDITASI MSQH EDISI 5

Setiap service standard hendaklah mendapat rating 3 atau 4
Setiap core criteria di dalam standard hendaklah mendapat ratig 3 @ 4
Prestasi keseluruhan untuk setiap service standard juga bergantung kepada keadaan semasa tahap keselamatan pesakit dan anggotakerja dari segala perkara / aspek / elemen / anasir yang berada di sekeliling mereka.
KATEGORI BAGI PENSIJILAN AKREDITASI 4 TAHUN
PENSIJILAN AKREDITASI MSQH EDISI 5
1. Kategori 1 ( Lulus Biasa )
1.1 Semua service standard hanya mempunyai rating 3 atau 4 sahaja
1.2 Nilai peratus yang diperolehi dari pengiraan keseluruhan rating service standard dari 80 %.
2. Kategori 2 ( Excellent Achievement Award )
2.1 Semua service standard hanya mempunyai rating 3 & 4 sahaja.
2.2 Nilai peratus yang diperolehi dari pengiraan keseluruhan rating services standard adalah 80 % dan ke atas.
3. Kategori 3 – Centre of Excellent (COE)
3.1 Semua service standard mendapat rating 4 sahaja.

STANDARD-STANDARD AKREDITASI BAGI HOSPITAL ( EDISI KE 5 – 5TH EDITION )

25 set of standards

Terbahagi kepada 2 iaitu :-

  • Hospital-Wide Service Standard List
  • Hospital Service Standard List

HOSPITAL-WIDE SERVICE STANDARD LIST
(Service Standard 1- 7) H-WSS

1. Governance, Leadership and Direction
2. Environmental and Safety Services
3. Facility and Biomedical Equipment Management and Safety
4. Nursing Services
5. Prevention and Control of Infection
6. Patient and Family Rights
7. Health Information Management System (HIMS)

*** Service Std 1- 7 adalah H-WSS
(Hospital-Wide Service Standard )

HOSPITAL-WIDE SERVICE STANDARD LIST
(Service Std 8- 25) HSS

8. Emergency Services
9. Clinical Services –Non-Specialist Facility (For District Hospitals)
9A. Clinical Services ( Medical Related Services)
9B. Clinical Services ( Surgical Related Services)
9C. Clinical Services ( Obstetrics And Gynaecology Services )
9D. Clinical Services (Paediatric Services )
9E. Clinical Services (Cardiology Services)
9F. Clinical Services ( Oncology Services )
10. Anaesthetic Services
11. Operating Suite Services
12. Ambulatory Care Services
13. Critical Care Services (ICU/CCU/CICU/CRW/HDU/BURNS CARE UNIT)
13A. Critical Care Services ( SCN/NICU/PICU/PHDW)
13B. Critical Care Services (Labour/Delivery/Services)
14. Radiology / Diagnostic Imaging Services
15. Pathology Services
16. Blood Transfusion Services
17. Rehabilitation Medicine Services
17A. Allied Health Professional Services ( Physiotherapy Services )
17B. Allied Health Professional Services ( Occupational Therapy Services )
17C. Allied Health Professional Services (Dietetic Services)
17D. Allied Health Professional Services ( Speech-Language Therapy Services )
17E. Allied Health Professional Services ( Audiology Services )
17E. Allied Health Professional Services ( Optometry Services )
17G. Allied Health Professional Services ( Health Education Services )
17H. Allied Health Professional Services ( Medical Social Services )
17I.  Allied Health Professional Services ( Psychology Counselling Services )
18. Pharmacy Services
19. Central Sterilising Supply Services (CSSS)
20. Housekeeping Services
21. Linen Services
22. Food Services
23. Forensic Medicine services
24. Standards For General Application – Generic
24A. Standards For Clinical Research Centre
25. Medical Assistant Services

15 FAIL UTAMA

  1. Fail Meja
  2. Fail Statistik 
  3. Fail Mesyuarat
  4. Fail Peribadi
  5. Fail “Incidence Reporting”
  6. Fail Peralatan (Inventori/Harta Modal)
  7. Fail PPM
  8. Fail Kewangan / Perjawatan
  9. Fail Orientasi Anggotakerja Baru
  10. Fail CME
  11. Fail Protokol / Prosedur / Polisi / CPG/ MPK
  12. Fail Aktiviti-Aktiviti Kualiti (QIA)
  13. Fail Akta & Regulasi
  14. Fail Pekeliling
  15. Fail Keselamatan / Bencana