Moving towards World Class RU Status - About us

ISSN: 1985-7217
http://www.quality.kck.usm.my
HEALTH CAMPUS, UNIVERSITI SAINS MALAYSIA
Vol.11.No.2/2010
Moving towards World Class RU Status
ISO 15189
ISO 17025
Advisor
Prof. Dato’ Mafauzy Mohamed
Coordinator
Ir Norazman Mahamood
Health Campus moved USM further towards
its goal of achieving World Class Research University status
with the accreditation of nine laboratories by Standards
Malaysia. Hospital Universiti Sains Malaysia led with the ISO
15189 Accreditation of eight laboratories by Standards
Malaysia. The initiative was headed by the Hospital Director,
Dato’ Dr. Zaidun Kamari and coordinated by AP Dr. Hasnan
Jaafar, Head of Department of Pathology. The accredited
Labs are in the disciplines of Pathology, Hematology / UPT,
Pharmacology, Human Genome, Microbiology, Therapeutic
Drug Monitoring, Chemical Pathology and Immunology. This
achievement is specially significant for the conduct of Clinical
Trials that USM actively participates in.
The Health Campus Calibration Laboratory
(Cal 25) also achieved ISO 17025 Accreditation by Standards
Malaysia. Spearheaded by Ir. Norazman Mahamood, the
laboratory provides calibration for laboratory equipment
that is critical for research at the Health Campus. Having
begun with a modest scope, the laboratory now aspires to
increase its scope to provide wider support for laboratories
on site at the Campus.
Advisor
Dato’ Dr. Zaidun Kamari
Hospital Director
Coordinator
AP Dr. Hasnan Jaafar
The awards were presented at the 2010 Health Campus Quality Convention by En.
Shaharul Sadri Alwi, Director of Accreditation Services, Standards Malaysia in the presence of Prof
Emeritus Dato’ Dr. Zawawi Ismail, Chariman of the USM Board of Directors. Also present at the function
were Datuk Hjh Jamaliah Kamis, Chairman of SIRIM Bhd and Dato’ Abd Aziz Mat, Chairman of
Accreditation, Moody International (Malaysia).
… more on pages 4-5
CONTENTS
01.9 Labs Achieve Accreditation
02.Message From The Editor
03.From The Director’s Desk
04.How we did it…ISO 15189
05. Success stories…ISO 17025
06.Health Campus Quality Convention
07.Health Campus Quality Convention
08.MPC ICC National Convention
09.Hitting It High in Hyderabad
10.Hospital Accreditation
11.5S At Health Campus
12.Prof. Asma Recognized As World Renowned Scientist
2
USM Health Campus Quality Bulletin
Advisor
Prof Dato’ Mafauzy Mohamed
Message from the Editor
Managing Editor
Dr. Mary Abraham
Editorial Board
Col (R) Dr. Wan Pauzi Wan Ibrahim
AP Phua Kia Kien
AP Dr. Shaharum Shamsuddin
Dr. Khairani Idah Mokthar@Makhtar
Wan Kamarudin Che Mohamed
Mohd Saberi Mohd Yusoff
Tetian Suriati Cynthia Abdullah
The image presented by an office sometimes does not correlate
with the message implied by the ISO 9001: 2008 Certificate
framed and displayed on the wall.
Clutter and lack of workplace organization, apart from providing
a poor image, is a recognized hindrance to productivity . The
Japanese recognized this and formulated a system named ‘5S’ to
address this. 5S has taken the world by storm including the
Malaysian Civil Service.
Graphic Designers
Mohd Tajudin Zakaria
Mohd Fahme Zainal Abidin
Based on principles of “a place for everything and everything in
its place” it seeks to reduce downtime in searching for
information in filed data., thereby increasing productivity. The 5S
acronym of Sort, Set, Shine, Standardize and Sustain promotes
tidiness, orderliness, cleanliness, standardization and discipline in
the workplace.
Quality Secretariat
Dr.Mary Abraham
AP Phua Kia Kien
Mohd Fahme Zainal Abidin
Alamiah Zakaria
Mohd Tajudin Zakaria
Siti Amirah Nasir
Health Campus introduced 5S recently and
the enthusiasm is growing with departments
and units jumping on to the bandwagon as the
School of Medical Sciences
benefits of the 5S system gradually sink in.
Col (R) Dr.Wan Pauzi Wan Ibrahim
Training has been conducted and visits made
by the consultant to participating
departments. Certification audit by Malaysia
Productivity Corporation (MPC) is expected to
take place within the next few months.
.
School of Dental Sciences
Dr. Khairani Idah Mokthar@Makhtar
“ Three Rules of Work:
Out of clutter find simplicity;
From discord find harmony;
In the middle of difficulty lies opportunity.”
- Albert Einstein
School of Health Sciences
AP Dr. Shaharum Shamsuddin
Hospital Universiti Sains Malaysia
Wan Kamarudin Che Mohamed
Health Campus
Quality Coordinators
Campus Director’s Complex
Mohd Saberi Mohd Yusoff
Dr. Mary Abraham
Quality Coordinator
Health Campus, USM
Institute for Research in Molecular Medicine
AP Phua Kia Kien
BLUE OCEAN STRATEGIES
USM Health Campus Quality Bulletin
From the Director’s Desk
The accreditation of 9 laboratories at Health Campus by
Standards Malaysia is a step forward in USM’s endeavor to
achieve World Research University status. The laboratories
are now on route to achieve recognition by ILAC
(International Laboratory Accreditation Cooperation).
The ISO 15189 Accreditation by the eight clinical laboratories
should have an impact on the conduct of clinical trials at
Health Campus such that the laboratory analysis of samples
collected can be managed on site. This should also result in
increased funding for USM. Syabas to Dato’ Dr. Zaidun
Kamari, Director HUSM, AP Dr. Hasnan Jaafar, ISO 15189
Coordinator and all staff who were committed to the cause
that led to this achievement.
Our own Calibration Laboratory (CAL 25) scored again when it achieved ISO17025
Accreditation by Standards Malaysia. This laboratory was set up for the calibration of
equipment in the campus, a critical aspect of laboratory accreditation. Having begun
services with a modest scope, the lab is now planning to expand its scope of services.
Syabas to Ir Norazman Mahamood and Rozilah Hamzah the ISO 17025 Coordinator.
These are exciting days for Health Campus, thanks to the talent and teamwork that
exemplifies the people that we are in Universiti Sains Malaysia.
Prof. Dato’ Dr. Mafauzy Mohamed
Director,
Health Campus, USM
Permanence, perseverance and persistence in spite of all obstacles,
discouragement s, and impossibilities: It is this,
that in all things distinguishes the strong soul from the weak.
Thomas Carlyle
(1795-1881) British historian and essayist
BLUE OCEAN STRATEGIES
3
4
USM Health Campus Quality Bulletin
Laboratory Accreditation
– how we did it …
ISO 15189 - by AP Dr. Hasnan Jaafar,
The champions for MS ISO 15189 were AP Fauziah Mohamad Idris, AP Rosline Hassan and AP Hasnan
Jaafar who first discussed with the Director of HUSM, Dato’ Dr Zaidun Kamari to go for recognized
accreditation for their own individual laboratories, way back in 2005. All three were qualified
assessors/auditors for Standards Malaysia and MOSTI. The Director was in favour for all interested
laboratories to apply as a group.
AP Hasnan, as the Chairman of Laboratory-Based Departments later formed a task force in January 2006
after eight laboratories agreed and committed to the cause. They were Pathology Laboratory, Hematology
Laboratory/Transfusion Medicine Unit, Medical Microbiology and Parasitology Laboratory, Chemical
Pathology Laboratory, Immunology Laboratory, Human Genome Center, Pharmacology Laboratory and
Therapeutic Drug Monitoring Laboratory. They were collectively called Medical Laboratories, HUSM.
The accreditation aimed to achieve a good Quality Management System (QMS) of International Standard
with emphasis on laboratory competency and excellent customer service. 40 laboratory staff were trained
as internal auditors by Mr. Phil Barne from New Zealand Accreditation Body (IANZ) in April 2006. After that
was a long period of gap analysis on laboratory strengths and weaknesses and awareness campaigns were
done under the task force till February 2007. Documentation of Laboratory Quality Manual and 20
laboratory core documents were completed and enforced into the QMS by 1 st November 2007. Due to
differences in nature and operation of each laboratory, AP Hasnan instructed that each laboratory create
Level 3 quality documents addressing specific needs of each individual laboratory. This they managed to
complete and implement by February 2008.
The laboratories had their first internal audit in April 2008 and pathologists from Hospital Raja Perempuan
Zainab II, Kota Baru headed by Dr Mukaramah were involved in taking part and helping the audit process.
Management Review Meeting was done on the 28 th August 2008. The application for accreditation to
Standards Malaysia was sent on Sept 2008. In February 2009, an adequacy audit team under Dr Rosidah
was sent by Standards Malaysia, followed by pre-assessment in July 2009. Compliance audit was
completed in April 2010. The team spirit and commitment by all laboratory staff especially those in the task
force were highly commendable.
On 1st November 2010, the medical laboratories of HUSM were awarded the prestigious MS ISO 15189
Accreditation by Standards Malaysia. Congratulations to all those involved and to HUSM .
Training
Documentation
AP. Hasnan Jaafar
Audits
The road to excellence …
USM Health Campus Quality Bulletin
Laboratory Accreditation
– success stories …
MS ISO/IEC 17025 - by Rozilah Hamzah , Quality & Technical Manager
The Calibration Laboratory CAL25 USM received the MS ISO/IEC 17025:2005 – “Calibration
Laboratory” Particular Requirements for Quality and Competence” accreditation certificate from the
Department of Standards Malaysia (STANDARDS MALAYSIA) on 08 October 2010. With this award, the
laboratory is now of equal standing internationally and is recognized to be competent in the equipment
calibration activities. We are honoured by this recognition to be awarded the MS ISO/IEC 17025:2005
accreditation under the Laboratory Accreditation Scheme of Malaysia (SAMM). During the accreditation
process, the laboratory had successfully demonstrated its technical competency in equipment calibration
and operation of a laboratory quality management system.
This laboratory is headed by the Head of Laboratory, Norazman Mahamood. We have engineers,
assistant engineers and technicians in the mechatronics field with strong support by scientific officers and
our academic staff that enabled CAL25 to be awarded the MS ISO/IEC 17025:2005 accreditation. I was
appointed the Quality and Technical Manager, fully responsible for the operation of the laboratory
according to the MS ISO/IEC 17025 standard including the verification and validation process for reporting
on the calibration once a signatory is certified for the certificate of calibration.
The objective of CAL25 establishment is to be the centre of excellence for equipment calibration
and measurement to support the Research Intensive University. CAL25 is committed to provide services in
calibration activities to meet the expectation and requirement of its customers. The results obtained from
instruments for research activities are verified, validated and accepted worldwide. With the accredited
services, all measurements are performed using processes that have been assessed by the external
auditing body, and that audit process will have also ratified the measurement uncertainties displayed on
the calibration certificate. This gives the highest degree of confidence to USM customers, as the
measurements are trustworthy.
Now, MS ISO/IEC 17025 is going through phase 2 for laboratory testing in Health Campus, Main
Campus and Engineering Campus laboratories. As a Technical Advisor in this MS ISO/IEC 17025 phase 2 my
main role is to advise the documentation and accreditation process to realize USM’s objective of being
awarded the MS ISO/IEC 17025:2005 accreditation for Testing Laboratories. With commitment and
cooperation of all Quality Members, our aspirations and dreams will become a reality.
“Precision for Excellence”
Documentation
Hands on training
on weighing devices
Rozilah Hamzah
Quality & Technical Manager
Audits by Standards Malaysia
5
- by Mohd Fahme Zainal Abidin
USM Health Campus made history at the 2010 Quality Convention on 29
th November
2010. Held at the ‘ Dewan Utama’, the convention was the
culmination of an annual agenda for Quality activities at Health Campus. This year the focus of the Convention was the celebration of the
Accreditation of nine laboratories at the Campus. Eight HUSM laboratories received the MS ISO 15189 Accreditation Award from Standards Malaysia.
The Campus Calibration Laboratory was awarded the MS ISO /IEC 17025 Accreditation. The awards were presented by En. Shaharul Sadri Alwi, Director
of Accreditation, Standards Malaysia. Meanwhile, PPSP, HUSM, PTJPK and PPSG also received the ISO 9001:2008 Recertification Certificates from Datuk
Hjh Jamaliah Kamis, Chairman, SIRIM Bhd. and Dato’ Abdul Aziz Mat, Head of Accreditation, Moody International (Malaysia). Other events included
the Keynote Address by Prof Emeritus Dato’ Dr. Zawawi Ismail, Chairman of the USM Board of Directors, who was also the guest of honour, a briefing
on Quality Activities at Health Campus was done by the Campus Quality Coordinator , Awards presentation for winners of the Annual Quality
Facility/Service Competition and an Exhibition of Quality Activities of the various institutions. High performers among ICC Groups were also honored.
ISO 9001:2008 Recertification
INSTITUTION
CERTIFICATION BODY
School of Dental Sciences (PPSG)
Moody International
School of Health Sciences (PPSP)
SIRIM QAS International
Campus Director’s Complex (PTJPK)
Hospital Universiti Sains Malaysia (HUSM)
SIRIM QAS International
SIRIM QAS International
INSTITUTION
CERTIFICATION BODY
ISO 15189: 2007 Accreditation
Hospital Universiti Sains Malaysia (HUSM)
Standards Malaysia
ISO 17025: 2005 Accreditation
Calibration Laboratory (PTJPK)
Standards Malaysia
Category
WINNER
Awards for International ICC
Achievers
QCR
INSTITUTION
Student Hostel
Desasiswa Murni 1
Office
Administrative & Support Services Division
‘Perpustakaan Hamdan Tahir’
PTJPK
Clinic
Pediatric Clinic
HUSM
Multimedia
BRAINNetwork CNS
PPSK
Diagnostic and analytical laboratory
Medical Microbiology & Parasitology Laboratory
PPSP
Computer laboratory
Digital Laboratory
PPSG
Research and innovation laboratory
Craniofacial Science Laboratory (CSL)
PPSG
Counter service
Student Affairs & Development ( BHEP)
PTJPK
Food premise
Chaly Café ‘Rumah Tetamu’
Ward
4 U ( Utara)
HUSM
Sustainable use of resources
Human Genome Center
PPSP
PTJPK
PERMATA
V-TIME
Recognition for National ICC
Achievers
SIGMA
G-SMART
WINNERS
Two ICC Groups from Health Campus, QCR (HUSM) and PERMATA (PPSG)
received Excellence Awards for Innovative and Creative Circles by virtue of
their excellent performance, winning GOLD for Malaysia at the International
Convention on Quality Circle Concept (ICQCC) 2010 in Hyderabad, India.
ICC Group, V-Time that was awarded SILVER at the same convention was
also appreciated. Each group received a plaque, certificate and financial
incentives.
Six ICC groups brought honor to USM
when all six were awarded GOLD 3
STARS at the 2010 National MPC
National ICC Convention. Their
achievements were recognized
at the Convention with plaques,
certificates and
financial incentives.
LESTARI
REHAB CHARGER
HUSM:University Hospital
PPSP: School of Medical Sciences
PPSG: School of Dental Sciences
PPSK: School of Health Sciences
PTJPK: Campus Director’s Complex
TAWAM
USMET
USM Health Campus Quality Bulletin
8
Human Capital Development through Innovative & Creative Circles (ICC)
Seven ICC Groups from Health Campus considered to be among Malaysia’s best were invited by MPC to participate in the 2010 MPC
National ICC Convention that was held from 7th -9th October 2010 in Genting Highlands, Pahang . They did extremely well and six of the
seven groups were awarded Gold 3 Stars and one group was awarded Gold 2 Stars. ICC Group Rehab Charger from HUSM was also placed
among the Top 10 groups from the public sector Rehab Charger will thus be representing Malaysia at the 2011 International
Convention on Quality Circle Concept (ICQCC) in Yokohama, Japan, scheduled for September 2011.
ICC Group
PTJ
Category
Result
1
REHAB CHARGER
HUSM
Technical
2
USMET
HUSM
Management
Gold 3Stars & Top
10
Gold 3Stars
3
SIGMA
HUSM
Management
Gold 3Stars
4
G-SMART
PPSG
Technical
Gold 3Stars
5
TAWAM
HUSM
Technical
Gold 3Stars
6
LESTARI
PPSK
Technical
Gold 3Stars
7
U-BALANCE
PPSK
Management
Gold 2Stars
Top Ten
REHAB CHARGER
G-SMART
TAWAM
National ICC Convention
- by Mohd Fahme Zainal Abidin
HUSM:University Hospital
PPSG: School of Dental Sciences
PPSK: School of Health Sciences
USMET
U-BALANCE
SIGMA
LESTARI
USM Health Campus Quality Bulletin
9
Human Capital Development through Innovative & Creative Circles (ICC)
- by Mohd Tajudin Zakaria
QCR
USM kept the Malaysian Flag flying at the International Quality Concept
Circles Convention (ICQCC) that was held in Hyderabad, India from 12th15th Oktober 2010. Three Innovative and Creative Circles (ICC) groups
from Health Campus, USM did Malaysia proud by their sterling
performance at the event. Group QCR from Hospital Universiti Sains
Malaysia and PERMATA from the School of Dental Sciences were
awarded Gold while the group V-TIME from the School of Health
Sciences brought home a Silver.
Being part of the USM’s human capital development program, the
members of the teams also had the opportunity to visit various historical
spots in Hyderabad, including the ‘Salar Jung Musuem’, ‘Shilparaman
(The Arts & Crafts Village)’ and Charminar. This trip abroad was the first
international outing for many of the members and allowed them to open
their minds to the wealth of culture and traditions in the world around us..
Our gratitude to Top Management for their Support throughout this
venture
PERMATA
V-TIME
10
USM Health Campus Quality Bulletin
Hospital Accreditation
HUSM MAKES ITS MOVE
The accreditation of hospitals has been accepted as an effective mechanism for the enhancement of patient
safety. Instituted in Malaysia more than a decade ago, Hospital Accreditation has become mandatory for
those hospitals pursuing Health Tourism . It has also become an effective instrument in risk management..
The compliance to protocols and evidence based clinical practice also provide effective defense mechanisms
in the event of litigation.
The body awarding Accreditation is the Malaysian Society for Quality in Health (MSQH). The Accreditation
process involves self assessment against set standards developed by peers in healthcare. This is followed by
third party review conducted by MSQH. The MSQH standards were developed collaboratively by clinical
experts from the Ministry of Health, Universities, The Association of Private Hospitals, The Academy of
Medicine, Professional organizations and the Malaysian Medical Association.
HUSM began its move towards Hospital Accreditation by inviting MSQH to provide training in Accreditation
Standards in December 2010. Top management and senior staff attended the session that was conducted by
Assoc. Prof. Dr. Kadar Maricar, CEO of MSQH along with senior MSQH executives. Following this, MSQH
invited Dr. Nik Min Ahmad, Deputy Director HUSM to participate in the Accreditation Survey of a major
hospital in the Klang Valley as a non-surveyor observer to get a first hand experience of the survey process.
HUSM has also set up its steering committee and has begun massive awareness sessions for its more than
2500 staff members.
Unlike hospitals in the Ministry of Health and the Private Sector, University Hospitals are unique with respect
to Governance. This is in relation to the role played by the Schools of Medical Sciences, Dental Sciences and
Health Sciences in the use of the hospital facilities during the teaching and learning process. Being aware of
this challenge, Prof. Dato’ Mafauzy Mohamed, Director of the Health Campus has set up a Campus level
Committee for the Accreditation of HUSM. This committee includes the Top Management of all institutions on
campus that utilize Hospital facilities. This should better facilitate the coordination of activities related to the
Accreditation Process of the Hospital.
Here’s wishing HUSM all the very best in its endeavor to ensure patient safety and achieve continuous quality
improvement in patient care.
PPSK : School of Health Sciences
PPSP : School of Medical Sciences
PPSG : School of Dental Sciences
HUSM : University Hospital
Campus
Director
HUSM
Director
Dean
PPSK
Clinical
Accreditation
Coordinator
PPSK
Dean
PPSP
Clinical
Accreditation
Coordinator
PPSP
Dean
PPSG
Accreditation
Coordinator
HUSM
Clinical
Accreditation
Coordinator
PPSG
Campus
Director’s
Complex
Accreditation
Coordinator
of
Respective
Department
Health Campus Organization Structure for the Accreditation of HUSM
Health
Campus
Quality
Coordinator
USM Health Campus Quality Bulletin
11
- by Siti Amirah Nasir
SEIRI
SORT
SEITON
5S is a workplace organization methodology that
uses the Japanese concept of seiri, seiton, seiso,
seiketsu and shitsuke. as a structured program to
systematically achieve organization, cleanliness,
and standardization in the workplace to facilitate
and improve productivity.
USM Health Campus has
embarked on the
implementation of 5S on a
voluntary basis. 21 units /
departments from all
institutions on campus have
shown interest. Awareness
sessions were conducted
followed by site visits from 4th –
8th July 2010. At the end of this
program, the participants
learned the concept and
application of the 5S system.
An Internal Audit Training session was
held from 9th – 10th August 2010 and
was enthusiastically received by 80
participants. The course provided
guidance on the evaluation of 5S
Practices and actions to be taken using
the internal audit report. Participating
units are currently involved in bridging
the Gap. Audit and certification will be
provided by MPC on request.
SET IN ORDER
SEISO
SHINE
Site Visits
SEIKETSU
STANDARDIZE
SHITSUKE
Internal Audit Training Session
SUSTAIN
Errata
Vol 10 page 10:
- Participating labs should read
- No.3 : Genome
- No.7 : Hematology/TDM
and not as reported. The error is regretted.
Prof. Asma Haji Ismail, Deputy Vice-Chancellor (Research and Innovation) is one of
the 58 new Fellows in the field of Medicine and Health Sciences who has been
appointed to join the ranks of 1000 distinguished scientists in the Academy of
Sciences for the Developing World during its October 2010 General Meeting in
Hyderabad, India.
TWAS is an international organisation founded in 1983 in Tieste, Italy by a group of
distinguished scientists, under the leadership of the late Nobel Laureate, Abdus Salam
of Pakistan. It was launched by the United Nations Secretary- General in 1985.
TWAS which has close ties with UNESCO represents distinguished scientists from
developing countries. Its principal aim is to promote scientific capacity and excellence
for sustainable development in the South countries. It also has close links with
academicians, research councils and the Ministry of Science and Technology from
various countries.
Prof. Asma Haji Ismail, 52, has a very keen interest in developing local technology and
innovation to generate national wealth and simultaneously improve the quality of life of
the people. Prof. Asma has received numerous prestigious awards including the
National Young Scientists Award in 1991, the Malaysian Toray Science and
Technology Award for her contributions to the field of science in 2002, the National
Innovation Award, 2006 and the National Academic Award for Product and
Commercialisation in 2007. She was also a Fellow of the Malaysian Science Academy
and since 2007 has served as its council member. She also sits on the “Board of
Trustees Women Scientist of the Muslim World’.
Prof. Asma was appointed USM Deputy Vice-Chancellor (Research and Innovation) in
May 2008 after having held the post of Director and Founder of the Institute for
Research in Molecular Medicine (INFORMM), USM since 2003.
Source : http://www.usm.my/index.php/en/about-usm/news