Hpia & Specific Indicators Tech Spec 2022

KEMENTERIAN KESIHATAN
MALAYSIA
TECHNICAL SPECIFICATIONS
HOSPITAL PERFORMANCE
INDICATORS FOR ACCOUNTABILITY
(HPIA)
MEDICAL PROGRAMME
2022
TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2022
LIST OF HOSPITAL PERFORMANCE INDICATORS

FOR ACCOUNTABILITY (HPIA)
HPIA Element Indicator
1 Internal Business Process 1 - 12
2 Customer Focus 13 - 15
3 Employee Satisfaction 16 - 17
4 Learning and Growth 18 - 20
5 Financial and Office Management 21 - 26
6 Environmental (Technical/ Community) Support 27 - 29
SECONDARY DATA
NO INDICATOR STANDARD REPORTING PAGE
FREQUENCY
INTERNAL BUSINESS PROCESS
1 ST Elevation Myocardial Infarction (STEMI) [Without
≤ 10% 3 Monthly 6
Shock] Case Fatality Rate
2 Non ST Elevation Myocardial Infarction (NSTEMI) Case
≤ 10% 3 Monthly 8
Fatality Rate
3 Percentage of paediatric patients with unplanned
readmissions to the paediatric ward within 48 hours of ≤ 0.5% 3 Monthly 10
discharge
4 Percentage of massive postpartum haemorrhage (PPH)
≤ 0.5% 3 Monthly 12
incidence in cases delivered in the hospital
5 Percentage of inappropriate triaging (UNDER-
TRIAGING): Category Green patients who should have ≤ 0.5% 3 Monthly 14
been triaged as Category Red
6 Percentage of patients ventilated in Emergency and
≤ 50% 3 Monthly 16
Trauma Department for more than 8 hours
7 Percentage of x-rays with turnaround time of ≤ 45
minutes of Urgent Plain radiographic examination (X-
≥ 80% 3 Monthly 18
ray) requested by the Emergency & Trauma Department
(ED/ A&E)
8 Percentage of laboratory turnaround time (LTAT) for
≥ 90% 3 Monthly 20
urgent Full blood count (FBC) within (≤) 45 minutes
9 Incidence of thrombophlebitis among inpatients with
≤ 0.5% 3 Monthly 22
intravenous (IV) cannulation
10 Percentage of Morbidity and/ or Mortality meetings
being conducted at the hospital level with
documentation of the cases discussed ≥ 80% 3 Monthly 25
State & Specialist Hospital: 12 times/ year
Other Hospital: 6 times/ year
11 Cross-match Transfusion (CT) ratio ≤ 2.0 3 Monthly 27
12 Rate of Healthcare Associated Infections (HCAI) ≤ 5% Yearly 29
CUSTOMER FOCUS
13 Percentage of medication prescriptions dispensed
≥ 95% 3 Monthly 31
within 30 minutes
14 Percentage of Aduan Biasa which were received
through SisPAA (Sistem Pengurusan Aduan Awam) ≥ 85% 3 Monthly 33
and settled within the stipulated period (working days)
15 Percentage of Medical Reports prepared within the
≥ 90%
3 Monthly
35
stipulated period: (Cohort)
2 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
State & Specialist Hospital: ≤ 4 weeks

Other Hospital: ≤ 2 weeks
EMPLOYEE SATISFACTION
16 Percentage of officers who were informed of their
performance marks by the First Evaluating Officer
≥ 95% Yearly 37
(Pegawai Penilai Pertama (PPP)) for the Annual
Performance Evaluation Report, (LNPT)
17 Percentage of new hospital staffs who attended the
Orientation Programme within 3 months of their ≥ 90% 3 Monthly 39
placement at the Unit or Department in the hospital
LEARNING AND GROWTH
18 Percentage of paramedics in acute care areas who have
a CURRENT trained status in Basic Life Support (BLS) in ≥ 70% 6 Monthly 41
the corresponding year
19 Percentage of research projects (Clinical Research/
Quality Research (HSA/ QA/ ISR) successfully conducted ≥ 80% 6 Monthly 43
within 2 years (based on 2% of staff number)
20 Innovative Culture: Number of innovation replicated
≥1 6 Monthly 45
and implemented within 2 years in the hospital
FINANCIAL AND OFFICE MANAGEMENT
21 Percentage of hospital vehicles that conformed to the
≥ 80% 3 Monthly 47
Planned Preventive Maintenance (PPM) schedule.
22 Percentage of personnel who confirmed in service
≥ 95%
3 Monthly
49
within 3 years of their date of appointment. (3 year cohort)
23 Percentage of paid bills by discharged patients from the
≥ 80% 3 Monthly 51
inpatient revenue
24 Percentage of assets in the hospital that were inspected
100% 6 Monthly 53
and monitored at least once a year
25 Hospital possesses CURRENT Accreditation (MSQH) or
1 6 Monthly 55
MS ISO Certification Status (YES = 1; NO = 0)
26 Percentage of personnel with complete documentation
3 months prior to their time-based promotion in the ≥ 90% 3 Monthly 57
corresponding year
ENVIRONMENTAL SUPPORT
27 Percentage of Safety Audit findings identified whereby
control measures had been taken in the corresponding ≥ 70% 6 Monthly 59
year
28 Percentage of Facility Engineering Plant Room
Inspection (EPR) with report submission done by ≥ 80% 3 Monthly 62
Engineering Unit Personnel in the corresponding year
29 Percentage of Fire Drill that has been carried out by the
64
hospital in the corresponding year:
a. Fire Drill at hospital level: Once a year 100% 6 Monthly
b. Table Top Exercise at hospital level: Twice a year 100% 6 Monthly

Description on ‘Data Collection & Verification’
TERM DEFINITION
Primary data • Raw data (original data source which were collected first
hand by assigned personnel).
• Data that is not cleaned/ altered or processed.
(e.g. Delivery Book, Ward Admission & Discharge record

book)
Secondary data Gathered primary data that were cleaned/ altered or
processed.
(e.g. Massive PPH census, Data of patients discharge within

48 hours)
Validated data **Details of personnel who prepared and validated the data
must be available; as below:
• Signature
• Full name
• Stamp
• Date stated
These data must not be edited once it is validated. It needs
to be revalidated if there is any form of alteration/ edition.
Validated 1. It is a hardcopy of summarised final count (any format) of
summarised the respective indicators; should have the minimum
secondary data following details:
• Name of Discipline
• Reporting period (e.g. January 2021/ January-March
2021/ January- June 2021)
• Name of indicator with standard
• Numerator, Denominator and Performance Values
• Signature, Full name and Stamp of personnel who
prepared and validated the secondary data; with the
date.
2. Hardcopy should be kept with respective department/
unit for audit purposes.
3. A copy of this needs to be sent to Quality Unit (either
hardcopy or softcopy) based on ‘Secondary Data
Reporting Frequency’.
4. Performance Verification Form (PVF) is not encouraged
to be used as Validated Summarised Secondary Data.
**For Hospitals with the source of primary data and/ or secondary data is the
Information System; these data do not need to be printed and validated manually.
However, it needs to be documented in the Validated Summarised Secondary Data
on the source of primary data & secondary data (e.g. Data in HIS); provided that
these data cannot be altered and can be filtered according to requirements of the
indicator.

**For Hospitals with secondary data in softcopy (Excel sheet, Google Sheet etc.), either
one of these two must be done;
• Print the secondary data in to hardcopy and validate manually (Refer ‘Validated
primary/ secondary data’; as above) OR
• Document Full name, Designation and Date of personnel who prepared and
validated the secondary data in the softcopy sheet; supported by hardcopy of
Validated Summarised Secondary Data (refer above).
Sekretariat Induk Teknikal KPI KKM

Unit Survelan Pencapaian Klinikal (CPSU)
Cawangan Kualiti Penjagaan Perubatan
Bahagian Perkembangan Perubatan
Kementerian Kesihatan Malaysia
Tel: 03-88831180
[email protected]

ST Elevation Myocardial Infarction (STEMI) [Without Shock]

Indicator 1 :
Case Fatality Rate
Element : Internal Business Process
Acute Coronary Syndrome is a frequent cause of hospital death.
Rationale
: It is important to measure the quality of care and adherence to
practice guidelines.
ST Elevation Myocardial Infarction (STEMI): A clinical syndrome
of acute myocardial death defined by a rise in cardiac
Definition of biomarkers in the presence of ST elevation on the
:
Terms Electrocardiograph (ECG). The biomarkers used may include
any of the following; Troponin T/I, Creatinine Kinase or its MB
fraction (CK, CKMB).
Inclusion:
1. Patients admitted under cardiology (for hospital with
Cardiology Services).
2. All deaths diagnosed with STEMI prior to hospital discharge,
including in CCU or CRW.
3. Patients admitted with STEMI as the primary diagnosis.
Criteria :
Exclusion:
1. Patients not admitted under cardiology (for hospital with
Cardiology Services).
2. Patients “brought in dead” to Emergency but resuscitation
still attempted.
3. STEMI complicated with shock.
Type of indicator : Rate-based outcome indicator
Number of patients diagnosed and/ or admitted with STEMI
Numerator :
and who died from STEMI
Total number of patients diagnosed and/or admitted with
Denominator :
STEMI
Numerator x 100%
Formula :
Denominator
Standard : ≤ 10%
1. Where: Data will be collected in the respective
department/ward that caters the above condition.
2. Who: Data will be collected by the Officer/ Paramedic/Nurse
in-charge (Indicator Coordinator) of the department/unit
3. How to collect: Data is suggested to be collected from the
record or log book/ patient’s file/ National Cardiovascular
Data collection : Disease for Acute Coronary Syndrome (NCVD-ACS) Registry.
4. How frequent: Monthly data collection within department.
Validated summarised secondary data to be sent 3 monthly
to Quality Unit of the respective hospital for monitoring. PVF
to be sent 6 monthly to Quality Unit of hospital.
5. Who should verify:
Prepared by Validated by

Primary Data Officer/ Supervisor of the

Paramedic/ person who
Nurse in-charge prepared the data
Secondary Officer/ Head of
Data Paramedic/ Department/
Nurse in-charge Specialist in-charge
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• This indicator is also being monitored as National Indicator
Remarks : Approach (NIA) and Universal Health Coverage (UHC)
indicator.

Non ST Elevation Myocardial Infarction (NSTEMI) Case Fatality

Indicator 2 :
Rate
1. Cardiovascular diseases accounted for the 25.6% of deaths
in Ministry of Health (MOH) Hospitals in 2011. The majority
of cardiovascular deaths are attributed to acute coronary
syndrome (ACS). This is a spectrum of disease with 3
accepted classes:
a. ST Elevation Myocardial Infarction (STEMI)
b. Non-ST Elevation Myocardial Infarction (NSTEMI)
Rationale c. Unstable Angina (UA).
:
2. Mortality rates quoted in the Malaysian Acute Coronary
Syndrome (ACS) Registry maintained by the National Heart
Association of Malaysia are 9% for NSTEMI and 3% for UA
between 2006 and 2010.
3. Survival is dependent on good monitoring with prompt and
continued use of specific medication (anti-platelets, anti-
thrombotics, hypolipidemic therapy, B-blockers and ACE-
Inhibitors).
Non-ST Elevation Myocardial Infarction (NSTEMI): A clinical
syndrome of acute myocardial death defined by a rise in cardiac
biomarkers in the absence of ST elevation on the
Electrocardiograph (ECG). The biomarkers used may include
any of the following; Troponin T/I, Creatinine Kinase or its MB
fraction (CK, CKMB). It is the final main diagnosis written during
Definition of discharge which is the cause of admission. It is not the
:
Terms admission diagnosis as it may change.
Death due to NSTEMI: It is the death directly related to ACS/

NSTEMI as well as complications of NSTEMI such as Heart
Failure, arrhythmia, sudden death, Heart Block,
Cerebrovascular Accident (CVA), Pulmonary Embolism and
Hospital Acquired Infection.
Inclusion:
1. Patient with ACS/ NSTEMI as a main diagnosis.
Exclusion:
1. Patients with STEMI or Unstable Angina (UA) as a main
Criteria : diagnosis.
2. Patients who are ‘Brought In Dead’ (BID) to Emergency
Department with or without resuscitation attempted.
3. Patients who developed ACS/ NSTEMI during their stay in
hospital who were admitted for other reasons than ACS/
NSTEMI.

Numerator : Number of patients diagnosed with ACS/ NSTEMI who died

Denominator : Total number of patients diagnosed with ACS/ NSTEMI
Numerator x 100%
Formula :
Denominator
Standard : ≤ 10%
1. Where: Data will be collected in Medical wards/ ICU/ CCU/
CRW/ NICU/ wards that cater for the above condition/
record office.
2. Who: Data will be collected by Officer/ Paramedic/ Nurse in-
charge (indicator coordinator) of the department/ unit.
3. How to collect: Data is suggested to be collected from
admission & discharge record book/ Hospital Information
System (HIS)
4. How frequent: 3 Monthly data collection within
department. Validated summarised secondary data to be
sent 3 monthly to Quality Unit of the respective hospital for
Data collection : monitoring. PVF to be sent 6 monthly to Quality Unit of
hospital.
• This indicator is also being monitored as KPI Clinical Services,
Remarks : Outcome Based Budgeting (OBB) and Universal Health
Coverage (UHC) indicator.

Percentage of paediatric patients with unplanned readmissions

Indicator 3 :
to the paediatric ward within 48 hours of discharge
Unplanned readmission is often considered to be the result of
Rationale : suboptimal care in the previous admission leading to
readmission.
Unplanned readmission: It includes the following criteria:
• Patient being readmitted for the management of the
same clinical condition (main diagnosis) he or she was
discharged.
• Readmission was not scheduled.
• Readmission to the same hospital.
Definition of
: • This does not include readmission requested by next-of-
Terms
kin or other department.
• This does not include patients were readmitted for
different reason but have the same underlying
conditions (‘other diagnosis’).
Same condition: Same diagnosis as refer to the ICD 10.

Inclusion:
1. All paediatric inpatient discharges from Paediatric Ward.
Exclusion:
Criteria :
1. Neonates of < 28 days of life.
2. Patients of > 12 years of age.
3. AOR (at own risk) discharged patients during the first
admission.
Type of indicator : Rate-based process indicator
Number of paediatric patients with unplanned readmission to
Numerator :
the paediatric ward within 48 hours of discharge
Total number of paediatric patients discharged during the same
Denominator :
period of time the numerator data was collected.
Numerator x 100%
Formula :
Denominator
Standard : ≤ 0.5 %
1. Where: For Hospitals with specialist, it is suggested that data
to be collected in the Paediatric Medical Ward. For Hospitals
without specialist, it is suggested that data to be collected in
the ward/ department that cater for the above illness and
patients.
Data collection :
2. Who: Data will be collected by the Officer/ Paramedic/
Nurse in-charge/ Indicator Coordinator of the
department/unit.
3. How to collect: For numerator, data is suggested to be
collected on the day of readmission. For denominator, data

is from admission & discharge record book/ Hospital

Information System (HIS).
to Quality Unit of the respective hospital for monitoring.
PVF to be sent 6 monthly to Quality Unit of hospital.
Remarks : Outcome Based Budgeting (OBB) and Universal Health
Coverage (UHC) indicator.

Percentage of massive postpartum haemorrhage (PPH)

Indicator 4 :
incidence in cases delivered in the hospital
The incidence of massive obstetric haemorrhage is reflective of
the effectiveness of the management of haemorrhage at
delivery. Post-partum haemorrhage occurs in 3-5% of pregnant
mothers and is still the leading cause of maternal death in
Malaysia. The use of this indicator would be reflective of the
Rationale prompt diagnosis and speed of instituting multidisciplinary care.
:
References:
a) Green-top Guideline No. 52, May 2009.
b) CEMD Training Module for PPH.
c) Hazra S et al. J Obstet Gynaecol 2004 Aug: 24 (5) 519-
20.
Massive post-partum haemorrhage: Total amount of blood loss
Definition of
: of > 1.5 litres within (≤) 24 hours of delivery. Delivery includes
Terms
both the vaginal and abdominal routes.
Inclusion:
1. All deliveries within the facility - Both vaginal and abdominal
routes.
Criteria : Exclusion:
1. Adherent Placenta (e.g. Accreta/ Increta/ Percreta).
2. Placenta Previa.
3. Abruption Placenta.
4. Patients delivered outside of the facility.
Number patients with massive Primary Post-Partum
Numerator :
Haemorrhage in the hospital
Denominator : Total number of deliveries
Numerator x 100%
Formula :
Denominator
Standard : ≤ 0.5%
1. Where: Data will be collected in the Labour
room/ward/HDW.
department/unit.
Data collection : patient’s case notes / delivery record book/ massive PPH
census .
Remarks : National Indicator Approach (NIA) and Outcome Based
Budgeting (OBB) indicator.

Percentage of inappropriate triaging (under-triaging):

Indicator 5 : Category Green patients who should have been triaged as
Category Red
• Triage is an essential function of Emergency Departments
(EDs), whereby many patients may present simultaneously.
Triage aims to ensure that patients are treated in the order
of their clinical urgency and that treatment is appropriate.
Triage also allows for the allocation of the patient to the most
appropriate assessment and treatment area.
• It is a scale for rating clinical urgency. The scale directly
relates triage category with a range of outcome measures
Rationale (inpatient length of stay, ICU admission, mortality rate) and
: resource consumption (staff time, cost).
• Studies have shown that the “under triaging” of critically ill
patients can increase their morbidity and mortality due to
delay in their resuscitation and the provision of definitive
care. Urgency refers to the need for time-critical intervention.
• This indicator measures the accuracy and appropriateness of
the Triaging system in the Emergency Department (ED) to
ensure that critically ill patients are not missed and
categorized as “non-critical”.
Definition of Under-triaged: Critically ill patient (MTC RED) who was triaged
:
Terms as “non-critical” patient (MTC GREEN).
Inclusion: NA
Period of time when the hospital unable to function as usual
because involved in mass casualty/ disaster/ crisis.
Number of MTC GREEN patients who should have been
Numerator :
triaged as MTC RED
Denominator : Total number of MTC GREEN patients
Numerator x 100%
Formula :
Denominator
Standard : ≤ 0.5%
1. Where: Data will be collected in the Emergency Department
department/unit.
3. How to collect: Data is suggested to be collected from the
Data collection :
record book (refer to KPI MOH Guidelines).


• This indicator is also being monitored as Outcome Based
Remarks :

Percentage of patients ventilated in Emergency and Trauma

Indicator 6 : Department for more than 8 hours

• Studies showed quality decline after 8 hours due to lack of
nurse: patient ratio, causing poor specific care such as oral
Rationale hygiene, positioning, physiotherapy and feeding which
:
leads to complications.
• Efforts must be initiated to maximize resources in the
affected hospitals to reduce morbidity and mortality.
Ventilation Time: Time taken from the initiation of invasive
airway till the patient get transferred out from ED.
Definition of
:
Terms
Affected Hospital: All hospitals with daily 2 or more ventilated
patients remain in ED for more than 8 hours.
Inclusion: All ventilated patients who stayed longer than 8
hours
Referred cases because of time biased by various factors such
as getting feedbacks from dedicated team in major hospital
and logistic reason.
Number of ventilated patients who stayed ≥ 8 hours in
Numerator :
Emergency and Trauma Department
The total number of ventilated patients in Emergency and
Denominator :
Trauma Department
Numerator x 100%
Formula :
Denominator
Standard : ≤ 50%
1. Where: Data will be collected in the Emergency Department
department/unit.
3. How to collect: Data collected from ventilated patients case
note using prepared data spreadsheet.
Data collection : Validated summarised secondary data to be sent 3 monthly


Remarks :

Percentage of x-rays with turnaround time of ≤ 45 minutes of

Indicator 7 : Urgent Plain radiographic examination (X-ray) requested by the
Emergency & Trauma Department (ED/ A&E)
X-ray is the most basic tool of investigations in the form of
imaging. In general, x-ray is used to visualize body internal
Rationale
: structures. Timely x-rays turnaround time, thus, have a major
impact on the patient management whereby it ensures the
clinicians to make prompt decisions and actions accordingly.
Turnaround time: The time taken between the order for the
plain radiographic examination received by the Diagnostic &
Imaging Department/ X-ray Unit to the time that the x-ray film
is available to be viewed by the doctor (≤ 45 minutes).
Plain radiographic examination: A modality of x-ray (static x-ray/

Definition of
: portable x-ray) to visualize the internal structures of a patient
Terms
without using any contrast. This includes chest x-rays, skeletal x-
rays, abdominal x-rays etc.
Urgent Plain radiographic examination: Urgent x-rays which

were ordered by the ED/ A&E Medical Officer/ Paramedics for
emergency cases.
Inclusion:
1. All urgent plain radiographic examinations performed on
patients in ED/ A&E.
2. Inclusive of portable x-rays.
Exclusion:
Criteria :
1. The time period when the hospital was unable to function
as usual due to mass casualty/ disaster/ crisis.
2. Any delay due to life-saving procedures performed to
stabilize the patient’s condition (e.g. the ordered x-ray
cannot be done because of the emergency team is
resuscitating the patient).
Number of urgent plain radiographic examinations with
Numerator :
turnaround time within (≤) 45 minutes requested by ED/ A&E
Total number of urgent plain radiographic examinations
Denominator :
requested by ED/ A&E
Numerator x 100 %
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected in the Diagnostic & Imaging
Department/ X-ray Unit.
Data collection :
2. Who: Data will be collected by the Officer/ staff in-charge in
Diagnostic & Imaging Department/ X-ray Unit.

3. How to collect: Data will be collected from the record

book/registration book at Diagnostic & Imaging
Department/ X-ray Unit.
• The hospital Diagnostic & Imaging Department/ X-ray Unit
is responsible for the performance achievement.
• It is suggested that CLOCK IN time (time of the urgent plain
radiographic examination request received) and CLOCK
OUT time (time that plain radiographic examination is
available) to be recorded at the Diagnostic & Imaging
Remarks : Department/ X-ray Unit.
• The CLOCK IN time will be written in the request book by
the medical personnel who send the request.
• Not all X-rays, which were done after office hours are
considered as Urgent. Urgent X-ray refers to a request/
decision by Medical Officer/ Paramedic in charge based on
the patient’s condition with the “URGENT” tag/ stamp.

Percentage of laboratory turnaround time (LTAT) for urgent

Indicator 8 :
Full blood count (FBC) within (≤) 45 minutes
1. One of the objectives of a haematology laboratory is to
provide fast laboratory results for the management of
medical emergency.
2. Timelines of the services is the capability of the laboratory
Rationale
: providing fast results.
3. A fast laboratory turnaround time (LTAT) is desirable and is
one of the indicators of efficient laboratory service.
4. FBC is a basic and commonly requested test provided in all
healthcare facilities.
Full Blood Count (FBC): Automated measurement of blood cell
parameters.
Laboratory turnaround time (LTAT): Measuring the time

Definition of
: laboratory receives the specimen to the time the test results is
Terms
validated.
Urgent FBC: FBC requested as urgent for immediate

management of patient or emergency cases.
Inclusion criteria:
1. All requests sent for full blood counts that are labelled as
urgent.
Criteria : Exclusion criteria:

1. Requests for non-urgent FBC.
2. Request short turnaround time (STAT) not for immediate
management of patient or emergency cases.
3. FBC done at POCT site.
Type of indicator : Rate-based Process Indicator
Number of urgent Full Blood Count (FBC) with LTAT within (≤)
Numerator :
45 minutes
Denominator : Total number of urgent Full Blood Count (FBC)
Numerator x 100 %
Formula :
Denominator
Standard : ≥ 90%
1. Where: Data will be collected in all laboratories providing
the tests.
2. Who: Data will be collected by the Officer/ assigned
laboratory personnel (indicator coordinator) of the
Data collection :
department/ unit.
record book/ registry system/ request form/ LIS (refer to KPI
MOH Guidelines).


• This indicator is also being monitored as KPI Clinical Services
Remarks :
and Outcome Based Budgeting (OBB) indicator.

Incidence of thrombophlebitis among inpatients with

Indicator 9 :
intravenous (IV) cannulation
Thrombophlebitis has a direct/ indirect impact on the patient
Rationale health as it can cause discomfort, pain and prolong inpatient
:
stays that may lead to the patient suffering from economic
consequences.
Thrombophlebitis: inflammation of the wall of a vein with
associated thrombosis.
Assessment of Thrombophlebitis with

Visual Infusion Phlebitis (VIP) Scores
VISUAL INFUSION PHLEBITIS (VIP) SCORE
Site Observation Sco Action
re
IV site appears healthy 0 No sign of
phlebitis
OBSERVE
CANNULA
One of the following signs 1 Possibility first
evident: signs of phlebitis
• Pain near IV site (pain OBSERVE
score of 1-3) CANNULA
• May not require analgesics
• Slight redness near IV site
Two of the following signs 2 Early stage of
Definition of evident: phlebitis
:
Terms • Pain at IV site (pain score RESITE CANNULA
of 4-6)
• Interfere with activities
• Redness around site
• Swelling
All of the following signs evident: 3 Medium stage of
• Pain along path of cannula phlebitis
(pain score of 4-6) RESITE CANNULA
• Interferes with CONSIDER
concentration TREATMENT
• Redness around site
• Swelling
All of the following signs evident 4 Advanced stage
and extensive: of phlebitis
• Pain along path of cannula Or the start of
(pain score of 7-9) thrombophlebitis
• Interferes with basic needs RESITE CANNULA
• Redness around site CONSIDER
TREATMENT
• Swelling
• Palpable venous cord
All of the following signs evident 5 Advanced stage

and extensive: of
• Pain along path of cannula thrombophlebitis
(pain score of 10) INITIATE
• Redness around site TREATMENT
• Swelling RESITE CANNULA
• Palpable venous cord
• Pyrexia
Inclusion:
1. All admitted patients with peripheral venous cannula
2. Peripheral cannulas that were inserted during current
admission.
Exclusion:
Criteria :
1. “Double counting” i.e. the complication that has been
counted during previous admission.
2. Psychiatry patient.
3. Neonates patient.
4. Paediatric patient.
5. Unconscious patient.
Numerator : Total Number of thrombophlebitis incidences
Denominator : Total Number of inserted peripheral venous cannulas
Numerator X 100 %
Formula :
Denominator
Standard : ≤ 0.5%
1. Where: Data will be collected from every ward of the
hospital.
2. Who: Data will be collected by the ward manager/ staff
nurse/personnel in charge of the ward.
3. How to collect: Data will be collected from the record book/
patient’s case notes.


• Thrombophlebitis Chart (BKJ-BOR-PPK-10 Pin. 3/2020) will
be used for thrombophlebitis monitoring.
• Report must be sent to State Matron (KPJN) for Nursing
Remarks : Division compilation.
• All peripheral venous cannula must be counted.

Percentage of Morbidity and/ or Mortality meetings being

conducted at the hospital level with documentation of the
cases discussed
Indicator 10 :
State & Specialist Hospital: 12 times/ year
Other Hospital: 6 times/ year
The main purpose of the meeting is to improve patient’s
management and quality of care. Regular morbidity and
Rationale mortality meetings serve to look at the weakness and the
:
shortfall in the overall management of patients, hence it will be
learnt, and the same mistake could be prevented and would not
be repeated in the future.
Morbidity: A diseased state or symptom.
Mortality: The quality or state of being mortal.
Morbidity Meeting: Discussion of case management in regards

to patient morbidity, incidence reporting, issue of patient safety,
clinical audit (at the hospital level).
Mortality Meeting: Discussions related to the management of

the case and cause of death of the patient. (e.g.: Clinical audit,
POMR, MMR, Dengue Mortality, TB Mortality, Mortality under 5
years of age (MDG5), Perinatal Mortality Reviews (MDG4),
Inquiries) (at the hospital level).
Definition of Hospital level: A meeting chaired by the Hospital Director or a

:
Terms person appointed by the Hospital Director with
multidisciplinary involvement (preferably). For district hospital/
institution, multidisciplinary involvement is not necessary.
Conduct: Meeting can be led by the Hospital Director/ Head of

Department/ Appointed Specialist/ Medical Officer/
Paramedics.
Documentation: Official minutes or notes taken during the

meeting with the attendance list (certified by the Hospital
Director).
Official Minutes: The minutes must be certified by the

chairperson of the
Meeting or by the Hospital Director.
Inclusion:
All Morbidity and/ or Mortality meetings being conducted at
Criteria : the hospital level
Exclusion criteria:
1. Time period when the hospital was unable to function as

usual due to mass casualty/ disaster/ crisis.
2. Grand Ward Rounds or activities with no official
documentation/ minutes.
Number of documented morbidity and/ or mortality meetings
Numerator :
that were conducted in a year.
Total number of morbidity and/ or mortality meetings that were
Denominator :
scheduled in a year.
Numerator x 100%
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected from the department involved
and the Hospital Director’s office.
2. Who: Data will be collected by the hospital director’s staff/
person in- charge in the department.
3. How to collect: The meeting must be organized at the
hospital level (i.e. it is open to hospital staff across
disciplines/ departments to join the Meeting).
Data collection : PVF to be sent 6 monthly to Quality Unit of hospital.
It is suggested that the frequency of the meetings to be
Remarks : scheduled in early of the year and the meetings must be
minuted for documentation and audit purposes.

Indicator 11 : Cross-match Transfusion (CT) ratio

• Cross-match transfusion ratio is an indicator of
appropriateness of blood ordering. A ratio of more than 2.5
reflects excessive ordering of blood cross matching tests,
thus imposing inventory problems for blood banks, an
Rationale increase in workload, cost and wastage.
:
• This indicator is intended to assist in the enhancement of the
cost efficiency of the cross-matching process, avoid
unnecessary additional workload on laboratory personnel
and results in better management of blood stocks.
Cross-match: A compatibility test carried out on patient’s serum
with donor red blood cells before blood is transfused.
Transfusion: The infusion of cross-matched whole blood or red

Definition of
: cell concentrates to the patient.
Terms
Cross-match transfusion ratio:
A ratio of the number of red blood cell units cross-matched to
the number of red blood cells units transfused.
Inclusion:
All cross-matches done in blood bank.
Criteria :
Exclusion:
Safe Group O blood given without cross-match in an
emergency situation
Numerator : Number of red cell units cross-matched
Denominator : Number of red cell units transfused
Numerator
Formula :
Denominator
Standard : ≤ 2.0
1. Where: Data will be collected from the Blood Bank of the
hospital.
2. Who: The Blood Bank staff/personnel will record and collect
the data.
3. How to collect: Data collected from the registration
book/record books/information system in the Blood Bank of
Data collection :
the hospital.

Remarks :

Indicator 12 : Rate of Healthcare Associated Infections (HCAI)

Healthcare Associated Infections are preventable illnesses and
the prevention of these infections continues to be the top
Rationale
: priority. Therefore, periodic surveillance is essential to assess the
effectiveness of the infection control programme in the hospital
setting.
Healthcare Associated Infection: An infection occurring in a
patient in a hospital or other healthcare facility in whom the
Definition of infection was not present or incubating at the time of
:
Terms admission. This includes the infections acquired in the hospital,
but appearing after discharge, and also occupational infections
among staff of the facility.
Inclusion criteria:
All patients who were admitted to the ward before or at 8.00
am and were not yet discharged from the ward at the time of
the survey.
Criteria :
Exclusion criteria:
Patients in Psychiatric Ward, Emergency Department, Labour
Room, Outpatient Department, Day care.
Number of patients with HCAI in the hospital on the day of
Numerator :
survey
Number of hospitalised patients in the hospital on the day of
Denominator :
survey (no. of hospital admissions)
Numerator x 100%
Formula :
Denominator
Standard : ≤ 5%
1. Where: Data will be collected from every ward of the
hospital except the place in exclusion criteria.
2. Who: Data will be collected by the infection control
personnel/ team.
3. How to collect: Data is collected through hospital wide cross
sectional point prevalence survey, which is conducted once
a year.
Data collection : 4. How frequent: Yearly data collection. Data will be sent to
JKN within 1 month after the survey.


Remarks :

Percentage of medication prescriptions dispensed within 30

Indicator 13 :
minutes
Element : Customer Focus
Rationale
: Long waiting time can adversely affect patient satisfaction.
Dispense: Process of delivering medication to the patient.
Definition of Dispensed within 30 minutes: Time taken from the prescription

:
Terms received by the staff at the pharmacy counter to the time that
the medication is delivered to the patient.
Inclusion:
1. All prescriptions received including extemporaneous
preparation and dangerous drug.
Criteria : 2. Prescriptions received at hospital pharmacy counter.
3. Prescriptions received during office hour.
Exclusion:
NA
Numerator : Number of prescriptions dispensed within 30 minutes
Denominator : Total number of prescriptions dispensed
Numerator x 100%
Formula :
Denominator
Standard : ≥ 95%
1. Where: Data will be collected from the Pharmacy
Department/Unit.
2. Who: Staff/personnel in the Pharmacy Department/ Unit
will record and collect the data.
3. How to collect
a. In hospitals without QMS (Queue Management
System)/ HIS (Hospital Information System)/ other
related system to monitor the performance, data
collection is done for five full consecutive working
days.
Data collection : b. In hospitals with QMS/ HIS/ other related system, it is
suggested ALL dispensing time to be analysed.


• Five consecutive working days for facility without QMS is to
reflect the trend of patient’s attendance from various clinics
in the facility.
• It is suggested that the CLOCK IN time (time of the
prescription received) and CLOCK OUT time (time of the
prescription dispensed to the patient, or the medication is
Remarks :
ready to be dispensed and the patient was called) to be
recorded at the Pharmacy Department/ Unit.
• In accordance to Manual Petunjuk Prestasi Utama (Kpi)
Program Perkhidmatan Farmasi

Percentage of Aduan Biasa which were received through

Indicator 14 : SisPAA (Sistem Pengurusan Aduan Awam) and settled within
the stipulated period (working days)
Rationale Any complaint received by the hospital needs to be taken
:
seriously to improve quality of services to the patient.
Complains received and recorded in SisPAA will be categorized
as either Aduan Biasa or Aduan Kompleks. Aduan Biasa needs
to be settled within 15 working days.
Aduan Biasa:
• Aduan yang boleh diselesaikan di peringkat unit/
bahagian/ agensi sahaja.
• Memerlukan tindakan segera.
• Kelewatan boleh menjejaskan keselamatan,
kepentingan awam serta mendatangkan mudarat; dan
• SOP pengurusan aduan adalah antara 1-15 hari bekerja
Aduan Kompleks:
Definition of
: • Aduan melibatkan pertambahan peruntukan,
Terms pengurusan tanah, salah laku atau isu yang kompleks;
• Memerlukan siasatan lanjut/ lawatan lokasi;
• Penyelarasan dan ulasan lanjut diperlukan daripada
agensi-agensi terlibat; dan
• SOP pengurusan aduan adalah melebihi 15 hari
SEHINGGA 365 HARI.
Settled: Complaint resolved and closed.
Official complaint: Any complaint to the hospital in any form

(letter/ facsimile/ email/ feedback in suggestion box/ print
media/ social media/ phone conversation/ verbal/ through the
official website of the hospital) and been documented/
recorded officially in SisPAA.
Inclusion:
All complains received by hospital and categorized as Aduan
Biasa
1. Complains not under the categories of Aduan Biasa.
2. Not categorized as complain (query, suggestion,
compliments)

Numerator : Number of Aduan Biasa settled within stipulated period
Denominator : Total number of Aduan Biasa received
Formula : Numerator x 100%
Denominator
Standard : ≥ 85%
1. Where: Data will be collected from the Hospital Director
Office / Administrative Office
2. Who: Data will be collected/ monitored by officer/
personnel in-charge for complaint.
3. How to collect: Data will be collected from the record/
registration book/ generated through Sistem Pemantauan
Aduan Agensi Awam (SiSPAA).
Data collection : PVF to be sent 6 monthly to Quality Unit of hospital.
• In accordance to :
Remarks :
o Garis Panduan Pengurusan Aduan Versi 1/2020

Percentage of Medical Reports prepared within the stipulated

period:
Indicator 15 :
State & Specialist Hospital: ≤ 4 weeks
Other Hospital: ≤ 2 weeks
Medical report is a written document of a patient record of his/
her medical examination and treatment. The preparation of this
Rationale document within the time period is essential in ensuring the
:
efficiency of the hospital in managing patient record and
request, especially in regards to insurance claims, police
investigations, court proceedings and medico-legal purposes.
Stipulated period: The preparation of a medical report
according to the given time period (non-inclusive of public
holidays and weekends):
• State & Specialist Hospitals: ≤ 4 weeks

: •
Definition of Other hospitals: ≤ 2 weeks
Terms
Performance measurement: The performance will be calculated
at the end the month on how many medical reports were
completed within the stipulated period compared to the
number of actual completed requests (i.e. medical report
requests).
Inclusion criteria:
All medical reports include “plain reports”, and reports for
insurance claims.
Exclusion criteria:
1. Specialist report
Criteria : 2. Report with requests for clarification on the previously
prepared report.
3. Report requested by in-patients.
4. Post mortem report
5. Police Report.
6. Report required by Skim Perlindungan Insurans Kesihatan
Pekerja Asing (SPIKPA).
Number of medical reports prepared within the stipulated
Numerator :
period
Total number of medical reports prepared in the surveillance
Denominator :
month
Numerator x 100 %
Formula :
Denominator
Standard : ≥ 90 %
1. Where: Data will be collected in the medical record office/
Data collection :
unit/ department.


medical record office/ unit/ department
3. How to collect: Data will be collected from the record
book/registration book/monitoring system.
4. How frequent: Monthly data collection (cohort of previous
month) within department. Validated summarised
secondary data to be sent 3 monthly to Quality Unit of the
respective hospital for monitoring. PVF to be sent 6 monthly
to Quality Unit of hospital.
• In order to streamline the data collection method, the
performance of the present month will be calculated based
on the numerator and denominator of the previous month
Remarks : (retrospective cohort). For example, the July performance
will be based on the data in June.

Percentage of officers who were informed of their performance

Indicator 16 : marks by the First Evaluating Officer (Pegawai Penilai Pertama
(PPP)) for the Annual Performance Evaluation Report, (LNPT)
Element : Employee Satisfaction
The Annual Performance Evaluation Report is an assessment
tool to evaluate the employee performance and to understand
Rationale
: the abilities of a person to further grow and develops within a
period of one year. It is an important tool in maintaining the
quality and productivity of every personnel in the hospital.
Officer: Pegawai Yang Dinilai (PYD).
First Evaluating Officer: Pegawai Penilai Pertama (PPP).

Definition of
: Notification: PPP notifies PYD on the LNPT marks through
Terms
HRMIS or via any other auditable method.
Notified: PYD acknowledged the LNPT marks through HRMIS or

via any other auditable method.
Inclusion:
All personnel whom being evaluated by the hospital.
Exclusion:
1. Staff who was transferred-in to the hospital for less than 3
Criteria : months.
2. Staff undergoes training (e.g. master programme, post basic,
PhD, etc.) for more than 6 months.
3. Staff whom being evaluated through the different system or
a system whereby the acknowledgement component was
not established.
Number of officers who were notified of their performance
Numerator :
mark by the PPP
Denominator : Total number of officers evaluated by the PPP
Numerator x 100%
Formula :
Denominator
Standard : ≥ 95%
1. Where: Data will be collected in the administrative
unit/department.
HRMIS/ Human resource/ Administrative department/ unit.
Data collection : 3. How to collect: Data will be collected from the record book/
registration book/ HRMIS system.
4. How frequent: Yearly data collection.


• Data can be collected by including the total number of the
hospital staff
Remarks : • OR through a sampling of 25% of the hospital staffs inclusive
of all categories (the format of the sampling shall be decided
by the individual hospital).

Percentage of new hospital staffs who attended the

Indicator 17 : Orientation Programme within 3 months of their placement at
the Unit or Department in the hospital
Element : Employee Satisfaction
Orientation Programme is a platform used to provide
information in regards to the institution/ hospital to the
Rationale newcomers (i.e. staffs). This Orientation Program will assist the
:
new staffs to be familiarized with the institution/ hospital,
hence, indirectly it will boost their productivity and their self
confidence in the new environment.
New staffs: Newly reported personnel (transferred in/ newly
appointed/ new placement) to the hospital/ institution.
Orientation Program: A structured program organized/
Definition of conducted by the Hospital/ Institution/ Department/ Unit
:
Terms comprises of introduction of the system, work process and
environment.
3 months: The period (3 months) from the date of reporting.

Inclusion:
Orientation Programme that was conducted by the Hospital/
Institution/ Department/ Unit
1. Staffs whom transferred out from the hospital ≤ 3 months
after reporting for duty.
2. Staffs whom postponed their transfer-in/ appointment/
placement to the hospital.
Number of new staffs who attended the Orientation Program
Numerator :
within 3 months of their placement in the hospital
Denominator : Total number of new staff reported to the hospital
Numerator x 100%
Formula :
Denominator
Standard : ≥ 90%
1. Where: Data will be collected in every
unit/department/wards.
2. Who: Data will be collected by the Officer/ staff in-charge
for the Orientation Program in each department/ unit/ ward
(Administrative unit/ department responsible for the overall
data collection)
Data collection :
human resource record.


• Staff whom reported after 31st March or after 30th September
of the current year will be carried to the next term/ year of the
denominator which means;
Remarks : - 1st Term Evaluation: 1st October of the previous year to the
31st March of the current year.
- 2nd Term Evaluation: 1st April of the current year to the 30th
September of the current year.

Percentage of paramedics in acute care areas who have a

Indicator 18 : CURRENT trained status in Basic Life Support (BLS) in the
corresponding year
Element : Learning and Growth
Basic Life Support is an important skill for all healthcare
personnel to possess and it is an important element of the
Rationale
: Continuous Professional Development. Therefore, continuous
update of the healthcare personnel will ensure the current/
latest management of patient care is being practiced.
Acute care area: Emergency and Trauma Department, and
Intensive Care Area (ICU, CCU, OT, HDW, Labour Room, Burn
Unit, PICU, NICU, Neuro ICU and Haemodialysis Unit).
Definition of CURRENT trained status: The valid period of BLS certification (i.e.
:
Terms 5 years) according to the Policy on Resuscitation Training for
Ministry of Health Hospitals.
Paramedic: Refer to medical assistant and staff nurse who is

currently working at the Intensive Care Area.
Inclusion:
Paramedic who is currently working in the acute care area for
more than 6 months.
Exclusion:
Criteria : 1. Paramedic who was transferred-in to the acute care area for
less than 6 months.
2. Paramedic who is currently working in the acute care area
for less than 6 months.
3. Paramedic who has been on medical leave for more than 6
months.
Number of paramedics in the acute care areas who have
Numerator :
CURRENT trained status in Basic Life Support (BLS)
Denominator : Total number of paramedics in the acute care areas
Numerator x 100%
Formula :
Denominator
Standard : ≥ 70%
1. Where: Data will be collected at each acute care area.
for the acute care area.
registration book from each unit/ department/ ward.
Data collection : 4. How frequent: Monthly data collection within department.


• This is a recurring indicator; therefore some of the numerator
for every corresponding year can be a duplicate numerator
from the previous years (referring to the 5 years BLS
Remarks :
certification period of validity).
• Personnel with a valid Advance Life Support (ALS)
certification are considered to possess a valid BLS certification.

Percentage of research projects (Clinical Research/ Quality

Indicator 19 : Research (HSA/ QA/ ISR) successfully conducted within 2 years
(based on 2% of staff number)
Research project is a part of Clinical Governance. Hence, in the
Rationale effort to strengthen and support Clinical Governance, 2% of
:
staff number from the Administration and Professionals Group
(P&P) and “Kumpulan Sokongan 1” are expected to participate.
Research / Study:
• Industrial Support Research (ISR), Clinical Trial and others.
• Quality Research : DSA / HAS / KMK / KIK and others
Definition of
: Research / Study are valid for the period of two (2) years from
Terms
the date it was registered for assessment. These includes new
research and also ongoing research (exception given for cohort
study ; proper documentation and evidence need to be
provided)
Inclusion:
1. Research projects (Clinical Research/ Quality Research
(HSA/ QA/ ISR) successfully conducted within 2 years
2. Staffs from the Administration and Professionals Group
Criteria : (P&P) and “Kumpulan Sokongan 1” only.
Exclusion:
1. Staffs from “Kumpulan Sokongan 2” and others (e.g.
students, Pegawai Sambilan Harian (PSH))
Type of indicator : Rate-based indicator
Number of research (new / ongoing) produced within two (2)
Numerator :
years period.
Estimated number of research (based on 2% of staff number
Denominator : from the Administration and Professionals Group (P&P) and
“Kumpulan Sokongan 1”.
Numerator x 100%
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected from the Formed Research
Groups.
for the Quality/ Research/ Innovation in each department/
unit (Administrative unit/ department responsible for the
overall data collection)
Data collection :
3. How to collect: Data will be collected from the research
record book from each units or departments.

• For Hospital or Institution with less than 100 staff number
from the Administration and Professionals Group (P&P) and
“Kumpulan Sokongan 1”, the standard is two (2) research.
Calculation examples:
Remarks : Number of Administration and Professionals Group
(P&P) and “Kumpulan Sokongan 1”:
• <75  standard is one (1)
• 75 – 124  standard is two (2)
• 125 – 174  standard is three (3)
• 175 – 224  standard is four (4)

Innovative Culture: Number of innovation replicated and

Indicator 20 :
implemented within 2 years in the hospital
Innovative cultures were meant to give a plus point on
Rationale enhancing the services provided by the Ministry of Health.
:
Hence, Hospitals are expected to contribute by ensuring there
is innovation produced/ replicated and implemented.
Innovation:
Creative ideas that can increase the quality and productivity of
service.
Definition of
:
Terms
Innovative Culture:
Initiative to apply creative idea for improvement of service
quality and productivity.
Inclusion:
1. Innovation that is replicated from any Ministry of Health
Malaysia facilities.
2. Innovation that was completed within 2 years from the
current year. (Eg: For Year 2021 – Only projects completed
in 2019,2020 and 2021 can be used)
Criteria :
Exclusion:
1. Replication and implementation of innovation that is more
than 2 years from the current year.
2. Innovation adapted from private sector.
3. Replicated innovation from Ward/Unit/Department from
the same Hospital.
Type of indicator : Process indicator

Number of innovation replicated and implemented within 2
Numerator :
years.
Denominator : NA
Formula : NA
Standard : ≥1
1. Where: Data will be collected in specific units or
departments
for the Quality/ Research/ Innovation in each department/
unit (Administrative unit/ department responsible for the
overall data collection)
Data collection :
3. How to collect: Data will be collected from the record book
from each units or departments.
PVF to be sent 6 monthly to Quality Unit of hospital. (If the

indicator is SIQ for Jan-Jun, SIQ form does not need to be

filled)
All innovation must have detail profile and can be shown
Remarks :
during audit activity.

Percentage of hospital vehicles that conformed to the Planned

Indicator 21 :
Preventive Maintenance (PPM) schedule.
Element : Financial and Office Management
PPM is a scheduled maintenance of an asset or item of
equipment of the hospital including the hospital vehicles. PPM
provides the renewal of any elements of the asset before they
fail. Having a detailed and well-costed PPM in place provides a
Rationale
: level of comfort, possible significant future savings and allows
hospital to spread maintenance costs over a planned period of
time. Moreover, good PPM and asset maintenance will ensure
the hospital vehicles will always be in an optimum condition in
order to ensure the safety of the users.
Hospital vehicles: All vehicles that belong to the hospital
(hospital assets).
Definition of PPM schedule: Planned maintenance for each vehicle in a

:
Terms specific period of time.
On schedule/ corresponding period: ± 5 working days or ±

500km.
Inclusion criteria:
All hospital vehicles, including ambulances.
Exclusion criteria:
Criteria : 1. Hospital vehicles which currently under beyond economic
repair (BER).
2. Hospital vehicles that were involved in an accident at the
time of the PPM Schedule.
3. Hospital vehicle which is still under warranty.
Number of hospital vehicles that conformed to the PPM
Numerator :
schedule
Denominator : Total number of hospital vehicles on the PPM schedule
Numerator x 100%
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected in the transport unit/
administrative unit/ departments or unit/ department
assigned by the Hospital Director.
2. Who: Data will be collected by the Officer/ staff/ unit in-
charge for Planned Preventive Maintenance (PPM)
schedule.
Data collection :
transport log book..

• The denominator is calculated based on 3-monthly schedule.
Remarks : • Each vehicle may have many PPM schedules based on the
kilometres or the schedule date.

Percentage of personnel who confirmed in service within 3

Indicator 22 :
years of their date of appointment.
Service confirmation for the civil servant is a crucial step in
ensuring the productivity of every personnel in the
government. This is in accordance to the Surat Pekeliling
Suruhanjaya Perkhidmatan Awam Malaysia Bil. 3/ 2011:
Prosedur dan Kaedah Pengesahan Dalam Perkhidmatan –
Rationale
: which stated that Seorang pegawai layak disahkan dalam
perkhidmatan apabila telah berkhidmat dalam tempoh
percubaan bagi tempoh satu (1) hingga tiga (3) tahun dan
memenuhi syarat-syarat perkhidmatan. By conforming to the
above circular, indirectly, it will reflect the efficiency of the
Hospital Administration in managing their staff.
Personnel: Hospital staffs who fulfilled the requirements.
Confirmation in service: Confirmation by the SPA/ JPA or any

authorized agency upon receiving the confirmation letter.
Definition of
:
Terms
Date of appointment: The date stated in the appointment letter
by SPA/ JPA or any authorized agency.
Within 3 years: ≤ 3 years from the date of appointment.

Inclusion:
1. Staffs who were newly appointed or newly promoted to a
higher post (Kenaikan pangkat secara lantikan, KPSL).
2. Staffs with an official appointment or promotion letter from
MOH.
Criteria :
Exclusion:
1. Staffs with disciplinary action/ under probation.
2. Staffs whom transferred in ≤ 6 months and the confirmation
was not yet been processed by the previous Pusat
Tanggungjawab (PTJ).
Number of personnel who confirmed in the service within 3
Numerator :
years from the date of appointment
Total number of personnel who were scheduled for
Denominator : confirmation within 3 years from the date of appointment in the
corresponding year
Numerator x 100%
Formula :
Denominator
Standard : ≥ 95%
1. Where: Data will be collected in the human resource/
administrative unit/ departments.
Data collection :
2. Who: Data will be collected by the Officer/ staff/ unit in-
charge for staff confirmation in service.


monitoring system in human resource/ administrative unit.
PVF to be sent 6 monthly to Quality Unit of hospital. (3-year
cohort).
• Cohort: a group of subjects who have shared a particular
event together during a particular time span and can be
tracked over extended periods.
Remarks : • It is suggested that the Hospital Administrative Unit to
prepare a list of the staffs that conform to the above circular
and be grouped into 3 monthly cohorts on the 1st of January
of every year.

Percentage of paid bills by discharged patients from the

Indicator 23 :
inpatient revenue
Being the main health care provider in Malaysia, government
hospitals are providing their services with low charges. By
Rationale
: making sure the arrears at the minimum, this will reflect a good
hospital revenue management and will lighten the financial
burden of the government hospitals per se.
Inpatient: Patient who was admitted to the ward.
Paid bill: Full payment/ settlement of the bill (of any amount that
Definition of
: have been charged/ decided by the hospital).
Terms
Discharged patient: Patients who were discharged from the
ward.
Inclusion:
All patients who were admitted to the ward and require to pay
for the hospital bill upon discharge.
Criteria :
Exclusion:
Patients who were exempted from hospital bill based on the
Akta Fi.
Numerator : Number of paid bills by discharged patients (inpatient)
Denominator : Total number of discharged patients (inpatient)
Numerator x 100%
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected from Unit Hasil.
2. Who: Data will be collected by the Officer/staff in-charge.
3. How to collect: Data will be collected from the registration
book or computerized record system.
Data collection :

• Pengecualian bayaran mengikut Perintah Fi (Perubatan

1982)
Remarks : • Garis Panduan Pelaksanaan Perintah Fi (Perubatan) (Kos
Perkhidmatan) 2014
• Surat Pekeliling Bahagian Kewangan Bil 2/2006

Percentage of assets in the hospital that were inspected and

Indicator 24 :
monitored at least once a year
Keeping track of assets by utilizing an updated inventory is an
essential task that facilitates hardware and software
Rationale management, license compliance and regulatory compliance of
:
the assets. A successful asset management solution (i.e. through
organized inspection and monitoring system), indeed, could
save a lot of hospital money and management hassle.
Asset: Hospital properties that are listed in the hospital
inventory.
Inventory: A complete list of items such as property, goods in

Definition of
: stock, or the contents of the hospital.
Terms
Inspect and monitor: Surveillance activity of the hospital assets
(placement of the assets/ location of the assets/ function) with
complete documentation.
Inclusion:
All assets in the hospital inventory
Criteria :
Exclusion:
Assets under beyond economic repair (BER)/ disposal/
investigation due to it being reported as lost.
Numerator : Number of assets that were inspected and monitored
Total number of asset and inventory that were listed in the
Denominator :
inventory
Numerator x 100%
Formula :
Denominator
Standard : 100%
1. Where: Data will be collected from the administration unit/
departments.
2. Who: Data will be collected by the Officer/ staff of the
Administration unit in-charge for assets and inventory.
registration book/ monitoring system in the administrative
unit/ department.


• The standard for Jan-Jun is ≥50%.
• It is suggested that the hospital assets inventory, should be
Remarks : generated early of the year.
• It is suggested that the final performance to be measured not
later than 15th December of the corresponding year.

Hospital possesses CURRENT Accreditation (MSQH) or MS ISO

Indicator 25 :
Certification Status (YES = 1; NO = 0)
Quality is about meeting the needs and expectations of
customers, i.e. the patients. In pursuing these measures of
Rationale quality, possession of MSQH Accreditation or MS ISO standard
:
certification proves the KKM hospital commitments in
delivering good quality healthcare with high standard of
services.
CURRENT: Belonging to the present time within the validity
period of the certificate.
Definition of Accreditation: 1 year or 4-year status, by the MSQH.

:
Terms
MS ISO: ISO 9000 family of Standards by International
Organisation for Standardization (ISO). It is an international
consensus on good quality management practices.
Inclusion criteria:
Hospital with Accreditation (MSQH) or MS ISO certification
Criteria :
Exclusion criteria:
MS ISO certification involving only specific department (ie: MS
ISO Certification for Pathology Department only)
Type of indicator : Sentinel outcome indicator
Numerator : Current Accreditation or MS ISO status: Attained or Renewed
Denominator : NA
Formula : Numerator Performance
Standard : Achieved or Sustained Accreditation/ MS ISO status (1)
1. Where: Data will be collected from the Hospital Director’s
Office or Unit/ Department assigned by the Hospital
Director.
2. Who: Data will be collected by the Officer/ staff of a Unit/
department in-charge and assigned by the Hospital
Director.
registration book/ Accreditation or MS ISO Certificate.
Data collection :
monitoring. PVF to be sent 6 monthly to Quality Unit of
hospital.


• In general, hospitals are encouraged to undergo
Accreditation. However, in the case of structural/
Remarks : infrastructure/ financial issues which prevent the hospitals
from undergoing Accreditation, it is suggested that these
hospitals undergo MS ISO Certification instead.

Percentage of personnel with complete documentation 3

Indicator 26 : months prior to their time-based promotion in the
corresponding year
Complete documentation within three (3) months prior to th
Rationale time-based promotion of a personnel shows the efficiency of th
:
hospital management. By ensuring the complete documentatio
the promotion of a personnel will not be delayed.
Complete documentation:
• Refers to that all needed/ required documents for
Definition of
: promotion have been prepared.
Terms
• The monitoring and documents should be prepared by the
Administrative/ Human Resource Unit
Inclusion:
All eligible personnel.
Criteria :
Exclusion:
Staff who were transferred in less than 3 months.
Type of indicator : Rate-based structural indicator
Number of eligible personnel with complete documentation
Numerator :
three (3) months prior to time-based promotion
Total number of eligible personnel due for time-based
Denominator :
promotion
Numerator x 100%
Formula :
Denominator
Standard : ≥ 90%
1. Where: Data will be collected from the administrative unit/
departments.
2. Who: Data will be collected by the Officer/ staff of the
Administrative unit in-charge for time based promotion.
monitoring system in the administrative/ Human Resource
unit/ department.
Data collection : PVF to be sent 6 monthly to Quality Unit of hospital. Who
should verify:

• It is suggested that the hospital to identify the staffs who are

eligible to be promoted according to the time-based
promotion in early of the year. Example: If an officer is
scheduled to be promoted in July, the documentation must
have been completed by April.
Remarks :
• The time-based promotion for Pegawai Kumpulan
Pelaksana is in parallel with perkara (10) Pekeliling
Perkhidmatan Bilangan 8, Tahun 2013, dan Garis Panduan
Kementerian Kesihatan Malaysia Ruj. (31) dlm. KK(S)-
523(681) Jld 2 bertarikh 26 November 2013.

Percentage of Safety Audit findings identified whereby control

Indicator 27 :
measures had been taken in the corresponding year
Element : Environmental (Technical) Support
To ensure safety of the patient and healthcare workers
Rationale :
involved.
Safety Audit: An audit that is conducted by the hospital Safety
and Health Committee (JKKK) / Person in charge of safety to
assess the compliance of the hospital to safety and health.
Safety Audit finding: Any item in the safety audit format OHU/
Audit/ BU (general) with score of 0 and 1.
Scoring scale:
0 Not comply
Definition of 1 Comply, but not complete
: 2 Comply, and complete
Terms
Control measures:
- Any effort to reduce the risk related to the hazard through
various control measures such as elimination, substitution,
engineering control (e.g. use automation or LEV),
administrative control (e.g. SOP, policies or work rotation)
and personal protective equipment (PPE).
- Multiple control measure can be used.
Taken: Action has been carried out as mentioned above.

Inclusion:
Hazardous areas, e.g. CSSD, kitchen, laboratory, Radiology or
Diagnostic Imaging Department/ Unit, Cytotoxic Drug
Reconstitution, Engineering Department (workshop),
mortuary, wards, hospital compound.
Areas that must be included:

- Critical Care Area (ICU/ CCU/ NICU/ HDW)
- ED
Criteria : - Pathology Laboratory
- Kitchen
- Radiology/ Diagnostic Imaging Department
Optional Areas:
- Cytotoxic Drug Reconstitution
- Engineering Department
- Wards – compulsory for hospital without Critical Care Area
- Mortuary

- Hospital compound
- Other area
Exclusion:
Areas under construction.
Number of Safety Audit findings identified during the safety
Numerator :
audit whereby control measures had been taken
Denominator : Total number of Safety Audit findings that had been identified
Numerator x 100%
Formula :
Denominator
Standard : ≥ 70%
1. Where: Data will be collected from the hospital’s Safety and
Health Committee (JKKK) / OSH unit/ departments.
2. Who: Data will be collected by the hospital’s Safety and
Health Committee (JKKK) / Person in charge of safety (Safety
Officer).
audit finding report/ minutes regarding safety/ monitoring
system by the hospital’s Safety and Health Committee
(JKKK).
Data collection : monitoring. PVF to be sent 6 monthly to Quality Unit of
hospital. (If the indicator is SIQ for Jan-Jun, SIQ form does
not need to be filled)
• Based on the requirements in Occupational Safety and Health
Act 1994 (Act 514), Safety and Health Committee must be
established in the hospital.
• Safety audit needs to be conducted in the hospital.
Remarks : • Based on the Safety Audit format given (OHU/ Audit/ BU
form), the problem identified will be scored 0 or 1.
• After the control measure, had been acted upon, the Safety
and Health Committee will need to discuss the effectiveness
of the control measure.

• Any form of action taken to improve the safety audit finding,

for example, a letter to the State Health Office, is accepted as
a control measure had been taken.
• All the findings should be identified and documented during
the assessment/ audit.
• Head of the OSH Unit needs to make sure that the Safety
Audit Report is sent to the State KPAS officer.
• Head of the OSH Unit needs to make sure that the HPIA report
is sent to Penyelaras OSH, Bahagian Perubatan, JKN.
• Safety Officer of the hospital must be appointed by Hospital
Director.
• The audit findings must be presented to the Hospital Director
before submission to the State Health Office.
• The report of the audit can only be submitted to the State
Health Office after validation by the Hospital Director.

Percentage of Facility Engineering Plant Room Inspection (EPR)

Indicator 28 : with report submission done by Engineering Unit Personnel in
the corresponding year
EPR allows the Engineer to identify any technical issues and
Rationale problems with the hospital facilities. By doing a schematic
:
inspection, it will ensure that FEMs in the hospital are well-
maintained throughout the year.
Facility Engineering Plant Room: A room which facilitates all
Facility Engineering Maintenance System (FEMs) that prolongs
the life span and enhances the performance of equipment and
facilities cost effectively.
Definition of
:
Terms
Inspection: Inspection done by the Engineer/ Assistant
Engineer
Engineering Unit Personnel: Engineer/ Assistant Engineer

Inclusion:
All EPR done by the Engineering Unit Personnel
Criteria :
Exclusion:
EPR done by the concession company representative only.
Number of EPR for Facility Engineering Maintenance System
Numerator :
(FEMs).
Total number of EPR that are supposed to be carried out in the
corresponding year:
- 52 times annually (once per week) in hospital with
Denominator : Engineering resident (Engineer/ Assistant Engineer/
Technical assistant).
- 26 times annually (fortnightly) in hospital without
Engineering resident.
Numerator x 100%
Formula :
Denominator
Standard : ≥ 80%
1. Where: Data will be collected from the hospital Engineering
Unit/ Department.
2. Who: Data will be collected by the Officer/ staff in charge of
the Engineering Unit/ Department assigned by the Hospital
Director.
Data collection :
log book of inspection.
PVF to be sent 6 monthly to Quality Unit of hospital. Who
should verify:

Remarks :

Percentage of Fire Drill that has been carried out by the hospital
in the corresponding year:
: a. Fire Drill at hospital level: Once a year
Indicator 29
b. Table Top Exercise at hospital level: Twice a year
Fire drills are essential in any workplace or public building for
practicing what to do in the event of a fire (Terry Penney, 2016).
Rationale Not only do they ensure that all staff, customers and visitors in
:
the premise understand what they need to do in case of fire,
but they also help to test how effective the fire evacuation plan
is and to improve certain aspects of the fire provisions.
Fire Drill: A practice of the emergency procedures to be used in
case of fire.
Fire Drill with multiple Agencies: Fire Drill that involves Fire &
Rescue Department or/and other agencies (e.g. St John
Ambulance/ Red Crescent) with the hospital staff/ personnel.
Definition of
: Tabletop exercise: A meeting to discuss a simulated emergency
Terms
situation. Members of the team/ hospital review and discuss the
actions they would take in a particular emergency, testing their
emergency plan in an informal, low-stress environment.
Tabletop exercises are used to clarify roles and responsibilities
and to identify additional campus mitigation and preparedness
needs. The exercise should result in action plans for continued
improvement of the emergency plan.
Inclusion: All hospital building.
Criteria :
Exclusion criteria: Nil
a. Number of Fire Drill that has been carried out in the
corresponding year.
Numerator :
b. Number of Tabletop Exercise that has been carried out in the
corresponding year.
a. Total number of Fire Drill that has been planned in the
corresponding year.
Denominator :
b. Total number of Tabletop Exercise that has been planned in
the corresponding year.
Numerator x 100%
Formula :
Denominator
Standard : 100%
1. Where: Data will be collected in the Administrative unit/
Safety department/ Engineering Department/ OSH Unit
Data collection : (depending on the hospital).
2. Who: Data will be collected by the Officer/ staff in-charge of
the unit/ department.


Action Report/ verified meeting minutes with the unit/
department.
monitoring. PVF to be sent 6 monthly to Quality Unit of
hospital. (If the indicator is SIQ for Jan-Jun, SIQ form does
not need to be filled)
Remarks :
• Please refer to Surat Arahan Pelaksanaan Pemantauan Petunjuk Prestasi Utama

(KPI) Pengarah Hospital Melalui Hospital Performance Indicator for
Accountability (HPIA) dan Pengukuhan KPI Perkhidmatan Klinikal Program
Perubatan, ruj : KKM87/P3/12/6/3 Jld.12(35) bertarikh 05 Mei 2014 and
Garispanduan Pengukuhan Pelaksanaan dan Aplikasi Hospital Performance
Indicator for Accountability (HPIA) dan Petunjuk Prestasi Utama (KPI)
Perkhidmatan Klinikal Program Perubatan.


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KEMENTERIAN KESIHATAN

LIST OF HOSPITAL PERFORMANCE INDICATORS

State & Specialist Hospital: ≤ 4 weeks

b. Table Top Exercise at hospital level: Twice a year 100% 6 Monthly

3 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Description on ‘Data Collection & Verification’

(e.g. Delivery Book, Ward Admission & Discharge record

(e.g. Massive PPH census, Data of patients discharge within

4 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Sekretariat Induk Teknikal KPI KKM

5 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

ST Elevation Myocardial Infarction (STEMI) [Without Shock]

6 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Primary Data Officer/ Supervisor of the

7 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Non ST Elevation Myocardial Infarction (NSTEMI) Case Fatality

Death due to NSTEMI: It is the death directly related to ACS/

8 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Numerator : Number of patients diagnosed with ACS/ NSTEMI who died

9 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of paediatric patients with unplanned readmissions

Same condition: Same diagnosis as refer to the ICD 10.

10 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

is from admission & discharge record book/ Hospital

11 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of massive postpartum haemorrhage (PPH)

13 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of inappropriate triaging (under-triaging):

14 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

5. Who should verify:

15 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of patients ventilated in Emergency and Trauma

Element : Internal Business Process

16 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Secondary Officer/ Head of

17 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of x-rays with turnaround time of ≤ 45 minutes of

Plain radiographic examination: A modality of x-ray (static x-ray/

Urgent Plain radiographic examination: Urgent x-rays which

18 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

3. How to collect: Data will be collected from the record

19 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of laboratory turnaround time (LTAT) for urgent

Laboratory turnaround time (LTAT): Measuring the time

Urgent FBC: FBC requested as urgent for immediate

Criteria : Exclusion criteria:

20 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

4. How frequent: Monthly data collection within department.

21 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Incidence of thrombophlebitis among inpatients with

Assessment of Thrombophlebitis with

All of the following signs evident 5 Advanced stage

23 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Secondary Officer/ Head of

24 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

Percentage of Morbidity and/ or Mortality meetings being

Mortality: The quality or state of being mortal.

Morbidity Meeting: Discussion of case management in regards