Head of Department YBrs. Dr S. Kasthoori a/p Supramaniam
Phone  603-26157373/6266 
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1. Background

This unit was established in 1995 with the aim of acting as a catalyst for the implementation of quality programs at the Kuala Lumpur Hospital (HKL). As one of the clinical support unit, it holds the responsibility as the secretariat for quality programs at the hospital level. With cooperation and support from HKL Management and all departments, this unit had implemented various quality improvement programs at this hospital such as the Quality Assurance  / Quality Improvement (QA/QI) Pogram including Hospital Specific Approach (HSA) and National Indicator Approach (NIA) since 1985. This unit also had successfully continuing the QA / QI Workshop and QA / QI Convention on a yearly basis.

2. Unit Objectives

2.1 Improve the quality of services provided by HKL through the Quality Management Council based  the Service Development Circular and meet the Malaysian Standards ISO (International Organization For Standardization) (MS ISO) and Malaysian Hospital Accreditation Standard (MHAS).

2.2 Serves as the secretariat who coordinates, monitors, manages data and reports on all quality activities such as QA / QI, ISO, Risk Management, Morbidity & Mortality Review and Incident Reporting at the hospital level

3. Vision

Together we strive to achieve the vision of HKL to become an excellent institution in providing quality and safe healthcare services

4. Mission

4.1 Design, plan and coordinate quality activities at the Departments and Hospital level to improve the quality of health care and patients safety.

4.2 Monitor the implementation of quality and patient safety activities.

4.3 Monitor continuous improvement actions to maintain MS ISO 9001 certification for HKL.

 

5. Scope of Service

This unit act as secretariat of several committees within the Quality Council management.

5.1 MS ISO Program

i) Quality Document Implementation

ii) Quality Document Control

iii) Implementation of Internal Quality Audit

iv) SIRIM Auditing Coordinator

v) Training Exercise

5.2 Quality Assurance and Quality Improvement (QA / QI)

i) QA / QI annual Workshop & Convention.

ii) Hospital Specific Approach.

iii) Department Specific Approach.

iv) Quality Innovation and Creativity Award.

v) Hospital Performance Indicator for Accountability (HPIA) and Key Performance Indicator (KPI)

5.3 Risk Management

i) Monitoring of Malaysian Patient Safety Goals

ii) Implementation of Workshop on Risk Management:

     - Patient Falls

     - Prevention of Pressure Injury

     - Patient Identification with 2 Identifier

     - Aggressive Behavioral Suicide & Therapeutic Control (PTTA)

iii) Coordination of the Kuala Lumpur Hospital Risk Assessment and Opportunities (Risk Registry)

 5.4 Incident Report

i) Conduct and manage and analyze incident reports for Kuala Lumpur Hospital

ii) Coordinate workshops on incident reporting at the hospital level

iii) Coordinate the implementation of Root Cause Analysis at hospital level

5.5 KLH Journal of Quality Improvement

i) Coordinate, edit and read the selected final QA / QI study reports to be published annually.

5.6 Customers Satisfaction Survey

i) Coordinate SERVQUAL Patient Satisfaction Study.

5.7 Free Pain Program

i) Coordinates Pain Free courses and workshops.

ii) Implementation of the Pain Free program audit.

5.8 Mortality & Morbidity Review

i) Coordinate the implementation of Mortality & Morbidity at the hospital level.

ii) Responsible for distributing agreed results to all relevant departments.

5.9 Management Review Meeting (Mesyuarat Kajian Semula Pengurusan) (MKSP)

i) Coordinate the implementation of annual meeting with Director and Top management of Kuala Lumpur Hospital.

ii) Obtain feedback on agreed actions.

6. Quality Management Unit Organization Chart

 7. Quality Management Unit Activities

7.1 HKL Internal Audit Quality Workshop

7.2  Workshop on Risk Management Implementation.

7.3 Management Review Meeting (Mesyuarat Kajian Semula Pengurusan) (MKSP)

7.4  Convention & Poster Competition for QA/QI

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