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MSQH Hospital Accreditation Standards 5th Edition- Standards 2 & 3. Ir. Al- Khairi Mohd Daud Ir. Gnana Sakaran. R MSQH Surveyor. Standards & Self Assessment Tool. What is the Goal of MSQH accreditation?. Patient, Staff, Visitor, Vendor, Owner Safety It is all about Risk Management
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MSQH Hospital Accreditation Standards 5th Edition- Standards 2 & 3 Ir. Al-KhairiMohdDaud Ir. Gnana Sakaran. R MSQH Surveyor
What is the Goal of MSQH accreditation? • Patient, Staff, Visitor, Vendor, Owner Safety • It is all about Risk Management • Making the risk as low as reasonably practical (ALARP)
WHAT WILL OCCUR • The surveyor(s) will visit patient care areas as well as non–patient care areas of the facility. • In all areas, the surveyor(s) will observe the facility and interview staff to learn how the hospital manages the facility to accomplish the following: • Reduce and control hazards and risks • Prevent accidents and injuries • Maintain safe conditions • Maintain secure conditions • Implement emergency response plans
What the surveyors look • Receipt of verbal information concerning implementation of standards or examples of their implementation • On-site observation (70%) • Review of documents that demonstrate compliance and assistance in orienting the surveyor(s) to the hospital’s operations (30%)
Strengths Weaknesses • What have the department achieved this year? • How can you harness the strength • What the department could improved next year? • What issues and complains that you received • What limitation that you face SWOT Analysis
Opportunity Threat • What can you achieved better? • How can you simplify your work? • How can you served better the patients? • What are the challenges that hinders your achievements? • Why are you not achieving better results? SWOT Analysis
Closing the Gaps • What policies, manuals, procedures, work instructions, checklist, guidelines that we need to established to ensure that the process is permanent
Documents Protocols General Auditable Operational Requirement Specific
Department Policies • Check your policies • Does it describes the fundamentals of what you want to achieve?
Basic Requirements • Plan – The document • Teach – The training and awareness • Implement – Actual practice • Check – Regular audit and inspection • Review – Set performance indicators • Improve – Regular updates of the practice
Things to remember • Plans must be practice • Drills and trainings must be regularly trained. • Performance must be recorded with statistics • Learning lessons and improvement need to be institutionalized and disseminated to relevant parties. • Review must involve all parties
General Requirement in the plans Rules and Regulations 1. Occupational Safety & Health Act 1994 & its regulations • Use and Standard of Exposure of Chemical Hazardous to Health Regulation 2000 (USECHH Regulation) • Classification, Packaging And Labeling Hazardous Chemicals 1997 Regulations (CPL) 2. Factories & Machineries Act 1967 3. Environmental Quality Act 1974 & its regulations 4. Private Healthcare Facility and Services Act 2006. & its regulation • Private Healthcare Facilities and Services (Private hospitals and other private healthcare facilities) Regulation 2006 • Private Healthcare Facilities and Services (Official identification card) Order 2006
General Requirement in the plans 5. Atomic Energy Licensing Act 1984 (Act 304) • Radiation Protection (Licensing) Regulation 1986 • Radiation Protection (Basic Safety Standards) Regulation 1986 • Radiation Protection (Transportation) Regulation 1989 6. Medical Device Acts 7. Uniform Building By laws 8. Fire Service Act 9. Electricity Supply Act • Efficient Management of Electrical Energy Regulations • Gas Supply Act
STANDARD N0.02 ENVIRONMENTAL & SAFETY SERVICES .
Preamble • The Person In Charge (PIC) shall ensure that the Facility is provided with a range of environmental and safety programmes throughout the Facility that address safety, comfort and conducive environment to reduce risks for patients, staff and visitors to the Facility. • The programmes shall cover requirements for but not limited to hazard identification, fire safety, workplace safety, disaster plans (internal and external) hazardous material management and security services.
Organization and Management The Environmental and Safety Services shall address but not limited to the following: a) Occupational Safety and Health b) Fire Safety c) Disaster Management i) External Disaster ii) Internal Disaster d)Hazardous Material and Recyclable Waste Management e) Security Services f) Vector and Pest Control
