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One of the objectives of Normah Medical Specialist Centre is to establish a hospital with high standard of care and safety for patients. We are trying to develop Normah Medical Specialist Centre into a hospital that is on par with hospitals in first world countries. This is to ensure that when patients come to Normah for medical treatment it is exactly the same as walking into any hospital in the US or in the UK. This is to boost public confidence that there is at least one hospital in the state that has achieved the same standards as other first world hospitals. This is very important because we all have families and loved ones here and it is important that we feel confident in going to a hospital in Kuching where high medical standards and patient safety are the only priority in the hospital and how you are being managed is no different from a hospital in the US or UK.
The first step to be on par with hospitals in developed countries is to have the same hospital accreditation as them. Joint Commission International (JCI) is one such accreditation. Accreditation must also not be an end in itself, it must be a mean to an end and the accreditation must be the minimal standard or platform by which Normah will continue to improve in terms of standard and safety.
JCI accreditation allows on-going practice evaluation of the doctors’ performance and ensure that there is a uniform standard of care and safety for patients. Patients are treated based on clinical practice guidelines and evidence based medicines and the on-going professional practice evaluation (OPPE) ensures that the doctors are current in their practice and up-to-date.
The accreditation also allows the hospital to benchmark the performance of the hospital and performance of the doctors including x-ray reports, angiogram reports to other hospitals in the US which we are currently doing to ensure that we get the same outcome for our patients as those hospitals in the US.
It is even more imperative in Malaysia as our doctors received training from different parts of the world. They have different experiences, skills and knowledge. All doctors are not the same. As a hospital we have to make sure that despite the varied background of the doctors there is a certain standard of care that the doctors must reach and OPPE and benchmarking of performance allow us to be sure that doctors in NMSC are up to the mark in their performance. This is very important for patient’s confidence as most of the time the patient is not familiar with the doctor or how good he or she really is. It is part of the responsibility of the hospital to assure the patient that the doctors working for the hospital has been monitored and audited with regards to their skill and knowledge and their practice is up to-date. The hospital can also send doctors for further training if they cannot perform up to the mark.
As an accredited hospital Normah must also act as an advocate for patient safety. OPPE and benchmarking is important to ensure that the doctors working in the hospital are really competent in their specialty and this in turn translate to safety for the patient coming to the hospital.
As such, the Board of Directors, Management, doctors and staff of Normah Medical Specialist Centre is proud to announce that Normah Medical Specialist Centre (NMSC) has been awarded the 3rd cycle of accreditation for quality healthcare and patient safety from the prestigious international healthcare accreditation body – Joint Commission International (JCI) in June 2017. This accreditation is valid for three years from 2017 – 2020.
Historical Background
Since its establishment in 1988, Normah Medical Specialist Centre at Petra Jaya, Kuching has been regarded as the leading health care facility for delivering high quality care to patients in the state of Sarawak. This first local private hospital has come a long way – from being just a local 130-beds non-profit healthcare facility to now a world-class quality healthcare provider today. Achieving such a prestigious status is not an easy step and it was spearheaded at the moment when NMSC was awarded with full accreditation for three years from the Malaysian Society for Quality in Health (MSQH) in 2005. Since then, NMSC had been re-accredited by MSQH every three years for re-confirmation of its status as being high quality healthcare provider in the region.
Although having already achieved the status of MSQH accreditation which is the highest national honor any local Malaysian hospital could have acquired, Normah Medical Specialist Centre did not stop there. Instead, NMSC proceeded to raise its profile and standard even higher by aiming at the much desired and prestigious international award and recognition of quality healthcare facility – the accreditation by the prestigiously recognized Joint Commission International (JCI). After much hard works with the full commitment of the NMSC’s Board of Directors, management team, doctors and its staff, NMSC finally received its first prestigious JCI accreditation in 2011 for three years (2011-2013). This accreditation and distinction not only reaffirms NMSC’s commitment to quality healthcare delivery and compliance with the highest standard of healthcare services. It also marks another milestone in NMSC’s endeavor to be the preferred healthcare provider in the region – and this is in alignment with NMSC’s mission and vision. Currently, there are only ten hospitals in Malaysia that are accredited by JCI and NMSC is the only JCI accredited hospital in East Malaysia.
But what is healthcare accreditation? Healthcare accreditation is a self-assessment and external peer review process used by healthcare organizations to accurately assess their level of performance in relation to established standards (either national or international) and more importantly, to implement ways for continuous quality improvement. Reduction of medical errors through continuous quality improvement and thus ensuring patient safety in healthcare setting is an important goal in the process of accreditation. Why chose JCI? JCI, founded in 1994, is the international arm of the USA-based Joint Commission on the Accreditation of Healthcare Organizations (JCAHO) which is the oldest and largest standards-setting and accrediting body in healthcare in the United States. JCAHO, an independent non-profit organization, evaluates and accredits more than 20,000 healthcare organizations and programs in the United States since its creation in 1951. JCAHO inspires hospitals and clinics in the United States to excel in providing safe and effective care to patients. And JCI does the same on a global scale.
The Joint Commission International (JCI) has established itself as the premier authority on the issue of improving patient care in more than 90 countries worldwide. JCI is a globally recognized body that accredits only those organizations that meets the high-level of standards of patient care specified by JCI. The JCI’s standards reflect the systems and processes needed to deliver high quality patient care in a healthcare organization. Ultimately, JCI works to improve patient safety and quality health care in the international community. Hundreds of excellent hospitals around the world have sought accreditation by JCI and have achieved it. To demonstrate quality and safety, international hospitals seek JCI accreditation which is also considered a seal of approval by medical travelers from the United States.
The JCI Survey
The path to JCI accreditation is long and tedious. Application for accreditation begins 6-9 months prior to the actual accreditation survey. On the date of the survey, 3-4 JCI surveyors come to the hospital for a three – four days survey. The surveyor team comprises of a team leader and two to three supportive surveyors. These surveyors can be doctor, nurse, pharmacist or a hospital administrator. The entire accreditation process will focus on the hospital compliance rate of the currently active JCI Standards Manual – which is now the 5th edition published and effective on April 1st, 2014.
This 5th edition of JCI Standards Manual contains 285 Standards and 1160 Measurable Elements (ME). The JCI Standards Manual focuses on Patient-Centered functions such as the International Patient Safety Goals (IPSG), Access to Care and Continuity of Care (ACC), Patient and Family Rights (PFR), Assessment of Patients (AOP), Care of Patients (COP), Anesthesia and Surgical Care (ASC), Medication Management and Use (MMU), and Patient and Family Education (PFE). In addition, JCI Standards Manual also stresses on Organization Functions such as Quality Improvement and Patient Safety (QPS), Governance, Leadership, and Direction (GLD), Facility Management and Safety (FMS), Staff Qualifications and Education (SQE) and Management of Information (MOI).
During the survey, the surveyors follow actual patient care through the facility and includes interviews with key hospital personnel (doctors, nurses, paramedical staff such as ambulance drivers, porters, housekeepers, laboratory workers and radiographers, etc.). Observation of the hospital’s administrative and clinical services, assessment of the physical facilities and patient care equipment, and review of clinical documents are part of the survey process.
Tracer methodology is the foundation of the JCI surveys. There are two type of tracers JCI utilizes in the survey. One is the Individual Patient Tracer where the surveyor picks a currently hospitalized patient and follows the experience of care of this patient through the hospital’s entire health care process. For example, the patient’s activity will be traced from the original visit to the Accident/Emergency department to admission to the ward, to the radiology and laboratory for testing and investigation, nursing and doctor’s assessment, treatment processes including medications prescription and dispense, surgery or procedures rendered, support from physiotherapy and dietitian, and finally the process of discharging the patient. The other tracer is the System Tracer which looks at a specific system or process across the hospital. During a System Tracer, the surveyors evaluate (1) the performance of relevant processes, with particular focus on the integration and coordination of distinct but related processes; (2) evaluate communication among various disciplines and departments; (3) identify potential concerns or problems in relevant processes. System Tracers include: (1) Medication Management System Tracer, (2) Infection Prevention and Control System Tracer, (3) Facility Management and Safety System Tracer, (4) Operating Theatre Tracer, (5) Central Sterile Supply Department (CSSD) Tracer and (6) Endoscopy Tracer.
During the survey, the surveyor will score each Measurable Element (ME) of a specific Standard as either: (1) Fully Met, (2) Partially Met, (3) Not Met or (4) Not Applicable. “Fully Met” means 90% or more of the observations or records are compliant with that Measurable Element (ME) of the Standard in focus and will be given a score of “10”. “Partially Met” is 50% to 89% compliant and is given score of “5”, and “Not Met” is less than 49% compliant and given a score of “0”.
The scores of all Measurable Element (ME) of a specific Standard are averaged to give a score of that standard. The scores of all Standards of a single chapter are averaged to obtain a single score for that chapter in the JCI Standards Manual. A hospital is approved for accreditation if all of the below are fulfilled:
1. Each Standard in the Manual must have a score of at least 5
2. Each chapter in the Manual must have an aggregate score of 8 or more
3. All Standards together must have a score of at least 9
4. No Measurable Element in the IPSGs is scored “Not Met”
The International Patient Safety Goals
In the United States, medical errors results in the death of between 44,000 and 98,000 patients every year. Reducing this amount of medical errors and thus leads to patient safety is the ultimate and foremost goal of JCAHO and its international arm, JCI. In 2010-11, JCAHO and JCI published a set of six (6) standards that was named National Patient Safety Goals (NPSG) in the USA and International Patient Safety Goals (IPSG) globally to address the issue of medical errors in healthcare organization. This set of 6 standards aim to promote specific improvements in patient safety and to highlight problematic areas in healthcare delivery. The ultimate aim is to provide evidence- and expert-based consensus solutions to these problems and thus achieving patient safety. The following is a list of the six International Patient Safety Goal (IPSG):
1. IPSG #1 – Identify patients correctly by using two patient identifiers.
• Wrong-patient errors occur in virtually all aspects of diagnostic and treatment process
• Patients may be sedated, disoriented, or not fully alerted at time of undergoing diagnostic test or procedure or receiving treatment
• Hospital needs to have policy and procedure to accurately identify the correct patient for the correct diagnostic test and for receiving the correct treatment
• Patient is identified by two (2) patient identifiers – name, birthdate, IC or passport number, medical record number (MRN) are some of the eligible identifiers used. Patient’s room number and location cannot be used as an identifier as patient may change bed or room during hospitalization
• Double patient identifiers are used when
i. Giving medications, blood or blood products
ii. Taking blood sample and other specimens for clinical testing iii. Providing any other treatments, diagnostic tests, procedures and surgeries
iv. Delivering hospital diet to hospitalized patients 2. IPSG #2 – Improve effective communication among healthcare workers
• Effective communications among healthcare workers reduces errors and results in improved patient safety
• Effective communications must be timely, accurate, complete, unambiguous, and understood by the recipient
• The most error-prone communications are patient care orders given verbally over the telephone by doctor to nurse
• Another error-prone communication is the reporting back of critical test results to the doctor or nurse from the laboratory or radiology
• Hospital needs to have policy and procedure that requires the receiver of the verbal patient care order or critical test result to read back to the individual who gives the order or critical test results and this individual must confirmed the read-back to be correct 3. IPSG #3 – Improve the safety of high-alert medications which have the higher likelihood of causing medication error.
• High-alert medications are those medications involved in a high percentage of life-threatening errors, medications that carry a higher risk of adverse outcomes, as well as look-alike, sound-alike medications
• Some of these high-alert medications include concentrated electrolytes solution such as potassium chloride, 3% sodium chloride, and magnesium sulfate
• Hospital needs to have policy and procedures that identify, label and store properly the list of high-alert medications in its own organization
4. IPSG # 4 – Ensure correct-site, correct-procedure, correct patient surgery so that no patient ever has the wrong site operated on or wrong surgery performed.
• Wrong-site, wrong-procedure, wrong-patient surgery is an alarmingly common occurrence in healthcare organizations
• These errors occur because of:
i. Ineffective or inadequate communication between members of the surgical teams
ii. Lack of patient involvement in marking the correct body part intended for the surgery
iii. Lack of procedures for verifying the correct body part for surgery
• A verification procedure named “Time Out” is employed before starting a surgical procedure to ensure the correct patient, surgery or procedure and body part are entailed in the planned procedure or surgery
• Hospital needs to have policy and procedures that require the preoperative “Time Out” procedure be done for all procedures that investigate and/or treat diseases of the human body through cutting, removing, altering, or insertion of diagnostic/therapeutic instruments.
“Time Out” should be carried out before starting the above mentioned procedures and should involve the entire operative team 5. IPSG #5 – Reduce the risk of healthcare-associated infections, specifically by implementing a strict hand-washing program for all hospital staffs in patient care.
• Rising rates of healthcare associated infection are a major concern for hospitals and patients
• Infections common to many hospital include hospital acquired urinary tract infections, bloodstream infections and pneumonia
• Central to the elimination of these healthcare associated infections is proper hand hygiene
• Hospital needs to have policy and procedures that address reducing the risk of healthcare associated infections. Formation of an Infection Control Committee is needed and implementation of an effective hand hygiene program is required for fulfilling this IPSG 6. IPSG #6 – Reduce the risk of patient harm resulting from falls.
• Falls account for a significant portion of injuries in hospitalized patients
• Nursing staff should evaluate each patient’s risk for falls and take actions to reduce the risk of falling
• Hospital needs to have policy and procedures that assess and periodically reassess each patient’s risk for falling, including the potential risk associated with the patient’s medication regimen, and take action to decrease or eliminate any identified risks
Closing Remark
Earning the national accreditation from local MSQH and international accreditation from prestigious global JCI has helped Normah Hospital to further improve all facets of its comprehensive ranges of services. Normah Medical Specialist Centre is proud to say that we adopt and strictly comply with the six International Patient Safety Goal. We believe that our patients deserve the best and safest healthcare in this region and we strive very hard to deliver that level of care to our patients. In the end, our patients can feel confident that their care is set against the highest international best practice standards and that their safety and well-being is our utmost and only priority.
Having a JCI accreditation also ensures that NMSC has an ongoing program for continuous quality improvement focusing on how to better provide safe, error-free, competent and affordable healthcare to our local and international patients. Patients can now be given greater assurance that they are receiving quality and safe care in a hospital that meets globally accepted standards.
Achieving this JCI accreditation is not only an internal milestone for Normah Hospital, but also recognition that NMSC is a centre of medical excellence.
This honour officially recognizes that the practices of doctors, nurses, medical assistants and the management team at NMSC meet or exceed the standards of medical facilities in the United States and United Kingdom.
With standard of care on par with any hospital and healthcare facility in the first world country, we would like our patients and the Kuching Community to be confident that when they seek treatment in NMSC, the treatment provided in NMSC is the same and no difference from any hospital in the United States or United Kingdom. Hopefully, this same level of care could reduce the need of our patients to go overseas to seek treatment.
Finally, providing high quality healthcare is a team effort and the end results depend very much upon a cumulative and consistent team effort from every individual and department of Normah Medical Specialist Centre.