Overview

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 Law Teik Yeong

Chairman of Medical Records

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