EXCELLENCE IN CLINICAL GOVERNANCE: FRAMEWOK FOR INTEGRATING QUALITY, SAFETY AND RISK MANAGEMENT PEMANTAPAN PROGRAM PERUBATAN KKM 6hb -8hb APRIL 2010 KLANA RESORT SERAMBAN Dr Kalsom Maskon Public Health Physician Deputy Director Quality in Medical Care Medical Development Division Ministry of Health Malaysia
Outline of presentation
Definition Background Essential elements of clinical governance Core process of clinical governance Outcomes Conclusion
Adoption of Clinical Governance as a framework for integrating all the Quality Improvement activities and initiatives in health sector Malaysia
Clinical Governance (NHS), a framework through which NHS organizations are accountable for continually improving the quality of their health services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.
The NHS in Scotland defines clinical governance as
"corporate accountability for clinical performance ".
The Ministry of Health Malaysia, as the lead agency for health in the country, is committed to driving the health care sector in the provision of safe, high quality services through the implementation of the Clinical Governance concept.
The MOH and the private health sector have implemented numerous quality initiatives and programmes; which appear to be separate and not integrated
To realize vision for health, mission of the MOH, there is a need for a framework for the improvement of the health care delivery system and governance in health care.
The objectives of the framework
To ensure that there is a systematic framework of quality management system for the health sector for the integration of quality, safety and risk management programmes to support and drive the provision of safe, effective and high quality services To drive core programmes for quality, safety and risk management To ensure that appropriate accountability, leadership and oversight arrangement are in place by the health sector to institutionalize and internalize quality and safety culture
Vision for Health Mission of the MOH Strategic Plan for Quality in Health
To facilitate & support the people to:
• Attain fully their potential in health • Appreciate health as a valuable asset • Take individual responsibility & positive action for their health
To ensure a high quality health system that is:
• • • • • Customer centred Equitable Affordable Efficient Technologically appropriate • Environmentally adaptable • innovative
With emphasis on:
• Professionalism, caring & teamwork values • Respect for human dignity • Community participation
QI activities in MOH
◦ NIA ◦ HAS ◦ KPI
◦ ◦ ◦ ◦ IR HCAI OHS World Alliance Patient Safety programme
◦ POMR ◦ NAICU ◦ Nursing
Patient centred services
◦ Patient satisfaction surveys ◦ Complaints mgt
◦ ISO ◦ Accreditation ◦ Star Rating
Statistical Process control
◦ eCUSUM &Registries
Innovations Many more…
Framework: integration of quality, patient safety and risk management
Framework for integrated Quality, Safety and Risk Management
Three key components to the framework:
Essential underpinning requirements Core processes and programmes Performance indicators
An Introduction to Quality Assurance in Health Care. Oxford University Press. 200. The three components is based the three components on Avedis Donabedian’s Structure, Process, Outcome Model
Essential underpinning requirement
1. 2. 3.
Communication and consultation with stakeholders Clear accountability arrangements Adequate capacity and capability Standardised policies, procedures, protocols and guidelines Monitoring and review arrangements Assurance...
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