Quality Improvement
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.
Overview
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 Indicators | MSQH Benchmark |
| Waiting time relative to triage category: Red zone seen immediately | 100% |
| 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 Red | 0.5% |
Cardiology
| Performance Indicators | MSQH 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% |
Chemotheraphy
| Performance Indicators | MSQH Benchmark |
| Percentage of patients developed extravasation during chemotherapy treatment | 5% |
| Central line / chemoport infection rate | 0% |
Dietetic
| Performance Indicators | MSQH 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% |
Endoscopy
| Performance Indicators | MSQH Benchmark |
| Unplanned admissions of ambulatory care patients as in-patients | 0% |
| Cancellation rate of ambulatory care cases | 10% |
Haemodialysis
| Performance Indicators | MSQH Benchmark |
| Catheter Related Blood Stream Infection (CRBSI) | < 3:1000 |
Infection Control
| Performance Indicators | MSQH Benchmark |
| Percentage of healthcare asociated infections (per 1000 admissions) | 5% |
Labour Delivery
| Performance Indicators | MSQH Benchmark |
| Incidence of massive Post-Partum Haemorrhage (PPH) of total deliveries | 1% |
| Complication rate from instrumental deliveries | 10% |
Laboratory
| Performance Indicators | MSQH Benchmark |
| Laboratory Turnaround Time (TAT) for urgent Full Blood Count within 45 minutes | 90% |
| Cross-match transfusion ratio | ≤ 2.0 |
Medical
| Performance Indicators | MSQH Benchmark |
| Dengue case fatality rate | 0% |
Operation Theater
| Performance Indicators | MSQH Benchmark |
| Pain Score on discharge from recovery room should be less than 4 | 100% |
| Percentage of Elective Operation cancellation rate | 10% |
| Percentage of patient awaiting emergency surgery for > 24 hours due to lack of OT time | 1% |
Paediatrics
| Performance Indicators | MSQH Benchmark |
| Percentage of paediatric patients with unplanned re-admission for the same condition within 48 hours of discharge | 2% |
Physiotherapy
| Performance Indicators | MSQH Benchmark |
| Incidence of burns sustained during delivery of electrotherapeutic modalities or thermal agents | 0% |
| Percentage of inpatient referrals seen on time by the physiotherapist (≤ 24 hours) | 85% |
Radiology
| Performance Indicators | MSQH Benchmark |
| Percentage of patients developed significant contrast media extravasation following CT examination with Intravenous (IV) contrast media | 1% |
Surgical
| Performance Indicators | MSQH Benchmark |
| Unplanned return to operating theatre within the same hospital admission following surgery | 0% |
Medical advisory committee
Head of MDAC sub-committee / 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.