Ringkasan laporan pembentangan akreditasi MSQH Jabatan Pergigian Pediatrik Hospital Melaka:
1. Terdapat beberapa penemuan audit berkaitan kelemahan sistem pemfailan dokumen, kekurangan dokumen penting difailkan, dan kekurangan polisi serta prosedur kerja difail.
2. Tindakan telah diambil untuk memperbaiki sistem pemfailan, mengemaskini fail, dan mewujudkan fail-fail penting seperti polisi, prosedur kerja, dan panduan k
2. Tugasan ahli kumpulan MSQH
Dr. Azreen & PPK Mahayon
• Std 1 : Governance, Leadership & Direction
• Std 2 : Environmental And Safety Services
• Std 4 : Nursing Services
• Std 9B : Surgical Related Services
JPK Nur Ilyanie
• Std 3 : Facility & Biomedical Equipment Management & Safety
• Std 5 : Prevention & Control Of Infection
Pt Roszila
• Std 6 : Patient & Family Rights
• Std 7 : Health Information Management System (HIMS)
3. Penemuan Audit
• 1/ Pengurusan fail yang lemah : tiada sistem, tidak seragam, tidak
kemas, tiada no turutan rekod
• 2/ > 50% Dokumen penting tidak difailkan
• 3/ 20 Fail penting tidak diwujudkan: research, all quality initiatives
activities need to be separately filed with ‘meaningful content’ - QA,
CA, Inovasi, KIK, incident reporting, infection control, M&M, aset
keperluan khas eg N2O machine, Hand Hygiene, Patients and Family
Rights, patient safety goals, pain free policy, MDAC (Women and Child
directorates meeting), COVID-19, budgeting, sharp injuries, tatatertib,
KPI, presentations , publications
4. • 4/ Pemfailan dokumen tidak bersistem: main ikat sahaja, tiada
penjilidan, tiada tarikh endorsement
• 5/ Pembuktian semua dokumen berkaitan latihan semua kakitangan,
pensijilan C&P, aset, inventori, PPM, kewangan, pengurusan sumber
manusia kurang dari 50%, orientasi kakitangan baru, NDOP
attachment programme, sistem stor - inventory consumables
dokumentasi keluar masuk
• 6/ Fail polisi Jabatan dan arahan kerja tidak lengkap, polisi hospital
tiada dlm fail, last policy review (2017)
• 7/ Peta pelan lantai, flow of patients dan keselamatan kebakaran
tiada
5. • 8/ Carta organisasi, misi, visi tiada paparan di dinding : tidak diupdate,
tidak diendorse
• 9/ Minit mesyuarat 2018-2020 utk national, state, district, hospital
dan dept level untuk SEMUA Jawatankuasa tidak bersistematik
• 10/ Tiada polisi jelas dan standard operating prosedur difail utk
SEMUA prosedur kerja Jabatan: klinikal dan non-klinikal
• 11/ Fail semua borang-borang penting klinikal dan non-klinikal (eg.
Consent, AOR dept dan hospital level)
• 12/ Fail peribadi yg tidak diupdate, fail data sumber manusia
kakitangan tiada
6. • 13/ Fail orientasi kakitangan yg tidak bersistematik
• 14/ Tiada surat lantikan untuk SEMUA kakitangan yg menjadi AJK/
comittee, pemegang portfolio dept dan hospital level
• 15/ Dokumen yg awal dari 2017 boleh dikeluarkan dari fail kerana
telah jumud kecuali polisi yang masih belum direview
• 16/ Tiada list kakitangan membaca dan menandatangani setelah
pekelililng/ polisi baru atau yg direview
• 17/ MyPortfolio / JD setiap perjawatan setiap satu fail mesti ada hard
copy : Pakar, Pegawai, PPP, JP, JT, PPK, PT
7. • 18/ Roster tugas kakitangan yang tak jelas dan tiada system : Pakar, MO,
supporting staffs, OT, on call,
• 19/ Tiada bukti pemantauan pematuhan polisi dan SOP Jabatan dan Hospital
• 20/ Agenda wajib Mesyuarat Pengurusan : polisi, SOP, aktiviti kualiti mesti
dimasukkan dalam mesyuarat Pengurusan Jabatan
• 21/ CPG’s - soft and hard copies
• 22/ Penguatkuasaan polisi dan SOP juga sederhana sahaja tanpa bukti kukuh
• 23/ Pelaksanaan prosedur kerja tiada pemantauan pada audit kali ini
8. • 24/ PPM schedule (2020) tiada dlm fail
• 25/ Ruang & tempat tidak mencukupi
9. Pemfailan
• Pemfailan sedang diseragamkan
• Jilid fail sedang dikemaskini
• Fail peribadi & sumber kakitangan sedang di update
• Dokumen dan surat tahun 2017 & ke bawah dalam proses utk dikeluarkan
• Fail penting telah diwujudkan :
-Mortaliti & Morbiditi -Pengurusan Tatatertib
-KPI -Bugdet
-Patient & Family Rights -APC
-Patient Safety Goals
-Pain Free Policy
-Covid-19
-Aset Keperluan Khas
-Infection control
-Incident reporting
-Hand hygiene
14. KPI
1. Percentage of patients with waiting time
of ≤ 90 minutes to see the doctor at the
department of paediatric dentistry (≥
90%)
2. Percentage of failed restorations done
under GA within 6 months (≤ 3%)
3. Oral soft tissue injury during dental
procedure in children (≤ 10%)
15. Guidelines / Buku Panduan
• Jumlah guidelines = 53
• Dental CPG = 13
16. Dental KKM Clinical Practice Guideline
1. Management Of Acute Orofacial Infection Of Odontogenic Origin In Child
2. Management Of Ameloblastoma
3. Management Of Avulsed Permanent Anterior Teeth In Children
4. Management Of Chronic Periodontitis
5. Management Of Mandibular Condyle Fracture
6. Management Of Severe Early Childhood Caries
7. Management Of Unerupted & Impacted 3rd Molar Teeth
8. Management Of Unerupted Maxillary Incisor (2nd Edition)
9. Orthodontic Mx Of Developmentally Missing Incisors
17. 10. Management Of Palatally Ectopic Canine
11. Antibiotic Prophylaxis In Oral Surgery
12. Management Of Anterior Crossbite With Mixed Dentition
13. Management Of Periodontal Abscess
27. Pain Free Hospital
• Pain Free Hospital Manual
• Guidelines : Pain As The 5th Vital Sign
28. Patient Safety Goals
13 Malaysian patient safety goals :
1. To Implement Clinical Governance
2. To Implement Who’s 1st Global Patient Safety Challenge : “ Clean Care Is Safer Care ”
3. To Implement Who’s 2nd Global Patient Safety Challenge : “ Safe Surgery Saves Lives ”
4. To Implement Who’s 3rd Global Patient Safety Challenge : “ Tackling Antimicrobial
Resistance “
5. To Improve The Accuracy Of Patient Identification
6. To Ensure The Safety Of Transfusions Of Blood And Blood Products
7. To Improve Medication Safety
8. To Improve Clinical Communication By Implementing A Critical Value Program
9. To Reduce Patient Fall
29. 10. To Reduce The Incidence Of Healthcare-Associated Pressure Ulcer
11. To Reduce Catheter-Related Bloodstream Infection (CRBSI)
12. To Reduce Ventilator Associated Pneumonia (VAP)
13. To Implement The Patient Safety Incident Reporting And Learning System
30. Guideline for PSG
• Achieving Excellence In Clinical Governance (No.42)
• Policies & Procedures On Infection Control (No.48)
• Safe Surgery Saves Lives Programme (No.43)
• Manual On Alert Organism Surveillance (No.47)
• Quick Guide Preventing Prescription Error (No.44)
• Quick Guide For Improving Notification Of Critical
Laboratory Results In MOH Hospitals (No.45)
• Falls Guideline For Hospitalized Older Adults In The
MOH (No.46)
31.
32. Surat pelantikan kakitangan jabatan
• AJK Klinikal dan pengurusan
• AJK Inovasi
• AJK QAP
• AJK MSQH
• AJK Latihan
37. Laporan Audit Pemantauan Dalaman
• Kaunter
• Bilik rawatan
• Bilik x-ray
• Aset
• Pentadbiran
• Keselamatan
• Kompetensi
• Lain-lain
38. Laporan Audit Kawalan Infeksi
A. Kebersihan tangan
B. Alat perlindungan diri (PPE)
C. Disinfeksi & sterilisasi
D. Pengurusan sisa klinikal
E. Pengurusan kecederaan tercucuk jarum / benda tajam
F. Etika batuk
39. Orientasi kakitangan
• Telah disusun atur &
diperbaiki
• Tiada senarai semak
orientasi kakitangan & hand
hygiene utk tahun 2021
40. Latihan
• Laporan latihan (Available : Jan-Oct 2020, tahun 2021 : tiada dlm fail)
• CDE (bukti kehadiran cde, meeting, kursus, etc)
• Latihan mycpd – laporan mycpd setiap 3 bulan (tak lengkap : tahun
2020, 2021)