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 2019, 2020 and 2021:

Accident & Emergency

Performance IndicatorsMSQH Benchmark
Waiting time relative to triage category: Red zone seen immediately100%
Waiting time relative to triage category: Green zone seen within 90 minutes> 70%
Percentage of inappropriate triaging: Green zone patients who should have been triaged as Category Red0.5%


Performance IndicatorsMSQH Benchmark
Major complication rate during Diagnostic Coronary Angiogram (death, acute myocardial infarction, stroke)1%
Major complication rate during Percutaneous Coronary Intervention (death, acute myocardial infarction, stroke)1%


Performance IndicatorsMSQH Benchmark
Percentage of patients developed extravasation during chemotherapy treatment5%
Central line / chemoport infection rate0%


Performance IndicatorsMSQH Benchmark
Percentage of urgent in-patient seen on time by the Dietician (≤ 24 hours)100%
Percentage of out-patient referrals seen by the Dietician within the stipulated time (≤ 48 hours)100%


Performance IndicatorsMSQH Benchmark
Unplanned admissions of ambulatory care patients as in-patients0%
Cancellation rate of ambulatory care cases10%


Performance IndicatorsMSQH Benchmark
Catheter Related Blood Stream Infection (CRBSI)< 3:1000

Infection Control

Performance IndicatorsMSQH Benchmark
Percentage of healthcare asociated infections (per 1000 admissions)5%

Labour Delivery

Performance IndicatorsMSQH Benchmark
Incidence of massive Post-Partum Haemorrhage (PPH) of total deliveries1%
Complication rate from instrumental deliveries10%


Performance IndicatorsMSQH Benchmark
Laboratory Turnaround Time (TAT) for urgent Full Blood Count within 45 minutes90%
Cross-match transfusion ratio ≤ 2.0


Performance IndicatorsMSQH Benchmark
Dengue case fatality rate0%

Operation Theater

Performance IndicatorsMSQH Benchmark
Pain Score on discharge from recovery room should be less than 4100%
Percentage of Elective Operation cancellation rate10%
Percentage of patient awaiting emergency surgery for > 24 hours due to lack of OT time1%


Performance IndicatorsMSQH Benchmark
Percentage of paediatric patients with unplanned re-admission for the same condition within 48 hours of discharge2%


Performance IndicatorsMSQH Benchmark
Incidence of burns sustained during delivery of electrotherapeutic modalities or thermal agents0%
Percentage of inpatient referrals seen on time by the physiotherapist (≤ 24 hours)85%


Performance IndicatorsMSQH Benchmark
Percentage of patients developed significant contrast media extravasation following CT examination with Intravenous (IV) contrast media1%


Performance IndicatorsMSQH Benchmark
Unplanned return to operating theatre within the same hospital admission following surgery0%

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.