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idOverview
Performance Indicators
Medical Advisory Committee
Nursing Advisory Council
Overview
At Regency Specialist Hospital, we emphasize on providing consistently high quality and safe health care services to our patients and clients. It has been our first priority since the Hospital was established.
We strive to improve by continuously identifying the pain points and bottlenecks in the processes and systems, as well as rethinking on the ways to better serve our patients. Once the changes have been implemented, measurements will be taken to check the outcomes of the action plan.
Our hospital mechanisms receive internal and external audits and validations. We have been accredidated by the Malaysian Society & Quality in Health (MSQH) for full 4 years.
Performance Indicators
Based on the following performance indicators, we have met and exceeded MSQH’s benchmark standard for Financial Year 2018 (July 2017 to June 2018):
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Accident & Emergency
| Indicator | MSQH Benchmark |
|---|---|
| Waiting time relative to triage category- Red zone seen immediately |
100% |
| Waiting time relative to triage category – Yellow zone seen within 15mins* |
≥85% |
| Waiting time relative to triage category- Green zone seen within 90 minutes |
≥85% |
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Haemodialysis
| Indicator | MSQH Benchmark |
|---|---|
| Dialysis Adequacy (Kt/V), >1.3 | 95% |
| Haemoglobin (Hb) patients in erythropoietin (EPO), achieved HB level 10-12g/dl | >80% |
| Catheter related blood stream infection (CRBSI) | <3:1000 |
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Intensive Care
| Indicator | MSQH Benchmark |
|---|---|
| Rate of Ventilator Associated Pneumonia (VAP) | <10 per 1000 Ventilator days |
| Rate of Unplanned Extubation | <5% |
| Rate of Catheter Related Blood Stream Infection | <5 per 1000 catheter days |
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Operation Theater
| Indicator | MSQH Benchmark |
|---|---|
| Percentage of Intra operative complications of anaesthesia (aspiration pneumonia & cardiac arrest) | <0.1%% |
| Percentage of patients with waiting time of more than three (3) days for fixation of long bone closed fracture | 0 |
| Percentage of patient awaiting emergency surgery for >24 hours due to lack of OT time | <1% |
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Surgical
| Indicator | MSQH Benchmark |
|---|---|
| Percentage of Surgical Site Infection | clean operation <2%) |
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Labour & Delivery Services
| Indicator | MSQH Benchmark |
|---|---|
| Incidence of massive(>1,5l blood loss) Post-Partum Haemorrhage (PPH) of total deliveries* | <1% |
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Paediatrics
| Indicator | MSQH Benchmark |
|---|---|
| Percentage of paediatric patients with dengue fever diagnosed within 24 hours of admission | 100% |
| Unplanned readmission within 48 hours of discharge | ≤2% |
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Medical
| Indicator | MSQH Benchmark |
|---|---|
| Dengue case fatality rate* | 0% |
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Oncology
| Indicator | MSQH Benchmark |
|---|---|
| Number of patients who had extravasation of chemotherapy line during the procedure in a six (6) months period | 0 |
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Physiotherapy
| Indicator | MSQH Benchmark |
|---|---|
| Incidence of burns sustained during delivery of electrotherapeutic modalities or thermal agents. | 0% |
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Laboratory
| Indicator | MSQH Benchmark |
|---|---|
| Cross-match transfusion ratio (C:T ratio) | 0% |
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Pharmacy
| Indicator | MSQH Benchmark |
|---|---|
| Number and value of expired drugs at end of month over a specified period | <0.5% |
Medical Advisory Committee
Dr Lau Kai Poh
Chairman
Head of MDAC Sub-Committee / Member
Dr Lau Kai Poh
Chairman of Quality Assurance
Dr Chang Hok Keong
Chairman of Hospital Infection Control & Antibiotics
Chairman of Drugs & Therapeutics
Dr Kumaravelu Muthiah Kumar
Chairman of Tissue Review & Operating Theatre
Dr Lo Woei Chung
Chairman of Blood Transfusion
Dr Paul Ling Kah Hing
Chairman of Continuous Medical Education
Dr Wong Cheng Yan
Chairman of Mortality & Morbidity Review
Dr Ong Guan Yeow
Member
Dr Thokha Muhammad
Member
Dr Zubki bin Hasan
Member
Nursing Advisory Council
The Nursing Advisory Council functions are to provide leadership and professional guidance for the practice of nursing; facilitate in the development, implementation and evaluation of a strategic plan to support professional nursing practice; promote a positive climate for nursing that includes effective communication mechanisms, partnership with other disciplines and other stakeholders.
Ee Lin Neo
Chairperson
Lee Yee Kew
Member
Lucia Voon
Member
Saw Lai Hong
Member
