KEMENTERIAN KESIHATAN

MALAYSIA

TECHNICAL SPECIFICATIONS
HOSPITAL PERFORMANCE
INDICATORS FOR ACCOUNTABILITY
(HPIA)
MEDICAL PROGRAMME

2023
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

LIST OF HOSPITAL PERFORMANCE INDICATORS

FOR ACCOUNTABILITY (HPIA)
HPIA Element Indicator
1 Internal Business Process 1 - 11
2 Customer Focus 12-14
3 Employee Satisfaction 15
4 Learning and Growth 16
5 Financial and Office Management 17-19
6 Environmental (Technical/ Community) Support 20-21

NO INDICATOR STANDARD PAGE

INTERNAL BUSINESS PROCESS

1. ST Elevation Myocardial Infarction (STEMI) [Without
≤ 10% 4
Shock] Case Fatality Rate
2. Non ST Elevation Myocardial Infarction (NSTEMI) Case
≤ 8% 5
Fatality Rate
3. Percentage of paediatric patients with unplanned
readmissions to the paediatric ward within 48 hours of ≤ 0.5% 7
discharge
4.
Percentage of massive postpartum haemorrhage (PPH)
≤ 0.75% 9
incidence in cases delivered in the hospital
5. Percentage of inappropriate triaging (UNDER-TRIAGING):
Category Green patients who should have been triaged ≤ 0.5% 11
as Category Red
6.
Percentage of patients ventilated in Emergency and
≤ 50% 13
Trauma Department for more than 8 hours
7. Percentage of laboratory turnaround time (LTAT) for
≥ 90% 14
urgent Full blood count (FBC) within (≤) 45 minutes
8.
Incidence of thrombophlebitis among inpatients with
≤ 0.5% 16
intravenous (IV) cannulation
9. Percentage of Morbidity and/ or Mortality meetings being
conducted at the hospital level with documentation of the
cases discussed ≥ 80% 19
State & Specialist Hospital: 12 times/ year
Other Hospital: 6 times/ year
10.
Cross-match Transfusion (CT) ratio ≤ 2.0 21
11. Rate of Healthcare Associated Infections (HCAI) ≤ 5% 22
CUSTOMER FOCUS
12. Percentage of medication prescriptions dispensed within
≥ 95% 23
30 minutes

2 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

NO INDICATOR STANDARD PAGE

13. Percentage of Aduan Biasa which were received through
SisPAA (Sistem Pengurusan Aduan Awam) and settled ≥ 85% 25
within the stipulated period (working days)
14. Percentage of Medical Reports prepared within the
stipulated period:
≥ 90% 27
State & Specialist Hospital: ≤ 4 weeks
Other Hospital: ≤ 2 weeks
EMPLOYEE SATISFACTION
15. Percentage of new hospital staffs who attended the
Orientation Programme within 3 months of their ≥ 90% 29
placement at the Unit or Department in the hospital
LEARNING AND GROWTH
16. Percentage of paramedics in acute care areas who have a
CURRENT trained status in Basic Life Support (BLS) in the ≥ 70% 31
corresponding year
FINANCIAL AND OFFICE MANAGEMENT
17. Percentage of hospital vehicles that conformed to the
≥ 80% 33
Planned Preventive Maintenance (PPM) schedule.
18. Percentage of paid bills by discharged patients from the
≥ 85% 35
inpatient revenue
19. Percentage of assets in the hospital that were inspected
100% 36
and monitored at least once a year
ENVIRONMENTAL (TECHNICAL/ COMMUNITY) SUPPORT
20. Percentage of Safety Audit findings identified whereby
control measures had been taken in the corresponding ≥ 70% 37
year
21. Percentage of Fire Drill that has been carried out by the
100% 40
hospital in the corresponding year

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]

3 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

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: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
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.
4 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Non ST Elevation Myocardial Infarction (NSTEMI) Case Fatality

Indicator 2 :
Rate
Element : Internal Business Process
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).
Definition of
: It is the final main diagnosis written during discharge which is
Terms
the cause of admission. It is not the 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 NSTEMI as a main diagnosis.

Exclusion:
Criteria :
1. Patients with STEMI or Unstable Angina (UA) as a main
diagnosis.
2. Patients who are ‘Brought In Dead’ (BID) to Emergency
Department with or without resuscitation attempted.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

3. Patients who developed ACS/ NSTEMI during their stay in

hospital who were admitted for other reasons than ACS/
NSTEMI.
4. Patients with NSTEMI who pass away within the same
admission before transfer to cardiac facility due to lack of
beds.
Type of indicator : Rate-based outcome indicator
Numerator : Number of patients with NSTEMI as a main diagnosis who died
Denominator : Total number of patients diagnosed with NSTEMI
Numerator x 100%
Formula :
Denominator
Standard : ≤ 8%
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
Data collection : admission & discharge record book/ Hospital Information
System (HIS)
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• This indicator is also being monitored as KPI Clinical Services,
Remarks : Outcome Based Budgeting (OBB) and Universal Health
Coverage (UHC) indicator.

6 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of paediatric patients with unplanned readmissions

Indicator 3 :
to the paediatric ward within 48 hours of discharge
Element : Internal Business Process
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

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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

is from admission & discharge record book/ Hospital

Information System (HIS).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• This indicator is also being monitored as KPI Clinical Services,
Remarks : Outcome Based Budgeting (OBB) and Universal Health
Coverage (UHC) indicator.

8 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of massive postpartum haemorrhage (PPH)

Indicator 4 :
incidence in cases delivered in the hospital
Element : Internal Business Process
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.
Type of indicator : Rate-based outcome indicator
Number patients with massive Primary Post-Partum
Numerator :
Haemorrhage in the hospital
Denominator : Total number of deliveries
Numerator x 100%
Formula :
Denominator
Standard : ≤ 0.75%
1. Where: Data will be collected in the Labour
room/ward/HDW.
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
Data collection : patient’s case notes / delivery record book/ massive PPH
census .
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• This indicator is also being monitored as KPI Clinical Services,

Remarks : National Indicator Approach (NIA) and Outcome Based
Budgeting (OBB) indicator.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of inappropriate triaging (under-triaging):

Indicator 5 : Category Green patients who should have been triaged as
Category Red
Element : Internal Business Process
• 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

Criteria : Exclusion:
Period of time when the hospital unable to function as usual
because involved in mass casualty/ disaster/ crisis.
Type of indicator : Rate-based process indicator
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
2. Who: Data will be collected by the Officer/ Paramedic/
Nurse in-charge/ Indicator Coordinator of the
department/unit.
Data collection : 3. How to collect: Data is suggested to be collected from the
record book (refer to KPI MOH Guidelines).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:

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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

PVF must be verified by Head of Department, Head of

Quality Unit and Hospital Director.
• This indicator is also being monitored as Outcome Based
Remarks :
Budgeting (OBB) indicator.

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of patients ventilated in Emergency and Trauma

Indicator 6 : Department for more than 8 hours

Element : Internal Business Process

• 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
Definition of airway until the patient transferred out from ED.
:
Terms
Affected Hospital: All specialist hospitals with ICU facility
Inclusion: All ventilated patients in ED

Exclusion:
Criteria :
Referred cases because of time biased by various factors such
as getting feedbacks from dedicated team in major hospital
and logistic reason.
Type of indicator : Rate-based process indicator
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
2. Who: Data will be collected by the Officer/ Paramedic/
Nurse in-charge/ Indicator Coordinator of the
department/unit.
3. How to collect: Data collected from ventilated patients case
Data collection : note using prepared data spreadsheet.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
Remarks :

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QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of laboratory turnaround time (LTAT) for urgent

Indicator 7 :
Full blood count (FBC) within (≤) 45 minutes
Element : Internal Business Process
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.
3. How to collect: Data is suggested to be collected from
record book/ registry system/ request form/ LIS (refer to KPI
MOH Guidelines).

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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

4. How frequent: PVF to be sent 6 monthly to Quality Unit of

hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• This indicator is also being monitored as KPI Clinical Services
Remarks :
and Outcome Based Budgeting (OBB) indicator.

15 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Incidence of thrombophlebitis among inpatients with

Indicator 8 :
intravenous (IV) cannulation
Element : Internal Business Process
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
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• 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.
Type of indicator : Rate-based outcome indicator
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/
Data collection : patient’s case notes.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• Thrombophlebitis Chart (BKJ-BOR-PPK-10 Pin. 3/2020) will
be used for thrombophlebitis monitoring.
Remarks : • Report must be sent to State Matron (KPJN) for Nursing
Division compilation.
• All peripheral venous cannula must be counted.
17 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• This indicator is also being monitored as Outcome Based

Budgeting (OBB) indicator.

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HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of Morbidity and/ or Mortality meetings being

conducted at the hospital level with documentation of the
cases discussed
Indicator 9 :
State & Specialist Hospital: 12 times/ year
Other Hospital: 6 times/ year
Element : Internal Business Process
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:
19 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

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.
Type of indicator : Rate-based process indicator
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
Data collection :
disciplines/ departments to join the Meeting).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
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.

20 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Indicator 10 : Cross-match Transfusion (CT) ratio

Element : Internal Business Process

• 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
Type of indicator : Rate-based Process Indicator
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.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.

21 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Indicator 11 : Rate of Healthcare Associated Infections (HCAI)

Element : Internal Business Process

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.
Type of indicator : Rate-based Process Indicator
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
Data collection :
a year.
4. How frequent: Yearly data collection. Data will be sent to
JKN within 1 month after the survey.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• This indicator is also being monitored as Outcome Based
Remarks :
Budgeting (OBB) indicator.

22 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of medication prescriptions dispensed within 30

Indicator 12 :
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
Type of indicator : Rate-based process indicator
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
Data collection : collection is done for five full consecutive working
days.
b. In hospitals with QMS/ HIS/ other related system, it is
suggested ALL dispensing time to be analysed.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• Five consecutive working days for facility without QMS is to
Remarks : reflect the trend of patient’s attendance from various clinics
in the facility.

23 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• 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
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
• This indicator is also being monitored as Outcome Based
Budgeting (OBB) indicator.

24 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of Aduan Biasa which were received through

Indicator 13 : SisPAA (Sistem Pengurusan Aduan Awam) and settled within
the stipulated period (working days)
Element : Customer Focus
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

Criteria : Exclusion:
1. Complains not under the categories of Aduan Biasa.
2. Not categorized as complain (query, suggestion,
compliments)

Type of indicator : Rate-based process indicator

Numerator : Number of Aduan Biasa settled within stipulated period
Denominator : Total number of Aduan Biasa received
Formula : Numerator x 100%
25 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

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
Data collection :
Aduan Agensi Awam (SiSPAA).
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• In accordance to :
Remarks :
o Garis Panduan Pengurusan Aduan Versi 1/2020

26 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of Medical Reports prepared within the stipulated

period:
Indicator 14 :
State & Specialist Hospital: ≤ 4 weeks
Other Hospital: ≤ 2 weeks
Element : Customer Focus
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
2. Report with requests for clarification on the previously
Criteria : 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).
7. Request multiple discipline
8. Report required by MySalam
Type of indicator : Rate-based process indicator
Number of medical reports completed within the stipulated
Numerator :
period
Total number of medical reports completed in the surveillance
Denominator :
month
Numerator x 100 %
Formula :
Denominator
Standard : ≥ 90 %

27 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

1. Where: Data will be collected in the medical record office/

unit/ department.
2. Who: Data will be collected by the Officer/ staff in-charge in
medical record office/ unit/ department
3. How to collect: Data will be collected from the record
Data collection : book/registration book/monitoring system.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• 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.
• This indicator is also being monitored as Outcome Based
Budgeting (OBB) indicator.

28 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of new hospital staffs who attended the

Indicator 15 : 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

Criteria : Exclusion:
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.
Type of indicator : Rate-based process indicator
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 : 3. How to collect: Data will be collected from the record book/
human resource record.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.

29 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• 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.

30 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of paramedics in acute care areas who have a

Indicator 16 : 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.
Type of indicator : Rate-based process indicator
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.
2. Who: Data will be collected by the Officer/ staff in-charge
for the acute care area.
3. How to collect: Data will be collected from the record book/
registration book from each unit/ department/ ward.
Data collection :
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.

31 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• 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
certification period of validity).
Remarks :
• Personnel with a valid Advance Life Support (ALS) certification
are considered to possess a valid BLS certification.
• Policy on Resuscitation Training for Ministry of Health
Hospitals.

32 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of hospital vehicles that conformed to the Planned

Indicator 17 :
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.
Type of indicator : Rate-based process indicator
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)
Data collection : schedule.
3. How to collect: Data will be collected from the record book/
transport log book..
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:

33 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

PVF must be verified by Head of Department, Head of

Quality Unit and Hospital Director.
• 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.

34 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of paid bills by discharged patients from the

Indicator 18 :
inpatient revenue
Element : Financial and Office Management
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.
Type of indicator : Rate-based outcome indicator
Numerator : Number of paid bills by discharged patients (inpatient)
Denominator : Total number of discharged patients (inpatient)
Numerator x 100%
Formula :
Denominator
Standard : ≥ 85%
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 : 4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• Pengecualian bayaran mengikut Perintah Fi (Perubatan
1982)
Remarks : • Garis Panduan Pelaksanaan Perintah Fi (Perubatan) (Kos
Perkhidmatan) 2014
• Surat Pekeliling Bahagian Kewangan Bil 2/2006

35 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of assets in the hospital that were inspected and

Indicator 19 :
monitored at least once a year
Element : Financial and Office Management
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.
Type of indicator : Rate-based process indicator
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.
3. How to collect: Data will be collected from the record book/
registration book/ monitoring system in the administrative
Data collection :
unit/ department.
4. How frequent: PVF to be sent 6 monthly to Quality Unit of
hospital.
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• 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.
36 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE
QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of Safety Audit findings identified whereby control

Indicator 20 :
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

37 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

- Hospital compound
- Other area

Exclusion:
Areas under construction.
Type of indicator : Rate-based process indicator
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).
3. How to collect: Data will be collected from the record book/
audit finding report/ minutes regarding safety/ monitoring
Data collection : system by the hospital’s Safety and Health Committee
(JKKK).
4. How frequent: 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)
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
• 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.
• 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,
Remarks :
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.

38 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

• 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.

39 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Percentage of Fire Drill that has been carried out by the hospital
Indicator 21 :
in the corresponding year
Element : Environmental (Technical) Support
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.
Definition of
:
Terms 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.
Inclusion: All hospital building.
Criteria :
Exclusion criteria: Nil
Type of indicator : Rate-based process indicator
Number of Fire Drill that has been carried out in the
Numerator :
corresponding year.
Total number of Fire Drill that has been planned in the
Denominator :
corresponding year.
Numerator x 100%
Formula :
Denominator
Standard : 100%
1. Where: Data will be collected by unit/ department assigned
by the Hospital Director.
2. Who: Data will be collected by the Officer/ staff in-charge of
the unit/ department.
3. How to collect: Data will be collected from the record book/
Action Report/ verified meeting minutes with the unit/
Data collection : department.
4. How frequent: 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)
5. Who should verify:
PVF must be verified by Head of Department, Head of
Quality Unit and Hospital Director.
This is a yearly data. However, PVF need to be sent 6 monthly
Remarks : for monitoring purposes. Therefore, SIQ will not be issued
based on 6 monthly data.
• 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

40 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION
 TECHNICAL SPECIFICATIONS OF
HOSPITAL PERFORMANCE INDICATORS FOR ACCOUNTABILITY (HPIA) 2023

Pelaksanaan dan Aplikasi Hospital Performance Indicator for Accountability (HPIA) dan
Petunjuk Prestasi Utama (KPI) Perkhidmatan Klinikal Program Perubatan.

41 CLINICAL PERFORMANCE SURVEILLANCE UNIT (CPSU), MEDICAL CARE

QUALITY SECTION, MEDICAL DEVELOPMENT DIVISION