1. BENGKEL NIA/KPIBENGKEL NIA/KPI
HOSPITAL CHANGKATHOSPITAL CHANGKAT
MELINTANGMELINTANG
Pengenalan kepada KPI/ NIAPengenalan kepada KPI/ NIA
Dr Lee Oi WahDr Lee Oi Wah
Pengarah HCMPengarah HCM

3. MALAYSIA VISION FOR HEALTH
1.1. Healthy nationHealthy nation with enhancedwith enhanced qualityquality
ofof lifelife
2.2. health system that is :health system that is :
equitable, affordable, efficient,equitable, affordable, efficient,
technologically appropriate, adaptabletechnologically appropriate, adaptable
consumer friendlyconsumer friendly
3.3. emphasis on : quality & innovation ,emphasis on : quality & innovation ,
health promotionhealth promotion
respect for human dignityrespect for human dignity
4.4. Promotes : individual responsibilityPromotes : individual responsibility
community participationcommunity participation

4. DEFINITION OF QADEFINITION OF QA
““SecuringSecuring optimum achievable resultoptimum achievable result
forfor each patient,each patient,
avoidance of iatrogenicavoidance of iatrogenic complicationscomplications
and giving attentionand giving attention
to theto the patientpatient
andand family needsfamily needs
in a mannerin a manner
that isthat is cost effectivecost effective
and reasonablyand reasonably documenteddocumented
Adapted from ThomsonAdapted from Thomson

5. Facilities and services are ofFacilities and services are of
high quality if they are:high quality if they are:
1.1. SafeSafe
2.2. Timely ( and appropriate )Timely ( and appropriate )
3.3. EffectiveEffective
4.4. Equitably accessedEquitably accessed
5.5. EfficientEfficient
6.6. Patient focus ( Consumer-Patient focus ( Consumer-
centered andcentered and consumer-friendlyconsumer-friendly))

6.  Apparent failure due to standardsApparent failure due to standards
vs product mismatchvs product mismatch
 Failure to conform toFailure to conform to
specificationsspecifications
 Poor designPoor design
 Design cannot be implementedDesign cannot be implemented
 Design not capable of producingDesign not capable of producing
desired resultsdesired results
 Circumstances beyond controlCircumstances beyond control
 Weak leadershipWeak leadership

7. 1.1. Not punitive:-Not punitive:-
 emphasis is on identifying solutions toemphasis is on identifying solutions to
SYSTEMS problem and not to WHO isSYSTEMS problem and not to WHO is
responsible for the problemresponsible for the problem
2.2. Helps ensure optimal Utilisation ofHelps ensure optimal Utilisation of
ResourcesResources
3.3. A means of defining performanceA means of defining performance;;
comparisons with pre-set standardscomparisons with pre-set standards
or Benchmark with similar areas inor Benchmark with similar areas in
same organisation or othersame organisation or other
organizationorganization
4.4. Allows objective confirmation andAllows objective confirmation and
documentation of performance indocumentation of performance in
measurable unitsmeasurable units
5.5. Serves to identify and help justify need forServes to identify and help justify need for
additional resources and facilities.additional resources and facilities.
Who’s fault is this ?

8. To ensure that :To ensure that :
 our limited resources are optimallyour limited resources are optimally
 utilisedutilised
 quality of care continues to improvequality of care continues to improve

9.  QuantifiableQuantifiable measurements andmeasurements and
agreed to beforehandagreed to beforehand
 Reflect the critical successReflect the critical success
factors of an organizationfactors of an organization
 Help an organization define andHelp an organization define and
measure progress towardmeasure progress toward
organizational goals.organizational goals.

10.  Quick way of seeing the actual performance ofQuick way of seeing the actual performance of
a goal or strategic objective.a goal or strategic objective.
 Decisions can be made much quicker whenDecisions can be made much quicker when
there are accurate and visible measures to backthere are accurate and visible measures to back
them up.them up.
 Allow management to see departmentAllow management to see department
performance in one place.performance in one place.
 A team can work together to aA team can work together to a common set ofcommon set of
measurable goalsmeasurable goals

11. Give everyone in the
organization a clear picture
of what is important, of
what they need to make
happen.

12.  The implementation of Key Performance IndicatorsThe implementation of Key Performance Indicators
(KPIs) in the Ministry of Health has been(KPIs) in the Ministry of Health has been
recommended in therecommended in the “Pekeliling Kemajuan“Pekeliling Kemajuan
Pentadbiran AwamPentadbiran Awam” (PKPA) 2/2005.” (PKPA) 2/2005.
 These indicators can be used toThese indicators can be used to assess the overallassess the overall
performanceperformance of the services provided by Clinicalof the services provided by Clinical
Departments in the MOH.Departments in the MOH.
 The KPIs areThe KPIs are not intended to replacenot intended to replace the currentlythe currently
running Quality Improvement activities.running Quality Improvement activities.
 It should be regarded as aIt should be regarded as a supplementsupplement to theseto these
activities which concentrate on the clinical aspects ofactivities which concentrate on the clinical aspects of
qualityquality

13.  State HealthState Health
Departments (Medical)Departments (Medical)
are:are:
 Clinical Governance inClinical Governance in
Service DeliveryService Delivery
 ResourceResource
ManagementManagement
PERFORMANCE
Aspect of Performance:
Clinical Governance Aspect of Performance:
Resource : Resource
Management
Dimension:
Patient-Centred
Services Care
Dimension:
Clinical /Technical
(Effectiveness)
Dimension:
Clinical Risk
Management
Dimension: Staff
Health
Dimension:
Human Resource
Dimension:
Financial
Management

14. ASPECT OF PERFORMANCE : CLINICAL GOVERNANCEASPECT OF PERFORMANCE : CLINICAL GOVERNANCE
DimensionDimension :: PATIENT-CENTRED SERVICESPATIENT-CENTRED SERVICES
(i)(i) Percentage of Hospitals Which Investigated ALL WrittenPercentage of Hospitals Which Investigated ALL Written
ComplaintsComplaints
Standard : 100% of all hospitalsStandard : 100% of all hospitals
(ii)(ii) Percentage of Hospitals in the State Achieving the ClinicPercentage of Hospitals in the State Achieving the Clinic
Waiting Time TargetWaiting Time Target at 3at 3 Selected ClinicsSelected Clinics
Standard : All (100%) relevant hospitalsStandard : All (100%) relevant hospitals
to achieve standardto achieve standard
at 3 Selected Clinicsat 3 Selected Clinics
Dimension :Dimension : CLINICAL / TECHNICAL (EFFECTIVENESS)CLINICAL / TECHNICAL (EFFECTIVENESS)
(iii)(iii) Hospital Accreditation / ISOHospital Accreditation / ISO CertificationCertification
Percentage of Hospitals with a CURRENT HospitalPercentage of Hospitals with a CURRENT Hospital
AccreditationAccreditation OROR ISO statusISO status
Standard :Standard : >> 70% of hospitals in the State70% of hospitals in the State
in the yearin the year
(iv)(iv) Quality Assurance Programme (QAP)Quality Assurance Programme (QAP)
National Indicator (NIA) PerformanceNational Indicator (NIA) Performance
Standard: All hospitals to achieve : NIAStandard: All hospitals to achieve : NIA
indicator Standards Attained in at leastindicator Standards Attained in at least
((>>) 80%) 80% of the NIA Indicators that Areof the NIA Indicators that Are
Relevant to the Hospital (every 6Relevant to the Hospital (every 6
months)months)
Dimension :Dimension : CLINICAL RISK MANAGEMENTCLINICAL RISK MANAGEMENT
(v)(v)
Percentage of hospitals with Specialist Services AchievingPercentage of hospitals with Specialist Services Achieving
Targeted MRSA RatesTargeted MRSA Rates
Standard: 100% must achieve theStandard: 100% must achieve the
standard set of < 0.4%standard set of < 0.4%
Dimension :Dimension : STAFF HEALTHSTAFF HEALTH
(vi)(vi) Percentage of Hospitals Attaining Set Standards for RoutinePercentage of Hospitals Attaining Set Standards for Routine
Medical Check-ups for Staff aged Over 40 yearsMedical Check-ups for Staff aged Over 40 years
Standard :Standard : At least 70 % (At least 70 % (>> 70%)70%)ofof
eligible staff have had a medical check-eligible staff have had a medical check-
up in the yearup in the year

15. ASPECT OF PERFORMANCE : RESOURCE MANAGEMENTASPECT OF PERFORMANCE : RESOURCE MANAGEMENT
Dimension :Dimension : Human ResourceHuman Resource
(vii)(vii) Percentage of Hospitals Attaining Set standardsPercentage of Hospitals Attaining Set standards
for Medical Officers Attending Training Coursesfor Medical Officers Attending Training Courses
(MTLS / ACS / PALS)(MTLS / ACS / PALS)
All hospitals to achieve at leastAll hospitals to achieve at least
((>>)70%)70% Doctors in ED andDoctors in ED and
Anesthesia trained in any of theAnesthesia trained in any of the
three coursesthree courses
(viii)(viii) Percentage of Hospitals Attaining Set StandardsPercentage of Hospitals Attaining Set Standards
for Paramedics Attending BLS Training Coursesfor Paramedics Attending BLS Training Courses
All hospitals have achieved theAll hospitals have achieved the
target of at leasttarget of at least ((>>) 70%) 70% of theirof their
Paramedic personnel IN ACUTEParamedic personnel IN ACUTE
CARE areas trained in BLSCARE areas trained in BLS

16.  The NIA for the Patient Care Services QAPThe NIA for the Patient Care Services QAP
(Quality Assurance Programme) began in 1985.(Quality Assurance Programme) began in 1985.
 The goal is to ensure that, within the constraints ofThe goal is to ensure that, within the constraints of
the MOH available resources, the patient, familythe MOH available resources, the patient, family
and the community obtained theand the community obtained the "optimum"optimum
achievable benefit”achievable benefit” from its services, in terms of thefrom its services, in terms of the
advancement of the health and welfare ofadvancement of the health and welfare of
individuals and the community as well as theindividuals and the community as well as the
Malaysian population.Malaysian population.

17. ** MOH set & provides:MOH set & provides:
-- aa standardstandard for eachfor each indicatorindicator
-- monitoring format for data collection ,monitoring format for data collection ,
analysis & reportinganalysis & reporting
-- protocols & format forprotocols & format for SIQSIQ investigation.investigation.
* Hospital has to carry out remedial actions* Hospital has to carry out remedial actions
& relook of its effectiveness.& relook of its effectiveness.
NIANIA

18.  Defining standards and establishingDefining standards and establishing
systemssystems
 to produce the desired attributes / standardsto produce the desired attributes / standards
of health care services as efficiently asof health care services as efficiently as
possible (Models of Good Care / Practice) forpossible (Models of Good Care / Practice) for
targeted areas of concerntargeted areas of concern
 Measuring the Quality of servicesMeasuring the Quality of services (and(and
comparing between observed standardscomparing between observed standards
against set standards)against set standards)
 Implementing Remedial measuresImplementing Remedial measures (Change(Change
management) to further improve quality (bymanagement) to further improve quality (by
meeting or exceeding previously-setmeeting or exceeding previously-set
standards)standards)

19. (a) Measure
quality
(b) Detect
shortfalls?
Yes
No
(c) Investigate
reasons for
shortfall
(d) Devise
strategies for
improvement
(e)
Implement
strategies
IDENTIFY AREAS OF
CONCERN
Figure 2:The National Indicator Approach (Problem-solving) Process

20. ProblemProblem
PrioritisationPrioritisation
ProblemProblem
AnalysisAnalysis
QualityQuality
AssuranceAssurance
StudyStudy
Identification ofIdentification of
Remedial ActionsRemedial Actions
Implementation ofImplementation of
Remedial ActionsRemedial Actions
Re-evaluation of theRe-evaluation of the
ProblemProblem
ProblemProblem
identificationidentification
QualityQuality
AssuranceAssurance
CycleCycle

21. LIST OF KPI/NIALIST OF KPI/NIA
Percentage of Customers Dissatisfied with the Hospital’sPercentage of Customers Dissatisfied with the Hospital’s
ServicesServices
< 8% of hospital’s in-patients< 8% of hospital’s in-patients
and out-patientsand out-patients
““Waiting Time to Consult Doctor / Specialist (T1)” at SelectedWaiting Time to Consult Doctor / Specialist (T1)” at Selected
Clinics in the Hospital Meets with the Set StandardsClinics in the Hospital Meets with the Set Standards
<<90 minutes for at least 90%90 minutes for at least 90%
of patients for General OPD,of patients for General OPD,
MO F/up Clinics and VisitingMO F/up Clinics and Visiting
Specialist ClinicsSpecialist Clinics
EITHER Hospital Accreditation OR ISO CertificationEITHER Hospital Accreditation OR ISO Certification Achieved Accreditation / ISOAchieved Accreditation / ISO
and/or Sustained Accreditationand/or Sustained Accreditation
/ ISO status)/ ISO status)
Quality Assurance Programme (QAP)Quality Assurance Programme (QAP)
National Indicator (NIA) Performance of HospitalNational Indicator (NIA) Performance of Hospital
Hospital meets standards in atHospital meets standards in at
least 80% of the relevant NIAleast 80% of the relevant NIA
indicators for the hospitalindicators for the hospital

22. INDICATORINDICATOR STANDARD SETSTANDARD SET
6-monthly Average Rate of MRSA in the Hospital6-monthly Average Rate of MRSA in the Hospital < 0.4%< 0.4%
Percentage of Staff Over 40 who had Undergone RoutinePercentage of Staff Over 40 who had Undergone Routine
Medical Check-upsMedical Check-ups
At least 70 % of their eligibleAt least 70 % of their eligible
staff have had a medicalstaff have had a medical
check-up in the yearcheck-up in the year
Percentage of Personnel Trained in Basic Life Support (BLS) in aPercentage of Personnel Trained in Basic Life Support (BLS) in a
YearYear
60% of clinical personnel60% of clinical personnel
(paramedics) in acute care(paramedics) in acute care
areasareas))
Percentage of Medical Officers inPercentage of Medical Officers in ED and AnesthesiaED and Anesthesia WhoWho
Attended MTLS / ALS/ PALS Training Courses in a YearAttended MTLS / ALS/ PALS Training Courses in a Year
60% to be trained60% to be trained
Hospitals Attains Set standards for: “Audit Queries Responded ToHospitals Attains Set standards for: “Audit Queries Responded To
and Action Taken by the Hospitals that have been Audited”and Action Taken by the Hospitals that have been Audited”
100% of audit queries100% of audit queries
responded to and actionresponded to and action
takentaken

23. INDICATORINDICATOR STANDARD SETSTANDARD SET
Acute Coronary Syndrome Case Fatality RateAcute Coronary Syndrome Case Fatality Rate Should not exceed 20%Should not exceed 20% ((<<
20%)20%)
Percentage of Asthma patients Discharged with an AsthmaPercentage of Asthma patients Discharged with an Asthma
Discharge Plan DocumentDischarge Plan Document
Not less than 75%Not less than 75%
Percentage of Patients with Ischemic Stroke treated with Anti-Percentage of Patients with Ischemic Stroke treated with Anti-
platelet therapy within 48 hoursplatelet therapy within 48 hours
>> 80%80%
Mild Head Injury Case Fatality RateMild Head Injury Case Fatality Rate Not > 5 %Not > 5 %
Percentage of Acute ST Elevation Myocardial InfarctionPercentage of Acute ST Elevation Myocardial Infarction
(STEMI) Patients Receiving Thrombolytic Therapy within(STEMI) Patients Receiving Thrombolytic Therapy within
30 Minutes of Presentation at the Emergency30 Minutes of Presentation at the Emergency
DepartmentDepartment
>> 70%70%
Dispatch and Ambulance Preparedness for Primary ResponseDispatch and Ambulance Preparedness for Primary Response > 90% with dispatch time of> 90% with dispatch time of
5 minutes or less5 minutes or less

24. INDICATORINDICATOR STANDARD SETSTANDARD SET
Inappropriate Triaging (Under-triaging) : Percentage ofInappropriate Triaging (Under-triaging) : Percentage of
Category Green Patients Who Should Have Been Triaged asCategory Green Patients Who Should Have Been Triaged as
Category RedCategory Red
Not > 0.5%Not > 0.5%
InappropriateTriaging (OVER- TRIAGING) :InappropriateTriaging (OVER- TRIAGING) :
Percentage of Cat. Red Patients Who Should HavePercentage of Cat. Red Patients Who Should Have
Been Triaged As Cat. GreenBeen Triaged As Cat. Green
Not > 0.5%Not > 0.5%
Proportion of Radiographs RejectedProportion of Radiographs Rejected
< 5%< 5%
Delivered KT/V in patients on centre haemodialysisDelivered KT/V in patients on centre haemodialysis At least 80% of patientsAt least 80% of patients
should have averageshould have average
prescribed KT/Vprescribed KT/V >> 1.2 yearly1.2 yearly
Effectiveness & Appropriateness ofEffectiveness & Appropriateness of
ADL intervention of stroke patientsADL intervention of stroke patients
75%75% of target group shouldof target group should
obtain a score of 70% MBIobtain a score of 70% MBI
after a minimum of 8after a minimum of 8
treatment sessionstreatment sessions in 12in 12
weeksweeks

25. INDICATORINDICATOR STANDARD SETSTANDARD SET
Incidence of Physical Contamination of Food Served to PatientsIncidence of Physical Contamination of Food Served to Patients SENTINEL EVENT.SENTINEL EVENT.
Incidence of Thrombophlebitis Among ADULTIncidence of Thrombophlebitis Among ADULT
In-patients Receiving Intravenous TherapyIn-patients Receiving Intravenous Therapy
Timeliness in the Preparation of Medical ReportsTimeliness in the Preparation of Medical Reports
Within 14 daysWithin 14 days
Not less than 95 % ofNot less than 95 % of
completed medical reportscompleted medical reports
Timeliness of Dispatching Medical Records of DischargedTimeliness of Dispatching Medical Records of Discharged
Patients to the Medical Records DepartmentPatients to the Medical Records Department within 72 hrswithin 72 hrs
Not less than 95%Not less than 95%
Incidence of Massive Primary Post-partum Haemorrhage (PPH)Incidence of Massive Primary Post-partum Haemorrhage (PPH) Not > 0.5% of total no. ofNot > 0.5% of total no. of
deliveriesdeliveries
Incidence of Recurrent Eclamptic Fits Occurring after HospitalIncidence of Recurrent Eclamptic Fits Occurring after Hospital
AdmissionAdmission
Sentinel Event (No cases)Sentinel Event (No cases)

26. INDICATORINDICATOR STANDARD SETSTANDARD SET
Death Due to Heart Disease in PregnancyDeath Due to Heart Disease in Pregnancy Sentinel Event (No cases)Sentinel Event (No cases)
Community–acquired Pneumonia Death Rate in previouslyCommunity–acquired Pneumonia Death Rate in previously
healthy children aged fromhealthy children aged from >>1 month to1 month to << 5 years5 years
<< 2.5%2.5%
Dengue Hemorrhagic Fever Deaths in Pediatric casesDengue Hemorrhagic Fever Deaths in Pediatric cases Sentinel event (No deaths)Sentinel event (No deaths)
Death due to Acute Gastroenteritis in Paediatric patientsDeath due to Acute Gastroenteritis in Paediatric patients
Sentinel event (No deaths)Sentinel event (No deaths)
Number of Paediatric Patients Who are Readmitted to HospitalNumber of Paediatric Patients Who are Readmitted to Hospital
For Acute Exacerbation Of Asthma Within 28 Days Of DischargeFor Acute Exacerbation Of Asthma Within 28 Days Of Discharge
Sentinel eventSentinel event
(No cases)(No cases)
Defaulter Rate of Psychiatric Patients AttendingDefaulter Rate of Psychiatric Patients Attending
Outpatients ClinicOutpatients Clinic
Less than 15%Less than 15%

27. TerimaTerima
KasihKasih