Muat Turun - Portal Rasmi Kementerian Kesihatan Malaysia

Transcription

Contributor(s)
Dr Azman Abu Bakar
Institute for Health Systems Research
Samsiah Awang
Datin Dr Siti Haniza Mahmud
Dr Nur Ezdiani Mohamed
Dr Roslinah Ali
Anis Syakira Jailani
Our appreciation to Ms Siti Aisah Mohd Sharif and
Ms Norsuhemaria Md Isa for their tireless efforts in
working with the abstracts.
Copyright
ISBN: 978-967-5398-27-8
First Edition 2011
ISBN 978 - 967 - 5398 - 27 - 8
Any comments, suggestion and
feedback please address to:
Mail
:
Address
The National QA Secretariat
Jalan Rumah Sakit Bangsar
59000 Kuala Lumpur
Telephone:
Fax
:
Web site :
E-mail
:
03 - 2297 1555
03 - 2297 1513
www.ihsr.gov.my
[email protected]
Contents
FOREWORD
iv
PREFACE
vi
CHAPTER 1 : SHARE SENSELESSLY, STEAL SHAMELESSLY
1
1.0PLEASE! DO NOT RE-INVENT THE WHEEL
1
2.0REFLECTION ON THE STRATEGY FOR CHANGE
1
3.0HOW CAN THIS COMPENDIUM HELP YOU IN REPLICATING THE PROJECT?
4
4.0LIMITATION
4
5.0CONCLUSION
4
CHAPTER 2 :LIST OF QA PROJECTS PRESENTED AT THE NATIONAL QA CONVENTION (2003-2011)
CHAPTER 3 :
5
DENTAL RELATED PROJECTS
21
CHAPTER 4 :FOOD QUALITY & SAFETY RELATED PROJECTS
41
CHAPTER 5 :LABORATORY SERVICES RELATED PROJECTS 49
CHAPTER 6 :NURSING RELATED PROJECTS
59
CHAPTER 7 :PATIENT CARE RELATED PROJECTS
65
CHAPTER 8 :PHARMACY RELATED PROJECTS 147
CHAPTER 9 :PUBLIC HEALTH RELATED PROJECTS 173
CHAPTER 10:TRAINING RELATED PROJECTS 219
CHAPTER 11:COLLABORATIVE PROJECTS
225
CHAPTER 12:OTHERS 229
Foreword
Deputy Director-General of Health (Research and Technical Support)
Ministry of Health Malaysia
Introducing and implementing the Quality Assurance Programme in the Ministry of
Heath is an important step forward in our quest for quality. Along the way, many quality
improvement activities have been carried out. Since 2001, the passion for conducting
Quality Assurance Projects gets rewarded biennially through sharing at the National Quality
Assurance Conventions.
Thus far, there have been considerable achievements in our Quality Assurance Programme.
We must continue to nurture and sustain the enthusiasm, commitment and innovative
actions of our healthcare providers in this initiative. Much still has to be done for Quality
Assurance Programme.
This Compendium reflects how the Quality Assurance Programme has brought about
improved practices in hospitals, institutions and health clinics. Through this Compendium
we hope to share and leverage the knowledge of best practices needed for an organisation
to succeed. I congratulate the authors for their hard work in carrying out the Quality
Assurance projects and documenting their works. I hold firm that we need to “do quality
from our heart”.
DATO’ DR MAIMUNAH A. HAMID
Deputy Director-General of Health
(Research and Technical Support)
Ministry of Health Malaysia
2011
Preface
The National Quality Assurance (QA) Secretariat is responsible for the coordination of all QA related
activities within the Ministry of Health (MOH) at the national level. This includes the compilation of
QA projects undertaken. Since 2003, the Secretariat has diligently collected all QA projects presented
by the Health Programmes and State Health Departments during the National QA Conventions. It
was during this process of compilation that a common trend had been identified- projects presented
either as oral or poster presentations revolved around common themes. Although this did not
actually come as a surprise, nevertheless, it became apparent to the Secretariat for the need to share
the strategies and best practices that had been introduced and successfully implemented in solving
similar quality issues but in their local context.
The production of “Compendium of QA projects” by the National QA Secretariat has two main
goals. Firstly, it is a collective effort towards advancing Knowledge Management and enhancing the
Innovation Culture within the MOH. Secondly, following the successful development of the four QA
Training Modules and the QA Workbook, this compilation is another contribution towards increasing
the armamentarium that a healthcare practitioner will have at his or her disposal in their strive to
solve quality problems.
It is the hope of the Secretariat that this painstaking effort will bear fruit. By sharing best (and
innovative) practices, resources such as manpower, money, material and even time can be optimised.
More importantly, it will be a step forward towards improving knowledge and skills in enhancing the
quality of health care.
The Team
Chapter 1
Share Senselessly, Steal Shamelessly
chapter 1
2
Sharing Best Practices
Compendium of Quality Assurance Projects presented at the National QA Convention 2003–2011
Share Senselessly, Steal Shamelessly
Azman AB, Samsiah A, Siti Haniza M.
• “Focus 90% of your time on solutions and only 10% of your time on problems.” (Anthony J. D’Angelo)
• “The reinvention of daily life means marching off the edge of our maps.” (Bob Black)
• “Don’t try to reinvent the wheel. Take what’s already there, and remix it.” (Unknown)
1.0 PLEASE! DO NOT RE-INVENT THE WHEEL
Everything in today’s healthcare world is pointing towards increased costs and lower quality in healthcare. The cost
of healthcare is a reflection of a number of phenomena which include increased in infrastructure and medication
costs. Sadly however all things remaining equal, the increased cost for healthcare has not resulted in better quality
care but the reverse.
There have been many attempts to improve quality in healthcare and many more will be made over the coming
years. Much have been written about quality, organisational development, motivation, teamwork and financing
with a Pollyanna perspective that with enough caring and hard work the quality of healthcare can improve. We
are of the opinion that there is some truth in this. There are success stories of the approaches and innovations that
have been undertaken and many of these are not even “rocket-science!” We do not need to look any further than
our own Malaysian shores for these examples.
This compendium does not claim to be comprehensive nor perfect. It is intended to provide a simple but useful
database of QA projects presented during the National QA Conventions beginning 2003 till 2011. It is the wish of
the authors that readers will find this useful and “share senselessly, and steal shamelessly” with others. As Anthony
J.D. Angelo once said, “Don’t reinvent the wheel, just realign it”, thus, we hope readers will be able to replicate
some if not all of the solutions by adopting and adapting these best practices in the strive for better quality care.
2.0 REFLECTION ON THE STRATEGY FOR CHANGE
In our context, strategy for change means what actual changes were made, how these changes were implemented
and who was or were involved in the change process. Browsing through all projects listed, the strategies
implemented are not “rocket science”. They are simple, cheap and easy to implement or replicate. Some have
already been practiced albeit may need modification and improvisation. The main lesson learnt is that no single
means lead to success; multiple approaches are required. Teamwork from all levels in the organisation is vital. The
benefits of teamwork should be merged with the creativity of the individual to generate workable ideas, ensuring
support and involvement of all levels in the process.
Generally, the implemented strategies can be grouped into:
• Reengineering of work process
• Improving communication skill
• Improving training to staff
• Improving and strengthening patient education
• Strengthening monitoring and evaluation process
• Improving tools used (forms, checklist)
• Improving time management
• Improving guidelines/protocol
• Changing attitude and practice
• Optimising existing resources
3
• Administrative arrangement
• Introducing of a new system
These are in line with the recommendations from the Institute for Health Care Improvement in the United States
of America which include nine groupings of general concept in change for improvement.
i. Eliminate Waste: Look for ways of eliminating any activity or resource in the organisation that does not add
value to an external customer.
ii. Improve Work Flow: Improving the flow of work in processes is an important way to improve the quality of
the goods and services produced by those processes.
iii. Optimise Inventory: Inventory of all types is a possible source of waste in organisations; understanding where
inventory is stored in a system is the first step in finding opportunities for improvement.
iv. Change the Work Environment: Changing the work environment itself can be a high-leverage opportunity
for making all other process changes more effective.
v. Producer/Customer Interface: To benefit from improvements in quality of products and services, the customer
must recognise and appreciate the improvements.
vi. Manage Time: An organisation can gain a competitive advantage by reducing the time to develop new
products, waiting times for services, lead times for orders and deliveries, and cycle times for all functions in the
organisation.
vii.Focus on Variation: Reducing variation improves the predictability of outcomes and helps reduce the frequency
of poor results.
viii.Error Proofing: Organisations can reduce errors by redesigning the system to make it less likely for people in
the system to make errors. One way to error proof a system is to make the information necessary to perform
a task available in the external world, and not just in one’s memory, by writing it down or by actually making it
inherent in the product or process.
ix. Focus on the Product or Service: Although many organisations focus on ways to improve processes, it is also
important to address improvement of products and services.
Congratulation to all individuals for their determined effort in making the project a success. They are the hero in
their own organisations. They have been able to overcome the obstacles in their effort to improve the service to
their customer. They are inspired by dissatisfaction with the status quo and managed to go through the process
and complete the QA cycle. We believe that they have gone through an experimental learning process in trying
new approaches, exploring new methods and testing new ideas for improving the various processes.
However, the issue of sustainability still exists. Many have said they do quality projects because they want to
improve the service, they want to serve the “rakyat” better, they want to reduce cost, they want to ensure patient
safety, etc. How sure are we that the effort that we have put through is sustainable? Or are we only doing QA
projects for the sake of the QA Convention?! Bear in mind that while the convention is a bonus or reward to the
group, the effort must continue. In ensuring this, monitoring and evaluation play very crucial roles. The projects
should be monitored closely and the standard should be improved optimally. We need to reach the level of
maturity where the indicators are successfully internalised and be part of our work culture.
chapter 1
chapter 1
4
3.0 HOW CAN THIS COMPENDIUM HELP YOU IN REPLICATING THE PROJECT?
3.1
This compendium of 198 projects is arranged according to the following headings to provide the
readers with a quick reference to their topic of interest.
3.2
Readers will be able to find all the titles of projects according to topics in the content table. The
presenters, their office addresses, category and year presented are also listed. In the last column
readers will find the page number where the abstract of the project is placed.
3.3
Should you have any enquiries about the project, please do not hesitate to contact
the presenter. (We must apologise that the presenters might have been transferred to another organisation,
their office addresses printed was based on the programme book in the year the project was presented). If you encounter
any problem in contacting the presenter, you may direct your enquiries to the National QA Secretariat.
The National QA Secretariat also has the slide presentation for the oral presentation category.
3.4
If the project is suitable for replication in your own organisation, why wait? Readers may want
to adopt and adapt the strategies that had been successfully implemented in other organisations
with some modification or improvement. There is a possibility that readers may find more than one
project for the same topic but with different strategies for change. In such cases, readers will have to
choose the most appropriate strategy(s) for their own organisation.
3.5
What’s next? Feel free to give us feedback about the projects that had been replicated. Just e-mail us
using the above mentioned e-mail address. Your cooperation is highly appreciated.
i. Dental Related Projects
ii. Food Quality & Safety Related Projects
iii. Laboratory Services Related Projects
iv. Nursing Related Projects
v. Patient Care Related Projects
vi. Pharmacy Related Projects vii.Public Health Related Projects
viii.Training Related Projects
ix. Collaborative Projects
x. Others
4.0 LIMITATION
This is only a compendium of projects presented at the previous National QA Convention. We believe many more
projects had been carried out and/or presented at the states or institutional level. We encourage the owners of
such projects to share senselessly and at the same time others to steal shamelessly those projects which are suitable
to be replicated; SHARING ….this is what quality is all about.
5.0 CONCLUSION
This compendium is just a small step in the quality journey. The authors urge each state to produce its own
compendium of QA project for the purpose of knowledge sharing.
Chapter 2
List of QA Projects Presented at the National QA Convention
(2003-2011)
chapter 2
6
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
Chapter 3
DENTAL RELATED PROJECTS
1. Meningkatkan Kehadiran Ibu Mengandung ke
Klinik Pergigian
Dr. Nor Sarah Alias
Klinik Pergigian Klebang, Melaka
OP
2011
24
2. Mengurangkan Peratus X-Ray Berulang yang
Tinggi di Klinik Pergigian
Dr. Morni Ab Rani
Pej Kesihatan Pergigian Daerah Hulu Selangor,
Klinik Pergigian Kerajaan, Jln Pdg Tembak,
Kuala K.Bharu, Selangor
PP
2011
25
3.
Increasing Retention Rate of Fissure Sealant among
Primary Schoolchildren
Dr. Hajar Hidayah Rossdan
Pej. Kesihatan Pergigian Bangsar,
Jalan Bangsar, Kuala Lumpur
PP
2011
26
4. Mengurangkan Peratus Kejadian Karies di
kalangan Murid Bebas Karies di Sekolah
Kebangsaan di Kedah
Dr. Norhayati Ahmad
Bahagian Kesihatan Pergigian,
Jabatan Kesihatan Negeri Kedah,
Alor Star, Kedah
PP
2009
27
5.
Improving the Rate of Post-Operative Review
Compliance of Children Treated Under General
Anaesthesia for Early Childhood Caries
Dr. Laila Abd. Jalil
Paediatric Dental Department,
Hospital Tuanku Jaafar,
Seremban, Negeri Sembilan
PP
2009
28
6. Towards Achieving Acceptable Percentage of
Patients Issued Complete Denture within 5 Weeks of
Start of Treatment
Dr. Jacob John
Oral Health Services,
Kelantan State Health Department,
Kota Bharu, Kelantan
PP
2009
29
7.
Improving the Percentage of Attendance of Primary
Schoolchildren Referred by Dental Nurses to Dental
Clinic
Dr Gnanavathy Kanapathipillai
Dato’ Keramat Dental Clinic,
Kuala Lumpur
OP
2009
30
8
Improving Antibiotic Prescription in Dental Clinic
Dr. Arlene Khaw Bee Hong
Dental Service Office Larut Matang & Selama,
Perak
PP
2009
31
9.
Meningkatkan Tahap Kebersihan Mulut Murid
Sekolah Rendah
Pn. Wan Manirah Wan Abd. Rahman
Klinik Pergigian Daerah Hulu Terengganu,
Terengganu
OP
2007
32
10. Improving the Retention of Fillings Done on
Permanent Posterior Teeth
Dr. Mazlina Mat Desa
Bhg. Kesihatan Pergigian,
KKM
PP
2007
33
11. Effect of Cessation of Water Fluoridation in Kelantan
and Terengganu on Caries Experiences of
12-year-olds
Dr. Norlida Abdullah
KKM
OP
2005
34
12.
Reducing the Rate of Rejected Dental Radiographs
in the Johor State Oral Health Service
Dr. Loh Kim Hong
KKM
PP
2005
35
*PP – Poster Presentation / OP – Oral Presentation
No.
Project Title
Presenter / Office
Category/
Year
Presented
7
Page
13.
Improving Oral Hygiene Status of Primary School
Children in the District of Kuala Selangor
Dr. Hasenah Mod Zaki
Klinik Pergigian Besar,
Selangor
OP
2003
36
14.
Peratusan Tampalan Semula Gigi Kekal Anterior
Melebihi Paras Standard di Daerah Rompin
Dr. Haryati Mohammed
Klinik Pergigian Rompin,
Pahang
PP
2003
37
15
The Rate of Permanent Tooth Loss (M+X/100)
among 12-year-old and 16-year-old School
Children in Kota Tinggi Distric, Johor- A 5-Year
Quality Assurance Study
Dr. Muz’ini Mohamad
Klinik Pergigian Mersing,
Johor
PP
2003
38
16.
To Improve the Coverage of Toddlers Attending
Toddlers, Programme in Sibu District
Dr. Chu Geok Theng
Pejabat Pergigian Bahagian,
Sibu, Sarawak
PP
2003
39
17.
Reducing Shortfall in Quality of Dental Radiographs
Taken at Klinik Pergigian Melaka Tengah
Dr. Lee Keng Chin
Klinik Pergigian Melaka
Tengah, Melaka
OP
2003
40
Chapter 4
FOOD QUALITY & SAFETY RELATED PROJECTS
18.
The Practices of Nil by Mouth for Procedures in
Intensive Care Unit and High Dependency Ward
Pn. L. Mageswary Lapchmanan
Dietetics and Food Services,
Hospital Kuala Lumpur
PP
2009
42
19. Patient Food Safety Goals : From the Farm to the
Patient’s Table
En. Ramli Jasam
Dietetics and Food Services,
Institut Jantung Negara,
Kuala Lumpur
PP
2009
43
20. Enhancing Understanding among Importers,
Retailers and Manufacturers Food Items on the
Food Labeling Requirement as Stipulated in 1985
Malaysian Food Act
Pn. Sunmuglvadivu Laili a/p Elumalai
Jabatan Kesihatan Negeri
Wilayah Persekutuan Labuan
PP
2007
44
21.
Keracunan Makanan Sifar di Pusat Latihan dan
Institusi Pengajian Tinggi. Bolehkah Ia Tercapai?
Dr. Junaidah Sabirin
Pejabat Kesihatan Daerah Sepang,
Selangor
PP
2005
45
22. Improving Food Processing Management
En. Ramli Jassam
Gleneagles Intan Medical Centre,
Kuala Lumpur
OP
2005
46
23.
Peningkatan Kes Kurang Zat Makanan
(KZM) di kalangan Kanak-kanak Berumur bawah
5 tahun di Daerah Seberang Perai Selatan
Puan Umi Kalsom Abd.Rahman
Pejabat Kesihatan Seberang Perai Selatan,
Pulau Pinang
PP
2003
47
24.
Food Safety Information of Malaysia (FoSIM)
Puan Noraini Sufian
Bahagian Kawalan Mutu Makanan
PP
2003
48
chapter 2
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8
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
Chapter 5
LABORATORY SERVICES RELATED PROJECTS
25.
Reducing Rejection Rate of Blood Film Malaria
Parasite Sample due to Unsatisfactory Smear from
Emergency and Trauma Department
En. T Chong Fook Lim
Jab Patologi Hosp Umum Sarawak, Jalan Hospital,
Kuching, Sarawak
PP
2011
50
26. Improving Turn-Around-Time Of Culture &
Sensitivity Testing
En. Wong Ming Kui
Unit Makmal & Tabung Darah,
Hosp Labuan, Peti Surat 81006, Labuan
PP
2011
51
27.
Increasing the Rate of Positive Microorganism
Isolates from Blood Cultures of Patients Suspected
to Have Bacteraemia in Medical Wards in a
Government Hospital
Dr.Muhammad Zakuan Abdul Jalil
Hospital Sri Manjung, Perak
PP
2009
52
28. Reducing Pre-Analytical Variables Affecting
Therapeutic Drug Monitoring (TDM) Requests in
Drug & Research Laboratory, Hospital Kuala Lumpur
Cik Sivasangkari Supremaniam
PP
2007
53
29. To Reduce High Incidence Rate of Rejected Full
Blood Count Specimens from Medical Ward in
Haematology Unit, Sarawak General Hospital,
Kuching
Puan Aishah Ahmad Narihan
Hospital Umum Sarawak,
Kuching, Sarawak
PP
2005
54
30. Pengurusan Inventori Darah: Merendahkan Kadar
Darah yang Lupus
Dr. Hakimah Mahsin
Unit Transfusi, Jabatan Patologi
Hospital Kangar, Perlis
PP
2003
55
31. High Specimen Rejection Rate in the Pathology
Department of Sungai Petani Hospital
Ms. Kala Devi Nadarajan
Hospital Sungai Petani, Kedah
PP
2003
56
32. Overcoming the Problems of Unnecessary Repeated
Blood Specimens
Puan Tai Kon Chu
Hospital Tawau, Sabah
OP
2003
57
PP 2011
60
Chapter 6
NURSING RELATED PROJECTS
33.
Meningkatkan Aktiviti Penyusuan di kalangan
Jururawat di Tempat Kerja
Pn. Ruzita Mohd Yasin
Unit Kejururawatan, HUSM,
Kubang Kerian, Kelantan
34.
THIS! Does It Improve Nursing Care
Puan Leong Foong Khuan
Hospital Putrajaya, WP Kuala Lumpur
OP
2005
61
35.
Towards Reducing the Incidence of Inaccurate
Intravenous Infusion
Puan Zaida Yahya
Hospital Tengku Ampuan Afzan,
Kuantan, Pahang
OP
2003
62
No.
36.
Project Title
Presenter / Office
Incidence of Thrombophlebitis among Patients
Receiving Intravenous Therapy – Hospital Miri
Experience
Puan Agnes Sitto Naming
Hospital Miri, Sarawak
Category/
Year
Presented
9
Page
OP
2003
63
Chapter 7
PATIENT CARE RELATED PROJECTS
ACCIDENT & EMERGENCY
37.
Masa Menunggu Lama bagi Kes Bukan Kritikal di
Jabatan Kecemasan
Pn. Umi Melan
Jabatan Kecemasan,
Hospital Pontian, Johor
OP
2009
66
38.
Reducing the Incidence of Deterioration of Acute
Trauma Cases During Interhospital Transfer from
Hospital Sg.Bakap
Dr. Teo Gim Sian
Hospital Sungai Bakap,
Pulau Pinang
OP
2007
67
39.
Improving the Rate of Dry Ambulance Run in
Ambulance Service of Emergency Department,
Sarawak General Hospital Kuching
En. Alexander Ak Tatag
Emergency Department,
General Hospital Sarawak
OP
2007
68
40. High Rate of Repeated Visits to A&E Unit by Acute
Asthmatics
Dr. Rozita Ismail
Hospital Dungun, Terengganu
OP
2005
69
41. Mengurangkan Kegagalan Pengesanan Kad
Rawatan Medikolegal bagi Pesakit-pesakit yang
Mendapat Rawatan di Jabatan Kecemasan
Hospital Segamat kepada 0%
Dr. Dul Hadi Mat Junid
Hospital Segamat, Johor
OP
2003
70
ANAESTHETICS & INTENSIVE CARE
42.
Reducing the Incidence of Ventilator Associated
Pneumonia among ICU Patients
Pn. Dominica Rose a/p J.S. Daniel
Jabatan Anaestesiologi dan Rawatan Rapi
Hospital Taiping, Taiping, Perak
OP
2011
71
43.
Reducing the High Number of Unnecessary Intensive
Care Unit Bed Booking for Elective
Dr. Soon Chien Chang
Anaesthesia and Intensive
Department Hospital Melaka
PP
2009
72
44. Mengurangkan Kadar Ventilator Associated
Pneumonia di Unit Rawatan Rapi
Cik Noraisyah Tahir
Unit Rawatan Rapi,
Hospital Pakar Sultanah Fatimah,
Muar, Johor
PP
2009
73
45.
Improving Percentage of Early Goal Directed Therapy
Implementation in Severe Sepsis Patients upon
Admission to General Intensive Care Unit
Dr. Marini Othman
General Intensive Care Unit
Hospital Raja Perempuan Zainab,
Kota Bharu, Kelantan.
OP
2009
74
46.
Reducing Ventilator Associated Pneumonia in
General Adult Intensive Care Unit, Hospital Alor Star
Dr. Ahmad Shaltut Othman
Hospital Alor Star, Kedah
OP
2007
75
47. Towards Achieving a 0% Cancellation of Elective
Cases in the Operating Theatre
Dr. Salimi Mohd Salleh
Anesthesia and Intensive Care Department,
Hospital Seremban, Negeri Sembilan
OP
2005
76
chapter 2
chapter 2
10
No.
48. Sharing Best Practices
Project Title
Improving Time in-between Elective Cases, Main
Operating Theatre, Hospital Melaka
Presenter / Office
Dr. Ho Wing Nan
Anesthesiology Department,
Hospital Melaka
Category/
Year
Presented
Page
PP
2005
77
DERMATOLOGY
49.
Reducing Wound Infection Rate for Diagnostic Skin
Biopsy in Dermatology Clinic
Dr Tang Jyh Jong
Hospital Tuanku Bainun,
Ipoh, Perak
OP
2009
78
50.
Reducing Non-Attendance at Dermatology Clinic,
Ipoh Hospital
Dr. Chan Lee Chin
Dermatology Department,
Hospital Ipoh, Perak
PP
2005
79
51. Reducing Defaulter Rate among Leprosy Patients
Receiving Multidrug Therapy (MDT) at Department
of Dermatology Hospital Kuala Lumpur
Dr. Sorya A. Aziz
Dermatology Department,
PP
2005
80
52.
Patient Education and Counselling in the
Management of Psoriasis – towards Better Patient
Compliances
Dr.Gangaram Hemandas
PP
2003
81
HAEMATOLOGY
53.
Iron Chelation amongst Thalassaemics: A Need for
Reappraisal
Dr. Norhasni Md. Zin
Tuanku Fauziah Hospital,
Perlis
OP
2009
82
54. Preventing Febrile Transfusion Reactions in
Thalassemia Patients
Dr. Aye Aye Hlaing
Transfusion Medicine Unit
Pusat Perubatan Universiti Malaya,
Kuala Lumpur
PP
2009
83
INFECTIOUS DISEASE
55.
Adherence Program to Improve Treatment Response
in HIV Treatment-Naive Patients in Infectious Disease
Clinic
Ms. Cheang Lai Fong
Hospital Pulau Pinang, ID Clinic,
ACC Building, 1st Floor,
Jalan Residensi, 10990 Penang
PP
2011
84
56. Reduction of Methicillin Resistant Staphylococcus
Aureus (MRSA) Infection in Alor Star Hospital
Dr. Noorhasmaliza Md. Noor
Hospital Alor Setar,
Kedah
PP
2005
85
MEDICAL
57. Optimisation of Glycaemic Control of Diabetic
Patient in Medical Outpatient Department
Dr. Mithali Abdullah @ Jacquline Sapen
Medical Outpatient Department,
Hospital Sultan Abdul Halim,
Sungai Petani, Kedah
OP
2009
86
58. Improving Provision of Diabetic Care at Diabetic
Clinic
Dr. Koay Beng Siang
Hospital Sungai Bakap,
Pulau Pinang
PP
2009
87
59. Reducing Waiting Time at the Warfarin Clinic,
Medical Outpatient Department
Dr Siow Kim Yoon
Department of Medicine,
Hospital Tuanku Jaafar,
OP
2009
88
No.
Project Title
Presenter / Office
Category/
Year
Presented
11
Page
60. Door-to-Needle Time for STEMI Patients in HKL,
How Good are We?
Dato’ Dr. Jeyaindran Tan Sri Sinnadurai
Department of Medicine,
OP
2005
89
61. The Review of In-Patient Investigation Results
Received after Discharge in Hospital Balik Pulau
Dr. Wong Li Wui
Hospital Balik Pulau, Pulau Pinang
OP
2003
90
PP
2003
91
OP
2007
92
MEDICAL RECORD
62. Kelewatan (Melebihi 72 jam) Menghantar Rekod
Pesakit Discaj dari Wad ke Unit Rekod
Puan Intan Bt Abdullah Sani
Hospital Kampar, Perak
NEPHROLOGY
63. Reducing Continuous Ambulatory Peritoneal Dialysis
Peritonitis Rate in Hospital Tuanku Ja’afar, Seremban
Pn. Shanmugavadivoo Kulamthaivel
Hospital Tuanku Ja’afar, Negeri Sembilan
OBSTETRICS & GYNAECOLOGY
64.
Meningkatkan Peratusan Kepatuhan terhadap
Perawatan Pesakit dengan Infusi Intravena di Wad
Obstetriks & Ginekologi
Pn. Nancy Borubui
Hosp Wanita & Kanak-kanak Sabah
Karung Berkunci No: 18788996
KK, Sabah
OP
2011
93
65.
Improving Time Interval from Decision to Caesarean
Delivery for Fetal Distress Cases
Dr. Yuzainov Ahmad
Hospital Seberang Jaya,
Bandar Baru, Jalan Tun Hussein Onn,
Seberang Jaya, Pulau Pinang
OP
2011
94
66.
Increasing Lower Segment Caesarian Section
without Post Partum Hemorrhage
Dr. Lim Kah Yen
Hospital Sultanah Nur Zahirah,
Jalan Sultan Mahmud, Kuala Terengganu
OP
2011
95
67.
Improving Admission Time at Maternity Patient
Assessment Centre
Dr. Mohd Azri Mohd Suan
Jab O&G, Hosp Sultan Abdul Halim,
Sg Petani, Kedah
PP
2011
96
68.
Reducing the Incidence of Third Degree Tear in
Obstetrics & Gynaecology Department
Pn. Molen Ahua
Hospital Bintulu Sarawak
Lebuhraya Abg Galau,
Bintulu, Sarawak
PP
2011
97
69. Delay in Induction of Labour with Oxytocin
Dr. Nik Azi Azuha Nik Hassan
Jab O&G, Hospital Sultanah Nur Zahirah,
Kuala Terengganu, Terengganu
PP
2011
98
70. Mengurangkan Kadar Kejadian LSCS Wound
Breakdown
Pn. Anna Tham
Hospital Tenom,
Peti Surat No.97,
Tenom, Sabah
PP
2011
99
71. Improving Pregnancy Rate of Intra Uterine
Insemination
Cik Siti Norfaizah Bte Wagiman
Kuala Terengganu
PP
2009
100
chapter 2
chapter 2
12
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
72. Reducing the Incidence of Rejected Laboratory
Specimens from Obstetrics Wards
Pn. Dorien Hee
O & G Department,
Women and Children Hospital,
Likas, Sabah
PP
2009
101
73. Re-engineering of Low Risk Birthing Centre
Dr. Nor Anita Abdullah
O & G Department,
Kuantan, Pahang
OP
2007
102
74. Towards Reducing the Risk of Retained Swab after
Perineal Repair in Hospital Sultanah Nur Zahirah
Pn. Fadilah Hassan
Kuala Terengganu
OP
2007
103
75. Episiotomy Wound Breakdown, How to Overcome
It?
Puan Rusnah Adenan
Hospital Kluang, Johor
OP
2005
104
76. Improved Screening of Distress Newborn to SCN
Dr. Norhafizah Mohd. Amil
O & G Department,
Hospital Batu Pahat, Johor
PP
2005
105
77. Active Management of Obstetric Hypovolaemia
Dr. Rohana Ismail
O & G Department,
Hospital Kuala Terengganu
PP
2005
106
78. Incidence of Post Partum Hemorrhage
Dr. Hasrina Hassan
OP
2005
107
79. Unsatisfactory Pap Smear Yield
Dr. Sharmini Diana Parampalam
Pulau Pinang
OP
2005
108
80. Inappropriate Waiting Time in Maternity Patient
Assessment Centre
Dr. Hamidah Omar
O & G Department,
Hospital Tengku Ampuan Rahimah,
Klang, Selangor
OP
2005
109
81. To Reduce the Waiting Time for Antenatal Patients
to Get Admitted to the Maternity Wards at Sarawak
General Hospital, Kuching
Puan Dayang Jakiah Awang Yahya
Labour Ward,
Hospital Umum Kuching,
Sarawak
OP
2005
110
82. Effect of Non-Compliance to Standard Operating
Policy Relating to Referral of Potential Obstetric
Patients in Premature Gestations to the Neonatal
Intensive Care
Dr. Paul Ng
Hospital Universiti Kebangsaan,
Malaysia
OP
2003
111
83.
Meningkatkan Tahap Penglihatan Pesakit Ambliopia
di Klinik Oftalmologi
OP
2011
112
OPHTHALMOLOGY
Pn. Nur Liyana Ishak
Klinik Mata, Jabatan Oftalmologi
Hospital Kuala Krai,
Kuala Krai, Kelantan
Presenter / Office
Category/
Year
Presented
13
No.
Project Title
Page
84. Reducing the Percentage of Clinical Progression of
Severe Non- Proliferative Diabetic Retinopathy Cases
to Proliferative Diabetic Retinopathy Stage over 1
year in an Ophthalmology Department
Dr. Adeline Khaw Mae Li
Jab Oftalmologi
Hosp Pulau Pinang
PP
2011
113
85. Re-Engineering the Cataract Surgery Wait-Time
Strategy
Dr. Shubhashini Yogeswaran
Jabatan Oftalmologi, Hospital Raja
Permaisuri Bainun, Jalan Hospital,
Ipoh, Perak
PP
2011
114
86.
Improving the Rate of Postoperative Endophtalmitis
after Cataract Surgery in the Department of
Ophthalmology, Hospital Ipoh
Dr. Poh Eu Ping
Department Of Ophthalmology,
Hospital Ipoh
OP
2007
115
ORTHOPAEDIC
87.
Reducing the Incidence of Long Transportation Time
of Patients from Orthopaedic Ward to the Operation
Theatre
Pn. Lydia Lee Yu Chin
Orthopaedic Department,
Hospital Umum Kuching,
Sarawak
PP
2007
116
88.
Meningkatkan Peratus Siap Laporan Perubatan
Ortopedik Dalam Tempoh 4 Minggu Kepada 80%
En. Mohd Uzuman Nordin Ali
Hospital Kuala Terengganu, Terengganu
OP
2003
117
PAEDIATRICS
89.
Reducing Central Venous Line Related Blood Stream
Infections among Paediatric Oncology Patients
Dr. Tan Pek Yong
Jab Pediatrik, Hosp Pulau Pinang,
Jalan Residensi, Pulau Pinang
PP
2011
118
90. Reducing Hypothermia in Post Caesarian Newborn
Admitted to Neonatal Intensive Care Unit in Hospital
Tuanku Fauziah
Dr. Shahannim Izham
Paediatric Unit, Hospital Tuanku Fauziah,
Kangar, Perlis
OP
2007
119
91. Prevention of Low Apgar Score Baby in Hospital
Kluang
Pn. Foo May Lan
Hospital Kluang, Johor
PP
2007
120
92. Meningkatkan Kualiti Rawatan Kes Akut
Gastroentritis di Wad Kanak-Kanak, Hospital
Muadzam Shah
Dr. Haizul Ikhwan Murat
Hospital Muadzam Shah, Pahang
PP
2007
121
93. Improving Platelet Transfusion Care in Paediatric
Haemotopoietic Stem Cell Transplantation Patients
in Pusat Perubatan Universiti Malaya, Kuala Lumpur
Dr. Indra Jeyajothi Ratnam
Pusat Perubatan Universiti Malaya,
Kuala Lumpur
OP
2007
122
94. Improving Thalassaemia Care in Paediatrics
Dr. Hasmawati Hassan
Hospital Raja Perempuan Zainab II,
OP
2005
123
PP
2011
124
PHYSIOTHERAPY
95. Mengurangkan Ketidakseimbangan Badan di
kalangan Pesakit Warga Tua di Wad Kronik
En. Clement Mike
Unit Fisioterapi, Hospital Mesra, Bukit Padang,
Peti Surat No. 11342,
Kota Kinabalu, Sabah
chapter 2
chapter 2
14
No.
Project Title
Recurrent Referral for Low Back Pain to
Physiotherapy Department
Presenter / Office
Cik Yew Su Fen
Physiotheraphy Department,
Hospital Pulau Pinang
Category/
Year
Presented
Page
OP
2009
125
PSYCHIATRY
97. Reducing Frequency of Readmission of Patients with
Schizophrenia after Last Discharge
Dr. Ruzita Jamaluddin
Jab atanPsikiatri & Kesihatan Mental,
Hospital Tuanku Fauziah,
Kangar, Perlis
PP
2011
126
98.
Improving the Effectiveness of Retrieval of
Psychiatric Follow-up Defaulters
En. Segaran Ramondran
Mesra Hospital,
Bukit Padang, Sabah
OP
2009
127
99. Preventable Falls amongst Long Stay Patients in
Psychiatric Wards in a Government Hospital
Pn. Fatimah Sinosi
Hospital Sentosa,
Kuching, Sarawak
PP
2009
128
100. Ke Arah Meningkatkan Kesinambungan Rawatan
Pesakit Mental di Klinik Lawatan Pakar Psikiatrik
Hospital Kuala Nerang
En.Yong Phooi Wah
Hospital Kuala Nerang,
Kedah
PP
2007
129
101. Improving Percentage of Lens Exclusion on Routine
Head Computerised Tomography Examination
Dr. Asmah Omar
Hospital Tuanku Fauziah
Kangar, Perlis
PP
2009
130
102. Meningkatkan Peratus Radiograf Servikal Lateral
Erect yang Sempurna
Dr. Sazali Satari
Jabatan Pengimejan Diagnostik,
Kangar, Perlis
PP
2007
131
103. Audit on Portable Radiography Done
after Office Hours in the Diagnostic
Imaging Department Hospital Raja
Perempuan Zainab II
Dr. Aniyah Mat Jelani
Diagnostic Imaging Department,
Hospital Raja Perempuan Zainab II
PP
2007
132
104. Ensuring Production of Optimally exposed
Radiographs
Dr. Sazali Satari
Perlis
OP
2005
133
105. Towards Reducing Substandard Portable Chest
Radiographs in Adult
Dr. Norie Azilah Kamaruddin
Department of Diagnostic Imaging,
Hospital Tengku Ampuan Afzan Kuantan,
Pahang
PP
2005
134
106. Audit on Defaulters for Special Radiographic
Examinations in Diagnostic Imaging Department
Dr. Fairos Abdul Muthalib
Hospital Raja Perempuan
Zainab II Kota Bharu,
Kelantan
PP
2005
135
107. The Human Factor in X-Ray Film Rejection
En. John Baptis Joannes
Department of Diagnostic,
Imaging Hospital Duchess of Kent,
Sandakan, Sabah
PP
2005
136
RADIOLOGY
No.
Project Title
Presenter / Office
Category/
Year
Presented
15
Page
108. Compromised Patient Safety by Being
Inappropriately Attended to during Radiological
Imaging in Hospital Seremban
Dr. Thevaraj
Hospital Seremban,
Negeri Sembilan
OP
2003
137
109. Meningkat Kadar Radiograf Dada Portable yang
Optima
Dr. Mohd Romzi Bin Abd Rahman
Jabatan Radiologi,
Hospital Kuala Terengganu
PP
2003
138
110. The Effectiveness of Hysterosalpingography
Appointments in Kuala Lumpur Hospital: A Study
Using Continuous Quality Improvement Method
Dr. Mastura Bte Talib
OP
2003
139
111.
Audit on the Turnaround Time in CT Scan
Examination in Patients with Improper Preparation
Dr. Brinder Nijhar
Hospital Kota Bharu, Kelantan
OP
2003
140
112. A Delay in the Patients’ Waiting Time for Plain
X-Rays in the Radiology Department, Hospital
Queen Elizabeth
En. Limon Md. Rupin
Hospital Queen Elizabeth,
Sabah
PP
2003
141
OP
2007
142
RESPIRATORY
113. Towards Better Control of Bronchial Asthma Patients in Hospital Tengku Ampuan Jemaah, Sabak Bernam
Dr. Jameela Banu A. Hasali
Hospital Tengku Ampuan Jemaah,
Sabak Bernam, Selangor
SURGICAL
114.
Menurunkan Peratusan Penolakan Kes
Pembedahan Dewan Bedah
Dr. Nurul Atikah Hamat
Hospital Pasir Mas,
Pasir Mas, Kelantan
PP
2011
143
115.
Open Access Endoscopy Service Reduces Waiting
Time and Increases Gastrointestinal Cancer
Detection
Dr. Mahadevan Deva Tata
Jabatan Bedah Hospital Tuanku Ja’afar Seremban
Jalan Rasah, Seremban,
Negeri Sembilan
OP
2011
144
116. Reducing Delay in Sending Patients to the Operating
Theatre in Department of Surgery, Hospital Tawau
Sabah
Dr. Mohan Raj
Surgical Department,
PP
2007
145
117.
Pemonitoran Neurofisiologi Semasa Pembedahan
En. Adnan Tahir
Unit Neurosains,
Hospital Universiti Sains Malaysia,
Kubang Kerian,
Kelantan
PP
2003
146
Chapter 8
PHARMACY RELATED PROJECTS
118. Reducing E-Prescription Error in a Hospital
In-patient Pharmacy
En. Ng Khai Yong
Hospital Putrajaya
Pusat Pentadbiran Kerajaan Persekutuan
Presint 7, Putrajaya
OP
2011
148
119. Re-Engineering the Process of Obtaining Special
Formulary Drugs by Oncology Patients
Pn Tan Pei Lin
PPUM, Lembah Pantai
Kuala Lumpur
OP
2011
149
chapter 2
chapter 2
16
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
120.
Improving Adherence to Blood Sampling Time for
Therapeutic Drug Monitoring in a Government
Hospital
Tn. Rosdi Md Zin
Jab Farmasi Dan Bekalan Hospital Melaka,
Jalan Mufti Haji Khalil,
Melaka
OP
2011
150
121.
Mengurangkan Kekerapan Pesanan Luar Jangka
dari Unit Pemesan bagi Item Bukan Ubat di Unit
Perolehan dan Pembekalan
Pn. Noor Mariati Othman
Jab Farmasi, Hosp Sultan Haji Ahmad Shah,
Temerloh, Pahang
OP
2011
151
122. Role of the Pharmacist in Improving International
Normalised Ratio Value of Warfarin Patients in a
Government Hospital
Cik Shakirin Shaik Rahmat
Unit Farmasi & Bekalan,
Hospital Labuan,
P.O. Box 81006, W.P. Labuan
OP
2011
a 152
123. Achieving International Normalised Ratio Targets
and Satisfaction of Warfarinised Patients
En. Subramaniam Thanimalai
Hosp Kuala Lumpur
Jalan Pahang, Kuala Lumpur
OP
2011
153
124. Reducing the Number of Medication Administration
Errors in a General Paediatric Ward
Cik Hiew Ching Ying
Hospital Tuanku Ja’afar,
Jalan Rasah, Seremban,
N. Sembilan
PP
2011
154
125. Optimisation of Pharmcare Service in a Tertiary
Hospital
Cik Giam Wei Li
PPUM, Lembah Pantai,
Kuala Lumpur
PP
2011
155
126.
Minimising the Filling Errors in a Pharmacy of a
Specialist Clinic
Cik Siow Chee Chen
Hospital Melaka,
Jalan Mufti Haji Khalil,
Melaka
PP
2011
156
127.
Clinical and Economic Impact of Pharmacist-Run
Medication Therapy Adherence Clinic Service on
Patients with Type 2 Diabetes
En. Navin Kumar Loganadan
Hospital Kuala Lumpur, Jalan Pahang,
Kuala Lumpur
PP
2011
157
128. Meningkatkan Pengetahuan Pesakit tentang
Perubahan Rupa Ubat f i Farmasi Pesakit Luar
Cik Abby Ang Shoon Yeun
Unit Farmasi, Hospital Raub,
Raub, Pahang
PP
2011
158
129.
Improving Complete Drug Prescription Yield in the
Obstetrics & Gynaecology Department
Dr. Mairin Dulasi
Pulau Pinang
PP
2009
159
130. Improving the Percentage of Compliance towards
Sampling Time Guidelines of Therapeutics Drugs
Monitoring Blood Samples in a Government Hospital
Pn. Rose Aniza bt. Rusli
Hospital Tengku Ampuan Rahimah,
Klang, Selangor
OP
2009
160
131. Dispensing Repeat Prescriptions on Appointment
Basis (S.M.A.R.T) as an Alternative Dispensing
Method to Reduce Patient Waiting Time at The
Pharmacy Department
En. Navin Kumar a/l Loganadan
Pharmacy Department,
OP
2009
161
No.
Project Title
Presenter / Office
Category/
Year
Presented
17
Page
132. Reducing the Incidence of Medication Error in
Pediatric Medical Ward
Dr. Wong Poh Fei
Pediatrics Department,
Hospital Melaka
OP
2009
162
133. Re-engineering Unit of Use Drug Distribution System
of Ward Supply to Cater Weekend’s Needs
Cik Tan Cheau Huey
Pahang
OP
2009
163
134. PHARMCARE: A Quality Improvement in Supplying
Long-Term Medications from the Outpatient
Pharmacy in the Medical Centre
Cik Nur Azrida Azhari Wasi
Pharmacy Unit/ Department of Pharmacy,
University of Malaya,
Kuala Lumpur
OP
2009
164
135. Improving Waiting Time in the Outpatient Pharmacy
Unit at a Government Hospital during Medical Clinic
Days
Cik Lou Jing Ying
Sibu Hospital, Sarawak
OP
2009
165
136. Counseling and Home Medication Review:
Do They Improve Compliance Among Patients
Taking Oral Hypoglycaemic Agents?
Pn. Chan Bee Leng
Pharmaceutical Services Division,
Melaka Health Department
OP
2007
166
137. Expedite Dispensing of Returned Prescription from
Medical Specialist Clinic
Cik Joanne Seow May Yoong
Outpatient Pharmacy Unit,
OP
2007
167
138. The Lumut Armed Forces Hospital Project on
Enhancing the Quality of Oral Form Drug
Management in Wards
Kapten Mohd. Adlan bin Adnan
Hospital Angkatan Tentera,
Lumut, Perak
OP
2005
168
139. Peningkatan Mutu Sistem Pembekalan Ubat ke
Jabatan Kecemasan
Puan Rokiah Isahak
Hospital Sri Manjung,
Perak
OP
2003
169
140.
Long waiting time at the Specislist Clinic Pharmacy
of Hospital Kangar
Puan Atia Hashim
Hospital Kangar,
Perlis
OP
2003
170
141. Reducing Waiting Time in an Outpatient Pharmacy
Ms. Melinda Phuah
Penang Adventist Hospital
PP
2003
171
Chapter 9
PUBLIC HEALTH RELATED PROJECTS
142. Menurunkan Kejadian Anemia di kalangan Ibu
Hamil pada Usia Kandungan 36 Minggu
Dr. Norasikin Mahdan
Pej Kesihatan Daerah Pontian,
Jln Alsagoff, Pontian,
Johor
OP
2011
174
143.
Improving the Percentage of Asthmatics Receiving
Optimal Assessment during Follow Up in Health
Clinics
Dr. Nor Azila Mohd Isa
KK Teluk Datok,
Banting, Kuala Langat
OP
2011
175
chapter 2
chapter 2
18
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
144. Meningkatkan Pengurusan yang Efektif bagi Ibu
Hamil dengan Anemia di Klinik Kesihatan
Dr. Suzaini Mat Daud
KK Arau, Arau, Perlis
OP
2011
176
145.
Meningkatkan Peratus Asma Bronkial Terkawal
Dr. Jayashree Manoharan
PKD Pendang, Jalan Sg Tiang,
Pendang, Kedah
PP
2011
177
146. Reducing Incidence of Severe Neonatal Jaundice
Pn. Gadung Abai
Seksyen Pembangunan Kesihatan Keluarga,
Jab Kesihatan Negeri Sarawak,
Jalan Tun Abang Hj. Openg,
Kuching, Sarawak
PP
2011
178
147.
Improving Proper Usage of Fetal Movement Chart
among Pregnant Women
Dr. Mohd Nazari Jaafar
KK Umbai, Melaka
PP
2011
179
148. Increasing the Success Rate of Quit Smoking Clinic
among Adolescents
Dr. Hjh Arbaiah Othman
Pej Kesihatan Daerah Datu Pahat,
Jalan Mohamad Khalid,
Batu Pahat, Johor
PP
2011
180
149.
Meningkatkan Pengesanan Komplikasi Pesakit
Diabetes yang Lengkap di Klinik-Klinik Kesihatan
Dr. Norhana Yazid
KK Bukit Payong, Bkt Payong,
Marang, Terengganu
PP
2011
181
150.
Mengurangkan Peratus Anemia Sederhana di
Kalangan Ibu Hamil pada Minggu 36
Pn. Norazlina Mohamad Noh
PKD Kubang Pasu,
Jitra, Kedah
PP
2011
182
151. Increasing Percentage of Asthma Control
Monitoring at District Health Clinic
Dr. Junaidah Ishak
Jab Kesihatan Negeri Perlis
Tingkat 8, Bangunan Persekutuan,
Kangar, Perlis
PP
2011
183
152.
Improving Detection Rate of Diabetic
Foot Problems among Patients with Diabetes
Dr. Samurah A. Rahman
KK Kg Pandan,
Jalan Kg Pandan,
Kuala Lumpur
PP
2011
184
153.
Menurunkan Kejadian Anemia Sederhana di
kalangan Ibu Hamil
Dr. Mohd Adam Mohd Akil
KK Seberang Takir, Kg Telok Ketapang,
Kuala Terengganu, Terengganu
PP
2011
185
154. Meningkatkan Peratus “Premis Bersih” Kantin
Sekolah Menengah
En. Samsir Asuwat Sabtu
Pej Kesihatan Daerah Sabak Bernam,
Kompleks Pejabat Kerajaan, Sg Besar,
Sabak Bernam, Selangor
PP
2011
186
155. Meningkatkan Aktiviti Fizikal melalui Kempen
10,000 Langkah di kalangan Masyarakat
Pn. Rubiah Lebar
KK Air Baloi, Pontian, Air Baloi,
Pontian, Johor
PP
2011
187
Presenter / Office
Category/
Year
Presented
19
No.
Project Title
Page
156.
Mengurangkan Pencemaran Longkang dan Saliran Awam oleh Sisa Minyak Terpakai
R. Azraei Ramli
Dewan Bandaraya Kuala Lumpur,
Km 4,Jalan Cheras, Kuala Lumpur
PP
2011
188
157. Improvement of Blood Pressure Management in
Diabetic Nephropathy Patients at Health Clinic
Dr. Wong Ping Foo
Pantai Health Clinic,
Wilayah Persekutuan Kuala Lumpur
OP
2009
189
158. Improving Compliance of Diabetic Care Assesment
by the Healthcare Providers Based on Clinical
Practice Guidelines at Health Clinic
Dr. Bariyah Kadas
Klinik Kesihatan Tangling,
Wilayah Persekutuan Kuala Lumpur
PP
2009
190
159. Meningkatkan Peratus Hadir Temujanji Pesakit
Diabetes di Klinik Kesihatan
Dr. Iza Noor Ruaida Deraman
Klinik Kesihatan Kijal,
Kemaman Terengganu
PP
2009
191
160. Kewajaran Pengurusan Hypertensive Disorder in
Pregnancy oleh Anggota Kejururawatan
Pn. Norlian Ismail
Pejabatan Kesihatan, Rompin
Pahang
PP
2009
192
161. Quality of Diabetes Care at Ministry of Health
Healthcare Facilities: Glycaemic Control
Dr. Feisul Idzwan Mustapha
Bhg Kesihatan Awam, KKM
OP
2009
193
162. Meningkatkan Pengambilan Sampel Darah Kedua
untuk Ujian IgM Denggi
En. Azirudin Ismail
Pejabat Kesihatan Daerah
Hulu Terengganu, Terengganu
OP
2009
194
163. Using Mosquito Larvae Tapping Device as Additional
Tool for Dengue Fever Control in Kuala Lumpur
Dr. Umi Hj Ahmad
Vector Borne Disease Control Division,
Dewan Bandaraya Kuala Lumpur
PP
2009
195
164. Improving the Management of PregnancyInduced Hypertension in Hulu Langat District
Health Clinics
Dr. Nik Mazlina Mohammad
Klinik Kesihatan Hulu Langat,
Selangor
PP
2007
196
165. Improving Tracing of Serological Results for Dengue
among Clinically Diagnosed Dengue Fever Cases
Notified to the Health Department,
City Hall Kuala Lumpur
Dr. Zainol Ariffin Pawanchee
Vector Borne Disease Control
Division Health Department
Dewan Bandaraya Kuala Lumpur
PP
2007
197
166.
COMBI - Keberkesanan Melawan Denggi di
Pangkalan TLDM Lumut
Brig. Jen. Dato’ (Dr) Hj. Samiran Sarijan
Perkhidmatan Kesihatan Angkatan Tentera,
TLDM Lumut Perak
PP
2007
198
167. Menurunkan Kadar Jaundis Teruk di Daerah
Segamat Johor
Dr. Suriati Hasim
Klinik Kesihatan Segamat,
Johor
OP
2007
199
chapter 2
chapter 2
20
No.
Project Title
Presenter / Office
Category/
Year
Presented
Page
168. Mengurangkan Kadar Kejadian Neonatal Jaundis
Teruk di Klinik Kesihatan Ibu & Anak Kuala
Kangsar
Dr. N. Leelavathy
Klinik Kesihatan Ibu & Anak,
Kuala Kangsar, Perak
PP
2007
200
169. Improving the Appropriate Management of Asthma
Patients in Klinik Kesihatan Sg. Acheh, Seberang
Perai Selatan
Dr. Rafidah Md. Noor
Klinik Kesihatan Sungai Acheh,
Seberang Perai Selatan, Pulau Pinang
PP
2007
201
170. Quality Improvement in Asthma Management at
Primary Care Setting
Dr. Narayanan N. Sundram
Klinik Kesihatan Mantin, Negeri Sembilan
PP
2007
202
171. Improving the Percentage of Exclusive Breast
Feeding in Health District of Marang
Dr. Siti Aminah Akbar Merican
Pejabat Kesihatan Marang, Terengganu
PP
2007
203
172. Improving the Use of Contraception among
Women with History of High Risk Pregnancy
Dr. Siti Aisah Hassan
Klinik Kesihatan Ibu & Anak,
Machang, Kelantan
OP
2007
204
173. Appropriate Management of Hypertension in
Hypertension Clinic in Bayan Baru Community
Polyclinic
Puan Hafizah Hamat
Polyclinic Community Bayan Baru,
Pulau Pinang
PP
2005
205
174. Impact of Tailored Interventions in Managing Poorly
Controlled Blood Pressure in Patients with Diabetes
Mellitus
Dr. Azah Abdul Samad
Polyclinic Tangling,
WP Kuala Lumpur
PP
2005
206
175. Towards Improving Appropriate Care of Gestational
Diabetes in Kulim District
Dr. Noorlia Yahaya
Klinik Kesihatan Kulim,
Kedah
OP
2005
207
176. Pengawalan Wabak Demam Denggi di Daerah
Seremban
En. Mariappan Semalai
Pejabat Kesihatan Daerah Seremban,
PP
2005
208
177. Improving Dengue Outbreak Control in Kg Koh,
Manjung District
Dr. Yeoh Soo Fan
Pejabat Kesihatan Manjung,
Perak
OP
2005
209
178. Meningkatkan Pengesanan Awal Kes Neonatal
Jaundis Teruk di Daerah Kangar, Perlis
Dr. Suzaini Mat Daud
Pejabat Kesihatan Daerah
Kangar, Perlis
PP
2005
210
179. To Increase Identified Tuberculosis Contacts Coming
for Screening in the Health District of Cameron
Highlands
Dr. Stella Jane
Hospital Cameron Highlands,
Pahang
OP
2005
211
No.
Project Title
Presenter / Office
Category/
Year
Presented
21
Page
180. Poor control of Blood Pressure among Diabetic
Hypertensive Patients in the District of Kulim,
Kedah Darul Aman
Dr. Noorlia Yahaya
Pejabat Kesihatan Kulim, Kedah
OP
2003
212
181 Reduction of Born Before Arrival (BBA) and Unsafe
Deliveries in Puchong District
Puan Norsiah Jaafar
Klinik Kesihatan Puchong, Selangor
PP
2003
213
182. Pengurangan Kadar Pembiakan Nyamuk Aedes di
Kawasan FELDA
En. Mohd Yazid Manan
Pejabat Kesihatan Tampin,
Negeri Sembilan
PP
2003
214
183. Quality Perinatal Bereavement Counseling Is There a Need?
Dr. Zainah Shaikh Hedra
Paediatrics Department,
Hospital Melaka
PP
2003
215
184.
Reducing Waiting Time in a Health Screening
Programme
Puan Madelene Tan
Penang Adventist Hospital
OP
2003
216
Chapter 10
TRAINING RELATED PROJECTS
185. Meningkatkan Kompetensi Pelatih Program
Diploma Pembantu Perubatan melalui Intervensi
Simulasi Klinikal
En. Elengovan Varutharaju
Bhg Pengurusan Latihan KKM, Aras 6,
No. 26, Persiaran Perdana, Presint 3,
Putrajaya
OP
2011
218
186. Improving the Passing Rate of Nursing Students in
Anatomy and Physiology Subjects
Pn. Tan Suei Ching
Bhg. Pengurusan Latihan, KKM Aras 6,
No. 26, Persiaran Perdana, Presint 3,
Putrajaya
OP
2011
219
187. Implementation and Evaluation of Communication
Skills Training Programme for Pre-Clinical Medical
Students: A Malaysian Context
Dr. Hera Lukman
Behavioural Sciences Section
International Medical University, Kuala Lumpur.
PP
2005
220
188. Peratusan Kelulusan Peperiksaan Semester 1 KKM,
di Kolej Kejururawatan Kubang Kerian tidak
Menepati Piawaian Bhg. Pengurusan Latihan
KKM (85%)
Puan Che Rasmaniah Bt Che Mat
Kolej Kejururawatan Kubang Kerian,
Kelantan
PP
2003
221
Chapter 11
COLLABORATIVE PROJECTS
190. Reducing Medication Administration Delays:
A Collaborative Approach
Pn. Yi Fuon Khum
Pharmacy Department and Nursing Department,
Institut Jantung Negara, Kuala Lumpur
OP
2009
224
191. Reducing Missing Laboratory Investigation
Results Sent from O&G Department Hospital Melaka
Dr. Nor Idayu bt. Kamaruddin
O&G and Pathology
Department, Hospital Melaka
PP
2007
225
chapter 2
chapter 2
22
No.
Project Title
High Incidence of Follow-up Patients Coming
without Appointment
Presenter / Office
Dr. Kasthuri Nagaratnan
Skin, Eye, ENT and Dental Clinic,
Melaka
Category/
Year
Presented
Page
OP
2005
226
Chapter 12
OTHERS
193. The BRAINWAVES SYSTEM: Development of A
Mind Stimulating System to Improve Neurocognitive
Health by Increasing Alertness in the Workplace
Prof. Zalina Ismail
Pusat Pengajian Sains Kesihatan, USM,
Kubang Kerian, Kelantan
OP
2011
228
194. Does Hand Hygiene Campaign Works?
IJN Experience
Pn. Rusmawati Khosim
Institut Jantung Negara, Kuala Lumpur
PP
2009
229
195.
Improving Hand Hygiene Compliance among
Health Care Workers in a Government Hospital
Pn. Wan Noraini Wan Yussof
Hospital Kajang, Selangor
PP
2009
230
196.
Prospective Studies of Patient’s Satesfaction Level in
Armed Forces Hospital Terendak from 2003-2005
Lt. Kol. (Dr.) Izzuniddin Mohd Yusof.
Hospital Angkatan Tentera Kem Terendak,
Melaka
OP
2005
231
197. Sistem Pengurusan Aset
En Lokman Ali
Hospital Universiti Sains Malaysia
OP
2003
232
198. Quality Assurance Programme in Hospital Support
Service – Managing Hospital Excellence
En. Zamane Ab.Rahman
Bahagian Kejuruteraan
PP
2003
233
Chapter 3
Dental Related Projects
24
OP/2011
chapter 3
Meningkatkan Kehadiran Ibu Mengandung ke Klinik Pergigian
Nor Sarah A, Suhaila AK, Nur Arliza P, Wan Mohd Ridzuan WJ.
Klinik Pergigian Peringgit, Melaka.
Pemilihan Peluang untuk Penambahbaikan
Ibu mengandung, selain mengalami masalah karies, cenderung mendapat penyakit gusi (periodontium)
kerana perubahan hormon semasa hamil. Jika dibiarkan, penyakit periodontium memdedahkan ibu
mengandung kepada risiko mendapat kelahiran pramatang dan bayi dilahirkan kurang berat badan.
Sejak tahun 2004 hingga 2009 didapati kehadiran ibu mengandung ke Klinik Pergigian Peringgit
sekitar 30% sahaja.
Pengukuran Utama Penambahbaikan
Peratusan kehadiran baru ibu mengandung ke klinik pergigian berbanding kehadiran baru ibu
mengandung ke KKIA adalah indikator District Specific Approach (DSA) yang ditetapkan dengan
piawaian lebih dari 50%.
Proses Pengumpulan Maklumat
Kajian irisan lintang dijalankan pada Januari dan Februari 2010 bagi mengenalpasti faktor ibu
mengandung kurang membuat pemeriksaan gigi. Dua set borang soal selidik melibatkan 40 orang ibu
mengandung dan 22 orang anggota pergigian dan Klinik Kesihatan Ibu dan Anak (KKIA) digunakan.
Analisis dan Intepretasi
Majoriti ibu mengandung tahu mengenai penyakit pergigian (71.1%) dan pernah diberitahu agar
membuat pemeriksaan gigi (68.4%). 57.9% menyatakan mereka telah membuat pemeriksaan gigi.
Majoriti (73.7%) tidak pernah diberi ceramah mengenai kesihatan pergigian. 92.1% menyatakan
tiada masalah untuk pergi menbuat pemeriksaan di klinik gigi di tingkat atas. Majoriti dari anggota
pergigian dan KKIA (68.2%) menyatakan bahawa maklumat kesihatan pergigian di KKIA tidak
mencukupi.
Strategi Penambahbaikan
Beberapa langkah penambahbaikan telah dilaksanakan termasuklah menempatkan Pegawai
Pergigian di KKIA, mewujudkan borang pemeriksaan dan rujukan untuk rawatan pergigian yang
akan dikepilkan ke dalam buku antenatal bagi tujuan peringatan serta mengelakkan dari keciciran
ibu mengandung mendapatkan pemeriksaan pergigian. Selain itu, pamplet dan poster kesihatan
pergigian diedarkan di KKIA sebagai bahan bacaan ibu mengandung dan ’Fast lane’ bagi ibu
mengandung yang datang mendaftar di klinik pergigian.
Kesan Penambahbaikan
Peratusan kehadiran baru ibu mengandung meningkat kepada 60.5% (Jan-Dis 2010)
Langkah Seterusnya
Kerjasama berterusan antara pihak pergigian dan KKIA akan dipertingkatkan. Laporan kehadiran ibu
mengandung ke klinik pergigian akan dihantar ke KKIA & Pegawai Perubatan Daerah (PPD) untuk
makluman dan pemerhatian. Ibu mengandung yang tercicir akan dihubungi melalui telefon untuk
temujanji pemeriksaan pergigian.
25
PP/2011
Morni AR, Siti FJ, Amran MY, Hasniza J, Irdawaty M.
Pejabat Kesihatan Pergigian Daerah Hulu Selangor, Selangor.
Pengambilan x-ray adalah salah satu langkah penting dalam pengendalian penyakit pergigian.
Imej x-ray yang terang dan jelas amat penting untuk mendapatkan diagnosis yang tepat. Di Klinik
Pergigian daerah Hulu Selangor, pengambilan x-ray yang berulang adalah tinggi iaitu 18.1% pada
tahun 2008. Ini telah memberi impak negatif terhadap kualiti perkhidmatan dengan meningkatkan
pembaziran bahan dan kos. Ia juga menyebabkan peningkatan pendedahan radiasi kepada pesakit
dan menyebabkan pesakit bimbang dan cemas, serta melambatkan diagnosis penyakit dengan
mempengaruhi keberkesanan dan ketepatan rawatan.
Objektif kajian adalah untuk mengurangkan peratus x-ray berulang di Klinik Pergigian daerah Hulu
Selangor dari 18.1% kepada < 10% (Objektif Kualiti MS ISO 9001: 2008). Tindakan penambahbaikan
diambil untuk mengatasi masaalah ini dengan mengenalpasti faktor penyumbang kepada x-ray perlu
diulang.
Empat sebab utama x-ray berulang adalah teknik pengambilan dan pemprosesan x-ray yang
tidak tepat, kualiti bahan yang kurang memuaskan dan masalah teknikal mesin x-ray. Kajian yang
dijalankan adalah kajian irisan lintang. Manakala maklumat diperolehi menggunakan borang daftar
pengambilan x-ray, jadual penyemakan bekalan, senarai semak prosedur pengambilan x-ray dan
borang kajiselidek.
Analisis dan Interpretasi
Peratus filem x-ray berulang tahun 2008 adalah 18.1%. Faktor penyumbang utama filem x-ray
berulang adalah teknik pengambilan x-ray yang salah dan kurangnya pengetahuan dalam
pengambilan dan pemprosesan x-ray oleh Pembantu Pembedahan Pergigian (PPP) yang merangkap
juru x-ray.
Penggunaan film holder semasa mengambil x-ray. Memberi taklimat dan demonstrasi prosedur
pengambilan dan pemprosesan filem x-ray kepada semua PPP. Carta aliran pengambilan x-ray
disediakan dalan bahasa Melayu untuk difahami. Manakala senarai semak pengambilan x-ray
diperbaiki.
Setelah penambahbaikan diambil, peratus x-ray berulang telah berkurang dari 18.1% ( 2008 ) ke
5.4% pada tahun 2009 dan terus menurun ke 4.6% pada tahun 2010.
Langkah Seterusnya
Pemantauan berterusan ke atas senarai semak dan rekod pengambilan x-ray. Mesin x-ray dikalibrasi
serta kualiti filem dan larutan x-ray dipantau secara berkala.
chapter 3
Mengurangkan Peratus X-Ray Berulang yang Tinggi
di Klinik Pergigian
26
PP/2011
chapter 3
Increasing Retention Rate of Fissure Sealant among
Primary School Children
Hajar HR, Vijayamanohar K, Wan Aini WY, Nadia DB, Umi A.
Bangsar Dental Clinic, Federal Teritory of Kuala Lumpur.
Selection of Opportunities for Improvement
Retention rate of Fissure Sealant (FS) in 2009 within a year of application in Bangsar Dental Clinic was
65%. Intact FS can prevent caries from occurring thus reducing cost and time needed for restoration.
Identifying the contributing factors for failure of FS application will enable us to implement necessary
corrective measures.
Key Measures for Improvement
By strictly adhering to Standard Operating Procedure (SOP) and Model of Good Care a (MOGC)
100% retention rate of FS within a year done by our Staff Nurses (SNs) was targeted.
Process of Gathering Information
A cross sectional study was conducted in five schools from September 2010 to January 2011. 81
students and nine SNs from Bangsar Dental Clinic were involved. Data were collected using FS Check
list and Review Form. All SNs were observed on how they carried out the FS procedure.
Analysis and Interpretation
This study revealed that poor tooth selection such as the molars were partially erupted, frank caries
and decalcified enamel (46.67%) contributed to poor retention of FS. Poor moisture control was
another factor, as the SNs did not isolate the tooth properly, did not use saliva ejector and continued
the procedure even after the surface was contaminated with saliva (40%). Lack of vaculysers resulting
in some SNs doing the procedure without a vaculyser was also a factor.
Strategy for Change
Talks, hands-on demonstration and one-to-one training were carried out to ensure all the SNs
understood the implementation of the procedure. Emphasis was given on the use of vaculysers
during the procedure.
Effects of Change
After remedial action was taken, the retention rate increased from 65% to 95.3% and only 4.7% FS
was partially lost.
The Next Step
To continue FS assessment in this clinic and to re-train all newly posted SNs in Bangsar Dental Clinic
on how to carry out this procedure by following SOP.
27
PP/2009
Norhayati A, Jamaliah O, Junaidah MT, Noor Azreen MN.
Bahagian Kesihatan Pergigian, Jabatan Kesihatan Negeri Kedah, Alor Setar, Kedah.
Peningkatan kejadian karies di kalangan murid akan menyebabkan kurang tumpuan terhadap
pembelajaran disebabkan kesakitan gigi serta peningkatan penggunaan bahan dan masa untuk
merawat karies. Peningkatan kejadian karies di kalangan murid yang Bebas Karies pada tahun 2006
adalah 8% seterusnya pada tahun 2007 telah meningkat kepada 30.6%.
Langkah Utama ke Arah Penambahbaikan
Penumpuan kepada aktiviti pencegahan dipertingkatkan bagi memastikan gigi yang berpotensi
mendapat karies dikenalpasti dan dilakukan rawatan pencegahan.
Analisa data retrospektif dari reten Sistem Maklumat Kesihatan Pergigian (SMKP) dilakukan bagi
mengesahkan peningkatan kejadian karies. Kajian prospektif selama setahun mulai April 2007
hingga April 2008 dijalankan dan aktiviti pencegahan telah dikenalpasti dan dilaksanakan.
Faktor penyumbang utama yang dikenalpasti adalah kurang aktiviti pencegahan dilakukan disebabkan
kurangnya peralatan pencegahan serta lebih tumpuan diberikan ke atas rawatan konservatif.
Strategi Penambaikan
Anggota dibekalkan dengan peralatan pencegahan iaitu bahan flourida topikal dan sealan fisur.
Latihan pemantapan aktiviti pencegahan iaitu kursus kalibrasi dan standardisation in oral charting
untuk Jururawat Pergigian dilakukan bagi memastikan anggota lebih mahir dalam mendiagnosa gigi
yang berisiko tinggi mendapat karies.
Selepas pelaksanaan penambahbaikan didapati tiada lagi peningkatan kejadian karies baru. Dari 85
murid yang Bebas Karies pada tahun 2007 didapati tiada seorang pun mendapat karies baru pada
tahun 2008. Peratus murid yang Bebas Karies telah dapat dikekalkan pada 57.4 %. Kumpulan murid
tersebut diperiksa semula selepas lapan bulan dilaksanakan aktiviti pencegahan tersebut
Langkah Seterusnya
Murid yang berisiko tinggi mendapat karies (dfx>3) perlu dikenalpasti. Gigi yang mempunyai white
spot lesion dibuat sapuan topikal dan gigi yang mempunyai fisur dalam diletakkan sealan fisur
bagi mencegah kejadian karies. Aktiviti pencegahan perlu diberi lebih penekanan dan diperluaskan
kepada semua murid di semua sekolah dan di seluruh daerah.
chapter 3
Mengurangkan Peratus Kejadian Karies di kalangan Murid
Bebas Karies di Sekolah Kebangsaan di Kedah
28
PP/2009
chapter 3
Improving the Rate of Post - Operative Review Compliance of
Children Treated under General Anaesthesia for Early Childhood
Laila AJ, Abd. Azim NA, Wan Nurazreena WH.
Paediatric Dental Department, Tuanku Jaafar Hospital, Seremban, Negeri Sembilan.
Early Childhood Caries (ECC) is a severe form of tooth decay in young children which frequently
necessitates General Anaesthesia (GA) as a mode of treatment. Postoperative review appointments
for children with ECC are necessary to detect new carious lesions and institute clinical preventive
measures to prevent recurrent problem.
Shorter review intervals and concurrent oral health education (OHE) can be effective in increasing
knowledge in the short term and also to some extent, review attendance. Reminders are made for
those who failed appointment. The targeted standard for post operative review compliance (PORC)
is more than 80%.
Retrospective analysis of the PORC rate was carried out from the year 2001 to 2003 to identify the
contributing factors. The effectiveness of remedial measures was evaluated by monitoring compliance
from the year 2005-2007.
A six months review interval decreases the effectiveness of OHE and can lead to increase in incidence
of recurrent caries.
Strategy for Change
Various strategies were introduced including shorter intervals of postoperative review from 6 months
to 4 months, concurrent OHE and a questionnaire to assess knowledge level were given constantly at
review appointments and reminder by letters or phone calls to the parents.
Effects of Change
An improvement was observed in the PORC following remedial measures taken. In our study, the
compliance rate at 4 months review interval was more than 90%. In previous survey of post operative
review at interval, the compliance rate at 6 months was 65.4% and 57.5% at 6 and 12 months
respectively.
The Next Step
Ensuring continuity of the implemented remedial measures will reduce active caries developing after
rendering the child with severe ECC dentally fit under GA.
29
PP/2009
Jacob John, Ruhil Sadina, Nik Rozainah.
Oral Health Services, Kelantan State Health Department, Kota Bharu, Kelantan.
Edentulism affects oral and general health as well as overall quality of life. Patients make multiple
visits to the dental clinic and wait for a long time to receive complete denture (CD) treatment. Only
29% of patients received their CD within 5 weeks from start of treatment in 2005 at Klinik Pergigian
Jalan Mahmud (KPJM) against the standard of 50% set by the State Oral Health Division.
Increasing the percentage of CD issued to 70% within 5 weeks from the start of treatment at KPJM.
Three audit cycles were completed during 2006-2008. Changes to practice were based on results of
each audit and taking into consideration the opinions of relevant staff.
The findings showed that factors like operators not available on appointment day (41%), poor
management of appointments (28%), patients missing on appointment days (5%), delay in
completing cases (16%), and inconsistency in the number of cases allotted to operators (10%) were
the major contributing factors for the delay in the issuance of CD.
Strategy for Change
The main changes made were, providing a case completion schedule for every new patient, allocating
cases according to the condition of the patient’s ridge and operator’s experience, removing one of
the clinical procedure for recommended cases and using “Denture Set-up Mould” for teeth setting.
Effects of Change
The initial treatment completion rate at KPJM within 5 weeks (2005) was 29%, improved to 34%
after the first cycle of audit, 56% after the second and 64% after the third cycle, which approximates
to the agreed audit standard of 70%.
The Next Step
Subsequent to taking up this study, it was possible to increase the number of patients receiving CD
within the stipulated time and also to increase the number of patients receiving treatment. These
changes can be implemented in all other dental clinics in Kelantan for the betterment of service to
our elderly population.
chapter 3
Towards Achieving Acceptable Percentage of Patients Issued with
Complete Denture within 5 Weeks from Start of Treatment
30
OP/2009
chapter 3
Improving the Percentage of Attendance of Primar Schoolchildren
Referred by Dental Nurses to a Dental Clinic
Gnanavathy K, Normala O, Hasmifaliza A, Rowena CYF, Azizul Firdaus AH.
Dato’ Keramat Dental Clinic, Kuala Lumpur.
Poor attendances of primary school children were observed when they were referred by the dental
nurses from the school to the dental clinic. The possible contributory factors include insufficient
involvement of parents and teachers.
To improve the percentage of attendance of primary schoolchildren referred to the Dental Clinic and
the standard set was 70%.
279 referral cases from 13 primary schools conducted from July 2008 until May 2009. Studies on
referral records, Health Information Management System and type of treatment, was done before
and after remedial action. A questionnaire on referral practices of nurses before and after remedial
action was undertaken. Data were collected on reasons for non-attendances.
Improvement was shown in the referral practices of dental nurses, where 100% nurses referred
students through the class teacher compared to only 16.7% before intervention. 100% nurses met
and motivated students before the appointment. 83% nurses followed up on non-attendances
compared to 0% previously. This resulted in an increase in attendances and the treatment needed for
a greater percentage of children was met.
Strategy for Change
Referral letters from nurses to students were given through the class teacher. Dental nurses followed
up on parents of students who failed to attend, to explain the reasons for dental appointment,
ascertain reasons for non attendance and reschedule, increased parents’ Involvement and awareness.
Interaction of nurses with students in school helped allay fear.
Effects of Change
Remedial measures undertaken improved attendances from 7.1% to 61.6%. The standard of 70%
was not achieved but ABNA was reduced from 62.9% to 8.4%.
The Next Step
Monitoring of dental nurses to be strengthened in referring cases that need further treatment. There
has to be greater involvement of parents in dental health promotion activities.
31
PP/2009
Khaw Arlene BH, Lim CL, Pun SL, Ferdinand JK.
Dental Service Office Larut Matang & Selama, Perak.
In general, over-prescription of antibiotics by dentists is not perceived as a problem. But studies have
found that dentists are prescribing antibiotics for dental infections which can be safely treated by
dental extraction of the offending tooth or extirpation of the dental pulp alone. Our initial study
showed that 23.1% of antibiotics prescribed by the government dentists in Larut Matang and Selama
(LMS) district were inappropriate according to current guidelines.
The percentage of appropriate antibiotic prescriptions in accordance with current National Antibiotics
Guidelines 2008. The standard set was 90%.
All dentists in LMS district completed a written questionnaire, sat for a written test and submitted
their prescription books for review by the Oral Surgeon, Hospital Taiping.
The majority of dentists perceived inappropriate antibiotic prescription as a serious problem and they
were aware about issues regarding antibiotic resistance. The study found lack of knowledge (76.4%),
poor clinical practice (50.5%) and other factors e.g. patient’s expectation (65.9%) to be the reasons
for inappropriate antibiotic prescriptions.
Strategy for Change
A continuous professional development (CPD) course covering basic principles of antibiotic therapy
was held and attendance was made compulsory for all dentists in LMS district. Written guidelines and
posters were distributed and exhibited at all dental clinics. A checklist system was introduced where
all dentists were instructed to complete a checklist prior to prescribing antibiotics.
Effects of Change
There was a 66.1% drop in the total number of antibiotic prescriptions made. The percentage of
appropriate antibiotic prescription increased from 50.5% to 59.6%.
The Next Step
A CPD course has been made compulsory for all first year dentists posted to LMS district. We are
currently assessing the situation in the rest of Perak and if found necessary, we plan to extend the
above strategies to the entire state.
chapter 3
Improving Antibiotic Prescription in Dental Clinics
32
OP/2007
chapter 3
Meningkatkan Tahap Kebersihan Mulut Murid Sekolah
Rendah
Wan Manirah WAR, Rashidah M, Zawidah A, Hanisah O, Salmahani W,
T.Roshayati TL.
Klinik Pergigian Daerah Hulu Terengganu.
Tahap kebersihan mulut yang optimum adalah penting untuk mencegah penyakit-penyakit pergigian
seperti karies gigi dan penyakit gusi. Mengikut klasifikasi yang ditetapkan oleh Bahagian Kesihatan
Pergigian tahap kebersihan mulut ‘A’ adalah bersih ‘C’ adalah sederhana manakala ‘E’ adalah
keadaan mulut yang kotor.
Langkah Utama Ke Arah Penambahbaikan
Berdasarkan standard yang digunapakai bagi negeri di bawah State Quality Assurance Specific
Approach, tahap kebersihan mulut ‘A’ murid sekolah seharusnya tidak kurang dari 85%.
Proses Pengumpulan Data
Kajian telah dijalankan secara retrospektif berdasarkan pencapaian QAP-SSA 2002-2004. Kajian
secara hirisan lintang juga dijalankan keatas 90 orang murid sekolah rendah yang dipilih secara
sampelan rawak mudah serta ibubapa/penjaga murid tersebut. Kaedah kajian adalah secara
pemeriksaan klinikal dan soalselidik di 3 buah sekolah yang dipilih pad a bulan Mac 2005.
Analisis dan Interpretasi Hasil Kajian
Hasil kajian mendapati bahawa faktor utama yang menyebabkan kebersihan mulut kurang
memuaskan adalah teknik memberus gigi kurang berkesan, ibubapa/penjaga kurang prihatin,
pendidikan kesihatan pergigian kurang berkesan dan kurang kesedaran murid untuk menjaga
kesihatan mulut.
Beberapa strategi telah dilaksanakan untuk peningkatan tahap kebersihan mulut iaitu pendidikan
kesihatan pergigian ditempat yang sesuai dengan menggunakan LCD, Latihan Memberus Gigi
ulangan kepada murid yang mempunyai kebersihan mulut ‘C’ dan ‘E’, status kesihatan mulut
anak dilaporkan kepada ibubapa/penjaga dan penilaian penyeragaman ceramah dan pemeriksaan
pergigian diberi kepada Pegawai dan Jururawat Pergigian.
Kesan Perubahan
Selepas tindakan baikpulih dilaksanakan selama setahun didapati peratus tahap kesihatan mulut
murid sekolah meningkat dari 60.9% pad a tahun 2004 ke 82.3%pada tahun 2006 dan 83.3% pada
tahun 2007.
Pelajaran Yang Diperolehi
Hasil dari projek yang dijalankan didapati bahawa murid yang mempunyai tahap kebersihan mulut
kurang memuaskan perlu diberi lebih perhatian semasa sesi Latihan Memberus Gigi. Ibubapa/
penjaga seharusnya diberi pendedahan penjagaan gigi anak dan pendidikan kesihatan pergigian
yang berterusan. Kedua strategi ini didapati efektif untuk meningkatkan tahap kesihatan mulut
murid.
Langkah Seterusnya
Tindakan baikpulih yang dilaksanakan di 3 buah sekolah yang dipilih telah diaplikasikan ke semua
sekolah dalam Daerah Hulu Terengganu mulai tahun 2006. Latihan Memberus Gigi kali kedua dalam
tahun yang sama dijalankan selepas 6 bulan tamat projek rawatan di sesebuah sekolah.
33
PP/2007
Mazlina MD, Norashikin MY, Norkhafidzah MA, Rahayu R, Norihan O.
Oral Health Services, District of Sabak Bernam, Selangor.
The percentage of repeat fillings done on permanent posterior teeth (2.72%) by dental officers and
nurses on school children under the ‘Incremental Dental Care’ school programme in the district of
Sabak Bernam exceeded the standard set by the National Indicator Approach for oral health services
(less than 1.0%).
To reduce the percentage of failed fillings within a year to meet the national standard.
Process of gathering Information
Treatment cards with repeat filling cases were reviewed and dental operators and assistants’ practice
and knowledge on dental filling procedures were assessed to verify causes of failed fillings and
shortfall in quality.
Improper tooth preparation, improper handling of filling material and inadequate post restorative
advice were found to contribute to the high repeat fillings. Percentage of failed fillings was 1.48%.
Only 75.0% of operators and 69.0% of the assistants have good level of knowledge of the dental
filling procedures.
Strategy for Change
Refresher course and training were provided to improve dental operators’ knowledge and skill on
filling procedures. Post-restorative advice note was created to assist operators deliver specific messages
to patients. Manufacturer’s instruction notes were placed on material boxes and equipment to help
improve handling of dental filling material.
Effects of Change
Percentage of failure reduced from 1.48% in 2005 to 0.92% in 2007.
The Next Step
Continuous Dental Education, regular monitoring and auditing of compliance to model of good
practice and future studies on factors contributing to the retention of different types of filling material.
Value Added Features
Percentage of failure within a year was chosen as the indicator since it is more accurate for a short
term evaluation. Availability of post-restorative advice note and manufacturer’s lnstruction notes had
assisted staff to perform more effectively. During post-restoration advice, information on expected
fillings lifespan generated greater patient’s satisfaction.
chapter 3
Improving the Retention of Fillings Done on Permanent
Posterior Teeth
34
OP/2005
chapter 3
Effects of Cessation of Water Fluoridation in Kelantan and
Terengganu on Caries Experiences of 12-year-olds
Norlida A, Wan MN, Hairiyah AM, Natifah CS, Mahrusah J, Azizah Y, Rosli I.
Oral Health Division, Ministry of Health Malaysia,
Background
Globally, water fluoridation (WF) is an established primary prevention strategy to prevent tooth decay.
In 1972, the Ministry of Health obtained cabinet approval to implement water fluoridation. Of those
receiving piped water supplies, more than 70% received fluoridated water in 2004. However, WF
was discontinued in Kelantan and Terengganu in 1995 and 1999, respectively. This had resulted in
shortfall in the quality standards under the National Indicator Approach (NIA) for the fluoridation
programme. The National Steering Committee on Quality Assurance recommended an assessment to
be carried out to determine the impact of WF cessation on tooth decay in both states.
Objective
To assess the impact of WF cessation on caries experiences among 12-year-olds (Year 6) in Kelantan
and Terengganu with that of the fluoridated state of Johor.
Material and methods
The districts of Pasir Mas (Kelantan), Kuala Terengganu (Terengganu) and Johor Bahru (Johor) were
purposively selected based on defined criteria. Retrospective HMIS data (PG 201) on caries experience
was obtained using a specially designed format. Data were collected for a period of eight years
(1996-2004) for Kelantan and Johor, and four years (2000-2004) for Terengganu.
Results
There were decreasing trends for caries experience in all three districts over the study period. However,
the year 2004 data showed that the caries prevalence in Pasir Mas (55.3%) and Kuala Terengganu
(52%) was about two-fold higher than that of Johor Bahru (26.0%). Caries severity (mean DMFX)
was about three-fold higher in Pasir Mas (Mean DMFX 1.5) and Kuala Terengganu (Mean DMFX 1.1)
compared to Johor Bahru (Mean DMFX 0.4). Caries prevalence remained persistently high at more
than 50% in Pasir Mas and Kuala Terengganu, while in Johor Bahru the caries prevalence reached an
all-time low of 26% in 2004.
Conclusion and Recommendation
Although there are decreasing trends in all three districts, caries experience continues to remain high
in the districts where fluoridation had ceased. This general downward trend could be due to the
benefit of systemic effects of fluoridation since all the 12-year-olds had been exposed to fluoridation
prior and at birth. In addition, they may be subjected to the topical benefits of other fluoride sources
such as fluoridated toothpaste, dental materials and foods, including the diffusion effects of foods
processed in fluoridated areas. However, the continuous fluoridation status of Johor Bahru had
conferred substantially greater benefits in caries prevention compared to that of Pasir Mas and Kuala
Terengganu. There is a need to maintain vigilance and collaboration with relevant authorities to
improve oral health status of populations at-risk.
35
PP/2005
Loh KH, Chan LH.
Oral Health Division, Ministry of Health.
Outline of problem
The rate of rejected dental radiographs from July 2004 to December 2004 in 4 districts in Johor
exceeded the standard set in the Quality Assurance programme.
Key measures for improvement
Criteria for good radiographs were specified and model of good practice for taking radiographs was
developed to reduce level of rejection to not more than the state DSA standard of 5%.
Process of gathering information
The study covered all dental radiographs taken by Dental Surgery Assisstants from July to December
2004 involving dental clinics in Muar, Batu Pahat, Segamat and Kota Tinggi. Data were collected
using a standard format to record all radiographs taken.
Analysis and interpretation
The rates of rejected radiographs before and after implementation of remedial actions were
determined.
Strategies for change
Dental Surgery Assistants were given hands-on courses and model of good practice on taking dental
radiographs was implemented.
Effects of change
The overall rate of rejected radiographs was reduced to 3.6%. Reduction was evident in all the 4
districts.
The next step
The remedial measures were found to be effective in achieving the targeted reduction in shortfalls. It
is recommended that personnel be given training to ersure consistency in taking quality radiographs.
The routine use of beam-centering device, auditing of compliance to model of good practice and
maintenance of X-ray machines are also recommended.
chapter 3
Reducing the Rate of Rejected Dental Radiographic in the Johor
State Oral Health Service
36
OP/2003
chapter 3
Improving Oral Hygiene of Primary School Children
in the District of Kuala Selangor
Hasenah MZ.
Klinik Pergigian Besar, Selangor.
Problem
There is a need to improve oral hygiene of Primary School children through effective oral hygiene care
so that 80% of all Primary School children can attain oral hygiene score A status.
Background
School Dental service provides incremental dental care for all school children with the aim of
producing dentally fit school children upon leaving schools. This can be achieved by first having good
oral hygiene. This will result in less incidence of dental caries, gum diseases and other related oral
diseases. At Quality Assurance meetings, the % achievement of Primary School children attaining
oral hygiene score A from each school were discussed.
Increasing number of school children practicing effective tooth brushing techniques. Professional
guidance given during dental health talks and toothbrush drills session should be interesting to
school children.
Strategy for Change
Using the Quality Assurance Cycle for guidance, an Opportunity for improvement was identified and
this is to improve knowledge and skills of the dental nurses and methodology in approaching these
children.
Effect of the change
There was an increase in the percentage of primary school children attaining oral hygiene score A
from 74.8% in 2000 to 82.0% in 2002. Surpassing the target set at 80% had boosted the morale
of the staff involved.
Lessons Learnt
An improvement can be accomplished when the area to be improved is within our control and is
feasible to do so. Communicating the importance of continuous improvement is an important effort.
The next project will concentrate on the schools having percentage of good oral hygiene score A,
below acceptable level of 70%. This project in its success will be at the greatest benefit and the
lowest cost.
37
PP/2003
Haryati M, Marsila AM, Zakiah U.
Klinik Pergigian Rompin, Pahang Darul Makmur.
Latarbelakang
Dari laporan QAP-NIA 1999, peratusan tampalan semula gigi kekal anterior bagi daerah Rompin
ialah 6.8% sedangkan standard sepatutnya tidak melebihi 5.0%. Kegagalan tampalan gigi kekal
anterior yang memerlukan tampalan semula boleh disebabkan oleh beberapa faktor. Antara faktor
yang utama ialah akibat lekatan bahan tampalan seperti komposit pada struktur gigi yang kurang
memuaskan. Penyiasatan telah dijalankan bagi mengenalpasti masalah tersebut agar tindakan
baikpulih yang sewajarnya diambil. Antara tindakan baikpulih yang diambil ialah memberi penekanan
dalam penggunaan teknlk etching dan bonding yang berkesan semasa tampalan komposit dijalankan
beserta kawalan lembapan, pembersihan dan pengeringan kaviti yang baik, jelas rnenunjukan
pengurangan dalam kes-kes tampalan semula gigi kekal anterior di daerah Rompin.
Objektif
Mengenalpasti dan mengesahkan punca masalah peratusan tampalan semula gigi kekal anterior
melebihi paras standard.
Metodologi
Kaedah kajian menggunakan cross sectional.
Keputusan
Tindakan-tindakan baikpulih yang telah dilaksanakan jelas menunjukkan perubahan yang sangat
membanggakan di mana peratusan tampalan semula di daerah Rompin telah menurun sehingga
6.2% menjadikannya hanya 0.1% dalam jangka masa 2 tahun iaitu antara tahun 1999 hingga 2001.
Sehingga Jun 2002 jelas menunjukan terdapat lagi penurunan dalam peratusan tampalan semula
gigi kekal anterior.
Rumusan
Kajian QAP ini berjaya mengenalpasti masalah dan berjaya mengatasi masalah tersebut dengan
tindakan baik pulih yang telah diambil.
chapter 3
Peratusan Tampalan Semula Gigi Kekal Anterior Melebihi Paras
Standard di Daerah Rompin
38
chapter 3
PP/2003
The Rate of Permanent Tooth Loss (M+X/I00) Among 12-year-old
and 16-year-old School Children in Kota Tinggi District,
Johor- A 5-year Quality Assurance Study
Muz’ini M, Lim SC.
Klinik Pergigian Mersing, Johor.
Problem
The rate of permanent tooth loss among 12-year old and 16-year old school children exceeds the
standard set in the Quality Assurance Program. There is a need to take remedial actions and to
monitor achievement after implementation of the remedial plan.
Design
The Quality Assurance Technical Committee had a discussion to determine causes for the high rate
of permanent tooth loss. The committee made recommendations on remedial steps to be taken. The
committee met twice a year to monitor progress.
Background and setting
Mobile dental teams in Kota Tinggi district were calibrated and trained on remedial measures. Data
on the rate of permanent tooth loss and permanent tooth indicated for extraction of the same cohort
of schoolchildren from Standard 6 to Form 4 were collected for every student each year.
Key measures to improvement
Reducing tooth mortality among school children.
Using a preventive strategy that includes caries standardisation and calibration exercise. More
emphasis is placed on antenatal and toddler programme. Close collaboration with Syarikat Air Johor
to ensure that fluoride levels in the public water supply are at optimal levels.
Using a targeted strategy to reduce tooth mortality that includes introduction of a fissure sealant
programme in mobile dental squads and priority setting targeting urgent cases.
Effects of change
Tooth mortality decreases by 71.3% among 12 year olds and 54.1% among 16 year olds.
Lessons learnt
The teams involved in incremental dental care among school children agree that a combination of
planned strategy in priority setting and preventive measures contribute to the reduction in tooth
mortality.
39
PP/2003
Chu GT.
Pejabat Pergigian Sahagian, Sibu, Sarawak.
The aim of the project is to improve coverage of toddlers with the goal of achieving better oral health
for the preschool children. The project started in 2000 and has been monitored in 2001 and 2002.
The prevalence of caries among 6-year-old children in Sibu District was 78.0% (1998-1999 HMIS).
The toddler’s programme, one of the strategies to increase the awareness of the mothers in the oral
health care for their toddlers from the age of 0 to 4 years old should thus be emphasised.
On the Toddlers Day, a MCH, the Jururawat Masyarakat refers toddlers to the dental nurses who
will give dental health education to the mothers and perform a simple oral examination for older
toddlers. The coverage in 1998 and 1999 was 13.7% and 12.2% respectively.
Problem analysis showed that the scheduling of the programme and the referral system should be
improved to achieve better coverage.
The schedule was planned early with more sessions and meetings were held with staff from both
MCH and dental clinics to discuss on how staff from the two disciplines could work together, A
Model of Good Care was formulated. The achievement was 14.9%to 15.5%, 18.8% in 2000, 2001
and 2002 respectively.
A well-defined work process is important, but the key success factor is good inter¬discipline
collaboration. Health Department staff can learn to work towards a borderless clinic serving the same
people with the aim of improving and maintaining the health of the people. Furthermore corporate
culture values can be fine-tuned.
chapter 3
To Improve the Coverage of Toddlers Attending Toddlers’
Programme in Sibu District
40
OP/2003
chapter 3
Reducing Shortfall in Quality of Dental Radiographs Taken at
Klinik Pergigian Melaka Tengah
Lee KC, Norliza M, Siti KD, Goh KW.
Klinik Pergigian Melaka Tengah, Melaka.
Outline of Problem
High rejection rate of 17% intra-oral dental radiographs was noted in the Dental Clinic Melaka Tengah
compared to NIA of 5% for Hospital Radiology units. This resulted in wastage of time and materials
besides inconveniencing patients, delaying diagnosis and adversely affecting departmental image.
Some of the perceived contributory factors included lack of personnel knowledge/skill, incorrect
techniques, and poor quality of materials.
A reduction in the rejection rate to 10% was targeted as improvement. A 3 point rating system,
based on UK standards was adopted to measure the quality of intra-oral dental radiographs taken.
Recording format to register all radiographs taken, associated defects and characteristics of
materials was used. Model of Good Care was developed and compliance to Model was assessed
by observation. Structured questionnaire was also used to capture personnel knowledge, training
received, involvement with dental radiology.
Quality shortfall confirmed - 19% rejected out of 350 radiographs taken over 3 month period. Defects
mainly due to processing and positioning errors. Statistically higher proportion of repeat takes end
up rejected a second time. Compliance to Model of Good Care found to be weak in areas such as
positioning and processing techniques and supported by poor knowledge in these areas.
Strategies for Change
Training/retraining of personnel involved provided by senior dental officer. Reduce positioning errors.
Introduction and training in use of beam-centering device processing errors. Reduce processing errors
– develop Guide for processing times. Provide clock.
Effects of Change
Radiographic quality assessed again after 1 month using same rating system. Total of 217 film
assessed over a 1 ½ month period. Rejection rate decreased to 7% and proportion of films without
defects increased to 81% compared to 62% previously.
The Next Step
Continuous training/retraining is essential. Beam-centering device should be used routinely.
Radiographic quality to be regularly audited for dental primary care.
Chapter 4
Food Quality & Safety Related Projects
42
PP/2009
The Practices of Nil by Mouth for Procedures
in Intensive Care Unit and High Dependency Ward
Mageswary L, Harizah MY, Sharifah Mariam SZA.
chapter 4
Department of Dietetics and Food Services, Kuala Lumpur Hospital, Kuala Lumpur.
Multiple interruptions of feedings, especially cessation for procedures limit the adequacy of nutrition
intake among Intensive Care Unit (ICU) patients receiving mechanical ventilation. The study was
carried out to identify timeliness in initiation of nutrition support, the duration patients were on Nil by
Mouth (NBM) before and after procedures, i.e. tracheostomy and extubation and to identify reasons
for NBM time of more than 6 hours.
Initiate enteral feeding within 24-48 hours of admission. Reduce NBM time to less than 6 hours
before and after procedures.
Pre-intervention study was done from Jan-July 2007. The post-intervention study was done in OctNov 2007 and followed by tracking and trending in 2008-2009.
Mean feeding initiation time was 41.2 hours in ICU with feeding protocol and 65.8 hours without.
Patients received optimal feeding in ICU with written feeding protocol. Prolonged NBM time was due
to avoidable reasons such as doctors order and procedure postponed or cancelled.
Strategy for Change
An evidence-based Nutrition Support Protocol was developed and implemented. Four continuous
medical education (CME) sessions were carried out for doctors and nurses to educate good nutrition
support practices.
Effects of Change
Implementation of evidence-based feeding protocol and multidisciplinary team effort improved the
provision of nutrition support. Mean NBM time before tracheostomy was reduced from 17.28 to 8.10
hours. After tracheostomy, fasting time was also reduced from 10.85 to 7.04 hours. Mean NBM time
before extubation was reduced from 6.55 to 5.91 hours post intervention. After extubation patients
were fasted for 4.40 hours in pre-intervention and increased to 6.22 in post-intervention.
The Next Step
Ensure optimal nutrition support services by multidisciplinary ward rounds, CME sessions and evidence
based practices.
43
PP/2009
Patient Food Safety Goals: From the Farm to the Patient’s
Table
Easaw M, Ramli J, Mustaffa MN, Wan Norzahrin WM, Salmah K, Pang WL,
Ho SF.
Food safety has a huge impact on patient’s wellbeing and for this reason, Institut Jantung Negara (IJN)
embarked on Hazard Analysis Critical Control Point Food Safety Certification (HACCP). The standards
were based on National Board of Experts - HACCP, The Netherlands, June 2006. The HACCP audit is
vital in ensuring quality and reducing hazards in food service.
They are temperature controls, equipment calibration, microbiological sampling of food, vendor
compliance and incorrect flow of clean and dirty trolleys.
A gap analysis was conducted by using the HACCP checklist. Secondly, 28 checklists were developed.
Thirdly, six HACCP plans and process were categorized: Raw materials, hot and cold kitchen, beverage
preparation, ready-to-eat, and tray-line. Compliance was met in most areas due to ISO 9001:2000
Certification and MSQH Accreditation.
The results of audit Stage 1 and 2 recorded that the documentation met all the criteria to achieve
certifications. In the final audit, there were 2 Minor Non-Conformities and 5 areas required for
corrective actions and continual improvement has been carried out in stages.
Strategy for Change
The physical layout of the kitchen was redesigned. The next challenge was to change the mindset of
the personnel in all staff and vendors involved. This certification also activated multi-disciplinary team
members including the Senior Management to achieve the HACCP standards.
Effects of Change
Complaints on food safety reduced from four to zero within the 8 months. The temperature for
cooking were maintained above 74ºC for gravies, 97ºC for clear soup and holding temperatures
above 63ºC daily.
The Next Step
HACCP sets a preventive system for food safety assurance. The statistics provides continuous quality
improvement activities. They are sanitizing raw vegetables and fruits, swab tests to ensure uncooked
and cooked food are safe to eat and vendors’ performance.
chapter 4
Dietetics and Food Services, National Heart Institute, Kuala Lumpur.
44
PP/2007
Enhancing Understanding among Importers, Retailers and
Manufacturers Food Items on the Food Labeling Requirement
as Stipulated in 1985 Malaysian Food Act
Sunmuglvadivu E, Mariam B.
chapter 4
Jabatan Kesihatan Negeri Wilayah Persekutuan Labuan.
To enhance the level of understanding on the Food Labeling requirement under the 1985 Food Act.
This is expected to reduce sale of wrongly labeled food items in Labuan Federal Territory.
Nutritional labeling of food items was introduced in September 2003 under the Malaysian Food
Act and began to be enforced in September 2005. The understanding level of the requirement for
Nutritional Labeling is still in infancy stage.
A survey of importers, retailer and food manufactures was carried out in December 2006. The
information was collected via questionnaire, which consisted of ten questions on major elements of
the labeling requirement of the Malaysian Food Act.
There were 36 respondents for the survey, 5 were food items manufacturers, 8 were involved in food
importing activities, 5 were retailers and the final 18 were involved on retail and food imports. The
respondents scored between 6 and 10 marks. Thus, the respondents understood the training which
had been provided earlier and had a better understanding of the labeling requirement.
Strategy for Change
All respondents were provided with the booklets of Organization Chart for Food Safety and Quality
of Labuan Federal Territories. The Organization Chart booklet provided information on the person to
contact in Labuan when the respondents faced problems regarding the food labels
Effects of Change
After the training on the Malaysian Food Act, specifically focusing on Food Labelling requirement and
completion of the survey, the Food Safety and Quality Unit of Labuan Federal Territory received more
than 6 enquiries from local importers and retailers. These enquiries were ito ascertain the correctness
of food label prior to selling of the product in Labuan Federal Territory.
Lesson Learnt and the Next Step
An inspection exercise was performed in September 2007 to ascertain the level of compliance to the
Food Labeling requirement. It involved three major retailers in Labuan Federal Territory. The result
showed that level of compliance was between 43 to 72%. Although there is improvement in 2 of
the retailers but one retailer is still at the same level as prior to training, thus a dialogue session will
be conducted with the retailers and importers to improve the current situation.
45
PP/2005
Keracunan Makanan Sifar di Pusat Latihan dan Institusi
Pengajian Tinggi. Bolehkah Ia Tercapai?
Junainah S, Halid A, Kamal A, Ahmad Faisal A, Ab Rahman N,
Salihin J, Mohamad Harawi H.
Penyataan masalah
Di dalam tahun 2001 terdapat 15 Pusat Latihan Kerajaan dan Swasta serta 4 Institusi Pengajian Tinggi
Awam dan Swasta di dalam Daerah Sepang. Bilangan episod keracunan makanan yang berlaku di
Pusat Latihan dan Institusi Pengajian Tinggi di Daerah Sepang telah meningkat sernenjak tahun 1999
iaitu daripada 1 episod kepada 6 episod di dalam tahun 2001.
Pengukuran utama penambahbaikan
Langkah-Iangkah yang boleh menyumbang kepada penambahbaikan ialah pengisian jawatan di Unit
Keselamatan dan Kualiti Makanan, memperkukuhkan proses kerja di Unit tersebut, peningkatan
pendedahan mengenai aspek keselamatan dan kebersihan makanan di kalangan pengendali serta
penyelia premis makanan dan peningkatan kerjasama di antara Pejabat Kesihatan Daerah Sepang,
Pusat Latihan dan Institusi Pengajian Tinggi dan Majlis Perbandaran Sepang .
Proses pengumpulan maklumat
Satu kajian irisan lintang telah dilakukan untuk mengenalpasti faktor-faktor yang menyumbang
kepada masalah tersebut. Data berkaitan pemeriksaan premis makanan, kejadian episod keracunan
makanan, suntikan serta latihan untuk pengendali dan latihan untuk penyelia premis makanan telah
dikumpulkan dan dianalisa.
Analisa dan interpretasi
Kekurangan anggota di Unit Keselamatan dan Kualiti Makanan, pemeriksaan premis makanan
di Pusat Latihan dan Institusi Pengajian Tinggi kurang diberi keutamaan dan kurang pendedahan
mengenai aspek keselamatan dan kebersihan makanan dikalangan pengendali (hanya 12.8%
menghadiri kursus) dan penyelia premis (hanya 31.6%).
Strategi perubahan
Pengisian jawatan, memperkukuhkan proses kerja, meningkatkan pendedahan mengenai aspek
keselamatan dan kebersihan makanan dikalangan pengendali makanan serta penyelia premis
makanan dan meningkatkan kerjasama di antara agensi.
Kesan perubahan
Pemeriksaan premis makanan di Pusat Latihan dan Institusi Pengajan Tinggi diberi keutamaan
dan peratus pengendali dan penyelia yang menghadiri kursus pengendali makanan telah dapat
ditingkatkan. Bilangan episod keracunan makanan di Pusat Latihan dan Institusi Pengajian Tinggi
dapat dikurangkan daripada 6 episod di dalam tahun 2001 kepada sifar di dalam tahun 2003.
Langkah seterusnya
Pelaksanaan tindakan penambahbaikan ini diteruskan di dalam tahun 2004 dan 2005.
chapter 4
Pejabat Kesihatan Daerah Sepang, Selangor.
46
OP/2005
Improving Food Processing Management
Ramli J.
chapter 4
Gleneagles Intan Medical Centre Kuala Lumpur.
Problem
The need to improve the whole food processing operational chain was deemed significant as the
complaints on food contamination with foreign bodies, cleanliness, freshness and portioning were
consistently in existence even though there were improvements initiatives implemented. These had
led to the review of the whole food processing operations and the implementation of the critical
control check points. They were seen to be the best way of food processing reengineering.
Reduction in complaints, improvements in compliance to Critical Control Check Points practices and
staff evaluation on their work after implementation of the check points denoting staff satisfaction,
were some of the major key indicators of improvements noted .
Complaints were derived from the standard customer feedback questionnaires upon discharge,
written letters and incidences reported by internal staff. They were continuously being collected end
monthly reported by the Quality Management Department.
A checklist for good practices’ at each Critical Control Points Reference (Romano Gatland of Texas
1999) was used to regularly check food processing and the compliances were analysed monthly and
quarterly. An ad-hoc staff evaluation survey was conducted and their opinion noted.
Results showed an almost complete elimination of complaints on food contamination with foreign
bodies, cleanliness, freshness and portioning. The compliance to practices according to the Critical
Control Checkpoints checklist had continuously improved. Staff understood their work process better
and showed high morale.
Lesson learnt
Implementation of the Critical Control Check Points had led to a better guided set of good practices
for all the Food & Beverage personnel.
47
PP/2003
Peningkatan Kes Kurang Zat Makanan (KZM)
di Kalangan Kanak-Kanak Berumur Bawah 5 Tahun
di Daerah Seberang Perai Selatan
Umi Kalsom AR, Ramlah S, Kharison Z, Rodzoh T, Azizah HAM,
Rafidah MN, Chitra S.
Jenis Kajian
Kajian keratan rentas telah dilakukan oleh anggota Pejabat Kesihatan Daerah Seberang Perai Selatan
mulai bulan Mei 2000 hingga Ogos 2001 bagi melihat faktor-faktor yang menyumbang kepada
masalah tersebut.
Latarbelakang Kajian
Kajian dijalankan ke atas 99 kes KZM dan 50 orang anggota kesihatan yang terpilih menggunakan
borang soal selidik isi sendiri. Hasil kajian menunjukkan 67.6% daripada kes berbangsa Melayu,
India 23.4% dan Cina 9%. Kajian menunjukkan 74.7% ibu berpendidikan sehingga ke sekolah
menengah, 84.8% berpendapatan melebihi RM500.00 dan suri rumah tangga sepenuh masa
72.7%. Pengetahuan ibu terhadap pemakanan anak ditahap yang rendah. Hasil kajian mendapati
tahap pendidikan, status ekonomi dan pekerjaan ibu bukanlah penyumbang utama KZM.
Ke arah Penambahbaikan
Tahap pengetahuan anggota kesihatan berkaitan aspek pemakanan bayi dan kanak-kanak adalah
masih rendah. Hanya 26% mengetahui dengan baik sebab-sebab berlaku KZM dan 22% tahu
tindakan sewajarnya bagi pengurusan kes KZM.
Langkah-Iangkah ke arah penambahbaikan
Tindakan remedi telah dilaksanakan di semua Klinik Kesihatan dan Klinik Desa di Daerah. Anggota
Kesihatan telah diberi latihan untuk mempertingkatkan pengetahuan dan kemahiran bagi
membolehkan pendidikan kesihatan berkaitan pemakanan kepada ibubapa/penjaga dengan betul
dan berkesan dapat dlberikan. Penyeliaan berterusan ke atas staf oksilari dijalankan.
Kesan terhadap langkah penambahbaikan
Tindakan yang dilaksanakan telah menunjukkan keberkesanan yang ketara. Tahap pengetahuan
anggota terhadap pengurusan kes KZM dipertingkatkan dari 22% kepada 63%. Tahap pengetahuan
ibu terhadap pemakanan dipertingkatkan. Peratusan kes KZM 38.3% bagi Januari - Mac 2000
menurun kepada 18.4% bagi tempoh Januari - March 2001.
Pengajaran yang diperolehi
Dengan menjalankan kajian ini ahli kumpulan dapat mengenalpasti faktor-faktor yang rnendoronq
kepada peningkatan Kes KZM di kalangan kanak-kanak bawah 5 tahun. Ini dapat membantu usaha
ke arah penambahbaikan bagi mengatasi masalah yang telah dikenalpasti dan juga bagi memastikan
ianya terus dilaksanakan secara berterusan. Seiain itu dengan manjalankan kajian ini dapat
meningkatkan pengetahuan dan kemahiran ahli kumpulan terhadap proses-proses kepastian kualiti.
chapter 4
Pejabat Kesihatan Seberang Perai Selatan, Pulau Pinang.
48
PP/2003
Food Safety Information of Malaysia (FoSIM)
Harrison S, A’aishah SF, Noraini S.
chapter 4
Food Quality Control Division, KKM.
The control of food safety is under the jurisdiction of Ministry of Health. This includes domestically
produced food, imported as well as food for export. Import food surveillance is being conducted by
authorized MOH officers at the entry points and districts throughout Malaysia. To date, there are 34
entry points in Malaysia that allow importation of food namely, through sea, air and land ports. These
ports vary in their infrastructure capabilities depending on the types of ports, and the economy of the
various states and these ranges from basic to fairly advanced infrastructures.
The laws and standards applied are those stipulated under the Malaysian Food Act 1983 and its
regulation 1985 and these standards apply to food sold in Malaysia. As practiced by other developed
nation particularly Japan, the use of an integrated system for the clearance of goods is essential
for coordinated inspection of relevant authorities at entry points. Food Safety Information System
Malaysia (FoSIM) was developed as an enabler in ensuring that imported food is fit for human
consumption and thus protecting public health and safety. The design of FoSIM based on the existing
procedural control of imported food in Malaysia with additional technical inputs from the Japanese
experts obtained through collaboration with Japanese International Cooperation Agency (JICA).
Being the first of its kind in the Ministry of Health (MOH), the web-based application (FoSIM) provides
a channel of information communication to importers/agents that import food, MOH enforcement
officers at 34 entry points, and FQC laboratories. The application system comes with inbuilt
intelligent engine and capability to interfere with Custom Information System. The application has
flexible security management system in controlling system access, edit and printing of information.
The system also has an in built capability to record all critical actions taken by a user, and ability
to establish auditing. The primary objective of the system is to strengthen import control activities
through consistent quidance recommended by the application.
Chapter 5
Laboratory Services Related Projects
50
PP/2011
Reducing Rejection Rate of Blood Film Malaria Parasite Sample
due to Unsatisfactory Smear from Emergency and Trauma
Department
Tchong FL, Nadiah AR, Noriah Y, Timothy B, Marilyn AA.
Department of Pathology, Sarawak General Hospital, Sarawak.
chapter 5
Blood Film Malaria Parasite (BFMP) is a screening test used to differentiate the malaria parasite species.
A good quality BFMP slide is important for the correct identification of malaria species; therefore
unsatisfactory BFMP slides will be rejected.
This study aimed to reduce the rejection rate of BFMP sample from ETD, SGH to less than 5% by
conducting appropriate remedial action.
Retrospective record review of 500 samples was carried out from 1 March 2010 until 30 June 2010
to identify the factors for sample rejection. After the remedial actions were taken, a cross sectional
study was done from 1 September 2010 until 31 December 2010. Data were collected from from the
Laboratory Information System (LIS) and Notification of Specimen Rejection Record.
The data showed 18% of the sample reviewed was rejected due to multiple factors. Unsatisfactory
smear received contributed to the most sample rejection due to poor preparation technique of BFMP
slides. Regular change of staff and lack of supervision were the perceived factors which contributed
to the existence of this problem.
Strategy for Change
Five sessions of hands-on training on proper technique of BFMP slide preparation and Continuous
Medical Education (CME) was conducted to ETD,SGH staff of all categories, involved in preparing
BFMP slides. Experienced personnel from the Vector Unit, Sarawak State Health Department, were
invited to be the trainers. Useful tools such as slide spreader and handy guideline were also given to
all participants. A short demonstration on proper BFMP slide preparation to all housemen attached
to the laboratory was also provided.
Effects of Change
Post intervention data showed the number of BFMP sample rejected was successfully reduced from
18% to 2% (total 500 samples). Re-evaluation carried out in January to April 2011 showed the
rejection rate from ETD,SGH was maintained at less than 5%.
The Next Step
To meet the standard, continuous education on sample preparation shall be given to the staff. The
remedial actions will be expanded to other departments in SGH for continuous quality improvement.
51
PP/2011
Improving Turn-Around-Time of Culture and Sensitivity Testing
Wong MK, Abdullah A, Justin F.
Laboratory and Blood Bank Unit, Hospital Labuan, Wilayah Persekutuan Labuan.
Two key measures for improvement, “Percentage of C&S TAT within Target (TAT%)” and “90th
Percentile of C&S TAT (TAT-P90)” were used. TAT% is an overall measure of performance by setting
the targeted TAT at the 3rd day. Meanwhile, TAT-P90 measures the process efficiency by showing the
longest TAT of 90% of C&S. The aims were to achieve 90% TAT within target and to have TAT-P90
less than 3 days. TAT was defined as the time from receiving samples to despatching reports.
A retrospective-prospective study design was employed starting from November 2010. Data
were collected retrospectively for November through LabNet to assess the extent of the problem.
Subsequent data were collected prospectively from December. Workflow Analysis was also carried
out to disclose inefficiency in the C&S procedure.
Workflow Analysis revealed that precious time was wasted over the weekend when microbiological
laboratory was closed. Critical information for treatment e.g. Gram-group and probable bacterial
identity already available on the 2nd day of culture was withheld until the final report was prepared.
Strategy for Change
Standardised preliminary C&S results were dispatched to wards since December. Holidays and
weekends duty roster were implemented from January onwards. Improving the TAT was also set as
Sasaran Kerja Tahunan for the staff.
Effects of Change
TAT% was increased to and maintained at more than 95% from January onwards. At the same time,
TAT-P90 was reduced to less than 3 days. This achievement boosted staff morale.
The Next Step
The interventions were shown to be effective and have been implemented since then and TAT% and
TAT-P90 have become the Key Performance Indicators for microbiological services.
chapter 5
Clinicians expect culture and sensitivity (C&S) reports to be ready within 2 days. Past experience had
showed that we were far from meeting the targeted turn-around-time (TAT) which is 76%. Delay
in producing reports had resulted in prolonged hospitalisation. This study aimed to improve TAT of
C&S.
52
PP/2009
Increasing the Rate of Positive Microorganism Isolates in the
Blood Cultures of Patients Suspected to Have Bacteraemia
in the Medical Wards in a Government Hospital
Muhammad Zakuan AJ, Tieh SC, Lee LY, Eow YN, Hamidah AK, Razliza R,
Saudi B, Siti Azlina MY, Tan TP.
Sri Manjung Hospital, Perak.
chapter 5
There was a decrease in the positive microorganism isolates in the blood cultures in the Medical
Department to 8.49% as compared to the standard of at least 10%.
The general objective was to increase the rate of positive microorganism isolates in the blood cultures.
The specific objectives were to determine the rate, identify the contributing factors to problem, to
formulate remedial measures and to evaluate the effectiveness of the remedial measures.
A retrospective laboratory record review was carried out from September to December 2007 to
determine the rate. A survey via questionnaire on practice of taking blood culture was done to
determine the contributing factors. A post interventional study was done from February to July 2008
to evaluate the effectiveness of the remedial measures.
The rate of positive microorganism isolates was 8.49%. The ABNA was 1.51%. The contributing
factors to the problem were improper sets use, improper disinfectant use, nonaseptic technique,
insufficient volume of blood specimen and taking blood culture after antibiotics.
Strategy for Change
Remedial measures were adherence to aseptic technique by doctors, use of Blood C&S set, use of
Chlorhexidine 1:200 in 70% alcohol as disinfectant, a minimum of 8 ml of blood specimen and
taking blood culture before antibiotics. Training was done via Continuous Medical Education (CME)
and Continuous Nursing Education (CNE) and house officers’ orientation. Check list for blood culture
taking was also implemented.
Effects of Change
The rate of positive microorganism isolates improved from 8.49% to 12.49%.
The Next Step
This quality improvement study has increased the rate of positive microorganism isolates in the blood
cultures in the Medical Wards. We plan to implement the new work process hospital-wide and
continue to monitor the rate.
53
PP/2007
Reducing Pre-Analytical Variables Affecting Therapeutic Drug
Monitoring (TDM) Requests in Drug & Research Laboratory,
Sivasangkari S, Raja Elina R, Kamarulzaman H, Aslinda T, Ernie JJ,
Muhammad Arif MK.
Pre-analytical variability can have profound impact on a laboratory’s ability to produce an accurate
result of a laboratory investigation. Inaccurate laboratory results will affect interpretation made by
the pharmacist on the drugs’ therapeutic effects and calculation of the required dosage. This quality
assurance project aimed to identify the contributing factors, formulate and irnplemest remedial
measures so as to reduce pre-analytical variables which can affect the quality of diagnosis.
To reduce the rate of laboratory rejection and improve the pre-analytical variability that can affect
results produced by the laboratory in monitoring therapeutic drug levels.
Prospective analysis from April 2002 to September 2004.
The main reasons for rejection were clotted blood, usage of wrong container, insufficient sample
collected, haemolysed blood and blood spilled or leaked.
Strategy for Change
Continuous customer education, training and implementation of new request form was executes to
overcome the problem of non-compliance to the criteria. Plan-Do-Check-Action (PDCA) cycle was
also adopted as a measure to improve the current situation.
Effects of Change
The number of specimen rejected due to clotted blood was reduced from 42% to 4%, use of
wrong container decreased from 26% to 4%, insufficient blood decreased from 14% to 6%, blood
hemolysed was reduced from 11 % to 3% and rejection due to blood spilled or leaked decreased to
2% as compared to 7% between 2002 and 2004.
Next Step
TDM forms are currently being evaluated and new forms shall be introduced and implemented once
agreed by all parties concerned, that is the clinicians, pharmacists and the laboratory personnel.
Close monitoring by the designated person-in-charge and continuous training and support through
consultation by the laboratory workforce are expected to give a positive impact.
chapter 5
Hospital Kuala Lumpur.
54
PP/2005
To Reduce High Incidence Rate of Rejected Full Blood Count
Specimens from Medical Ward in Haematology Unit, Sarawak
General Hospital, Kuching
Aishah AN, Jong NK, Dyg. Jauyah AA, Mijen N, Dong KY, Rosella D, Liah E.
chapter 5
Sarawak General Hospital, Kuching, Sarawak.
Outline of Problem
The Haematology Unit, Pathology Department, Sarawak General Hospital provides diagnostic testing
for diagnosis, classification and treatment of diseases. The results must be accurate and fast for
appropriate management of care. Data analysis showed that the rejection rate of specimens from the
Medical Ward was higher than the national’s norm. This has caused delay in processing specimens
and producing results. Consequently, treatment may be delayed and this will increase the risk of
complications in patients.
Key measure for improvement
The key measure for improvement was the rejection rate of specimens for full blood count (FBC). The
national target for this indicator is <0.86% of FBC samples.
A retrospective quantitative study was conducted to identify factors leading to the problem.
The rejection rate of FBC samples in Medical Ward was 2.49%. The main causes were lack of
communication between laboratory staff and ward staff, lack of knowledge on proper blood
collection procedure and absence of a standard rejection protocol from the laboratory.
Strategy for change
Improve knowledge and competency of staff in managing blood collection and handling. Ward staff
were briefed on proper blood collection procedures and criteria for rejection of blood specirnens. A
‘Notification of Rejection Form’ was also introduced to the ward.
Effects of change
The specimen rejection rate for FBC from Medical Ward was reduced to 0.48%. Better communication
and cooperation between ward staff and laboratory staff was achieved and the overall knowledge of
ward staff on proper blood collection techniques had improved.
The next step
The rejection rate of specimens for FBC will continue to be monitored and the usage of ‘Notification
of Rejection Form’ will be standardised throughout Pathology Department, Sarawak General HospitaI
beginning in 2006.
55
PP/2003
Pengurusan Inventori Darah: Merendahkan Kadar Darah Yang
Lupus
Hakimah M, Mariyah A, Asmashah, Hazim A, Hui TK, Ahmad MI, Zaiton J,
Yusniza Y.
Setiap unit darah yang lupus melibatkan pembaziran sumber yang terhad. Kadar darah yang lupus
di Hospital Kangar adalah 9.26% (Jul-Dis/2002). Kemungkinan penyebab masalah ini adalah darah
terikat kepada pesakit (in reserve), inventori darah yang tinggi, stok darah yang rendah dan darah
dari hospital lain yang selalunya mempunyai jangka hayat yang pendek ketika penerimaan. Objektif
kajian ini adalah untuk mengurangkan kadar darah yang lupus dan seterusnva dapat mengelakkan
pembaziran sumber.
Piawaian kebangsaan kadar darah yang lupus adalah kurang dari 5% dari darah yang dikumpul.
Pada 2002, kadar lupus darah merah bagi seluruh negara adalah 5.29% (BTSIS 2002)
Kajian retrospektif menggunakan data-data unit transfusi antara 1 Julai hingga 31 Disember 2002
telah dilakukan. Data-data dimasukkan kedalam format-format yang disediakan.
Keputusan menunjukkan kadar lupus darah merah bulanan’ adalah 5.9-20.3%. 4/5 dari darah
yang disimpan dalam reserve tidak digunakan. 26% dari darah yang lupus adalah dari hospital lain,
walaubagaimana pun hanya 7.4% sumber kutipan datang dari sumber ini.
Penyebab yang paling ketara adalah bilangan darah reserve yang tinggi. Tindakan penambahbaikan
yang diambil adalah semua permohonan untuk reserve darah akan menjalani Group, Screen and
Hold kecuali bagi kes-kes antibodi, pediatrik dan aneamia, darah akan dibekalkan dalam masa 20min
apabila transfusi dikehendaki. Surat makluman kepada pakar-pakar, pegawai perubatan dan wadwad diedarkan. Kakitangan unit transfusi telah diberi taklimat.
Pemantauan berterusan menunjukkan selepas 6 bulan, kadar lupus darah merah telah menurun
ke 3.4%, purata harian darah dalam reserve (mengikut kumpulan) dapat diturunkan tidak melebihi
14 unit/hari (19-20 unit/hari sebelumnya) dan purata harian darah dalam stok telah meningkat ke
92.3365 unit/hari (dari 81.5559 unit/hart). Bilangan darah yang terpaksa diambil dari hospital lain
telah menurun ke 21.3 unit/bulan. Lebih banyak darah dalam stok memudahkan pengurusan darah.
chapter 5
Unit Transfusi, Jabatan Patologi, Hospital Kangar, Perlis.
56
PP/2003
High Specimen Rejection Rate in Pathology Department
of Sungai Petani Hospital
Kala Devi N.
Hospital Sungai Petani, Kedah.
Objectives
A need arises to look into the reasons behind the increment of rejection rate for the year 2000 in the Pathology
Department. A retrospective study from July - Dec 2000 showed that errors occurring in the pre-analytical phase
had increased the rejection rate from 0.11% in 1999 to 0.78% in the year 2000. The National Standard is
only 0.86%. This study hopes to improve the process of specimen taking in the pre-analytical phase as well as
transportation of specimen to laboratory, hence reducing the rate of rejection of specimens.
chapter 5
Design
A team was established which consisted of a pathologist, scientific officers, ward managers and Medical Lab
Technologist. The team outlined an action plan based on the continuous quality improvement methodology. The
whole study was a retrospective study.
Background of setting
In Sungai Petani Hospital, the integrity of laboratory services is often challenged by the poor quality of specimens
that reaches the laboratory. An average 30,000 specimens received in a month and these contribute to about
90,000-100,000 tests. Presence of a pathologist and the increase in number of specialists had increased the
number of specimens received, thus increasing the rejection rate of specimens.
Study Participant/Population
Analysis of data showed that the errors in the pre-analytical phase, outside laboratory, had increased the rejection
rate. In order to prove that knowledge, skills and attitude were the major factors, which contributed to the errors
that take place in the pre-analytical phase, a multistage sampling method was used. A total of 150 staff nurses
who were involved in the pre-analytical phase were chosen to participate in a cross¬sectional study.
Key Weaknesses/Shortfall In Q Identified
The knowledge and skills among the staff in pre-analytical phase, outside laboratory, were key weaknesses. In
addition, the work process of transportation and checking mechanism of specimen received in laboratory was
also among the contributing weaknesses identified.
Intervention/ Remedial Measures
Remedial measures included training of staffs who were involved in the pre-analytical phase and a specimenreceiving counter in the laboratory had been created to ensure that the specimens were sent with proper
labels. The latter is to ascertain the integrity of the specimens. To ensure that every specimen was accompanied
by laboratory investigation form, the ward staffs were instructed to attach the specimen on the laboratory
investigation form. Assigning a ward manager had reduced the number of rejected specimens from female
wards, A3 (the highest rejection contributor). Finally, a special checklist, entitled “why your specimen was
rejected”, attached with the rejected specimen’s investigation form, had also given awareness to the staff nurses.
Implementation
The remedial measures implemented from January - June 2001 and re-evaluation was from July - December
2001.
Main outcome measures re-evaluation
The rejection rate had decreased to 0.41 % in the year 2001 and for the year 2002, the rejection rate (reevaluation second cycle) was 0.48%. This had reduced the rejection rate below the standard, which is 0.5%.
Conclusion
By reducing the rejection rate, delay in instituting treatment for patient was reduced, meaning better patient
management. Customer satisfaction is further enhanced, whereby patients were not put in uncomfortable
situations, since repeated bleeding was almost eliminated. Unnecessary workload was eliminated thus increasing
efficiency for both the ward staffs as well as the laboratory staffs. Finally, management of cost had improved, in
which an average of RM 16.32 can be saved if a specimen is not rejected.
57
OP/2003
Overcoming The Problems of Unnecessary Repeated Blood
Specimens
Yap YS, Vun YM, Tai KC, Gumpil J.
Tawau Hospital, Sabah.
Design
Overcoming the problem of unnecessary repeated blood specimens was identified as a priority.
Continuous quality improvement (CQI) methodology and the Plan-Do-Study-Act cycle (PDSA) were
applied for this QAP study.
Tawau Hospital had an average of 1,428 admissions per month in year 2001. Blood was taken by
nurses and doctors for every admission, and delivered by hospital attendants to the laboratory.
Reducing the incidence of repeated blood specimen would mean saving of resources for both the
patients and hospital. Consequently, this would reduce complaint from patients.
Designed guidelines on correct technique of blood taking were given out to all wards. The committees
conducted educational teaching and random checking on blood taking. All units concerned were
advised to use the standard MOH approved test tubes during the study period.
Effect on change
The results indicated that before and after remedial action, there was a total reduction of 2.1%
unnecessary repeated blood specimens from 3.6% to 1.5% respectively.
Lessons learnt
From this study, it is recommended that all staff must follow guidelines when taking blood. The team
plans to carry out re-evaluation study every six months as a constant reminder to ensure adherence
to standard practice.
chapter 5
Problem
Repeated blood specimen can result in time and money wastages, and stress on the patients
concerned. The aim of this study was to investigate the contributing factors to the problem and to
recommend measures to overcome them thus improve quality of patient care.
chapter 5
Chapter 6
Nursing Related Projects
60
PP/2011
Meningkatkan Aktiviti Penyusuan di kalangan Jururawat
di Tempat Kerja
Norbaizora M, Ruzita MY, Sapinah MK, Kalsom M, Rohani H, W. Mohd Faizal
A, Ahmad Syahir S, Norhasriza Z, Nor Syarahani J.
Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan.
chapter 6
Pemilihan Peluang untuk Penambaikan
Hospital Universiti Sains Malaysia (HUSM) merupakan Hospital Rakan Bayi, namun bilangan
jururawat yang melakukan aktiviti penyusuan ketika di tempat kerja masih rendah (26.7%). Antara
penyebabnya ialah pakaian seragam jururawat sedia ada labuh dan sukar disingsing. Ini menyukarkan
untuk memerah / memberi susu kepada bayi serta mendedahkan anggota badan yang tidak terlibat
semasa aktiviti penyusuan. Projek ini dilakukan untuk mempermudahkan aktiviti penyusuan di
kalangan Jururawat di HUSM dengan menjadikan Jururawat sebagai Role Model.
Sasaran projek untuk menurunkan tahap keparahan atau tahap kesukaran melakukan aktiviti
penyusuan dari 100% kepada 50% di kalangan jururawat yang mempunyai anak yang berusia
kurang dari 2 tahun.
Kaedah pengumpulan data menggunakan borang soal selidik yang diedarkan kepada 60 orang
jururawat yang mempunyai anak berusia kurang dari 2 tahun dan masih menyusu untuk mengetahui
masalah yang mereka hadapi semasa aktiviti penyusuan di tempat kerja. Soalselidik pemilihan 4
rekabentuk pakaian seragam juga diedarkan kepada 30 orang jururawat di zon penyusuan iatu
pakaian seragam berbutang tengah, pakaian seragam berbutang serong, pakaian seragam berzip 6
inci yang diletak 2 sm dari puting ke bawah.
Analisis pemilihan rekabentuk didapati undian tertinggi (76.6%) adalah pakaian seragam berzip 6
inci yang diletak 2 sm dari puting ke bawah.
Penambahbaikan pakaian seragam sedia ada dibuat dengan cara menambahkan zip sepanjang 6 inci
pada bahagian kiri dan kanan hadapan pakaian seragam, zip ini diletakkan 2 sm dari atas puting ke
bawah.
Projek kami telah berjaya menurunkan tahap keparahan sebanyak 62%. Perbandingan dilakukan
sebelum dan selepas penambahbaikan pakaian seragam menggunakan borang soalselidik yang
diedarkan kepada responden yang diujicuba. Hasilnya mendapati penjimatan dari segi masa dan kos
serta keselesaan ketika aktiviti penyusuan.
Langkah Seterusnya
Antara faktor yang menghalang jururawat melakukan aktiviti penyusuan di tempat kerja adalah
rekabentuk pakaian seragam yang sedia ada. Pengubahsuaian yang dilakukan memudahkan semua
jururawat menyusukan bayi dengan susu dada. Projek ini tidak terhad kepada jururawat sahaja tetapi
akan digunapakai oleh Pembantu Kesihatan HUSM.
61
OP/2005
THIS! Does It Improve Nursing Care
F.K Leong, Shona, Siti, Elizabeth, Norshidah, Zamizah, Norhanita, Azizah,
N. Tan, Fitgerald Putrajaya.
Hospital, Wilayah Persekutuan Kuala Lumpur.
Outline of problem
Transcription of doctor’s prescription has a potential to contribute to medication errors. Poor medication
administration and documentation compromise patient’s safety. A nursing audit conducted from
01.03.2005 to 15.04.2005 showed that 67% of doctor’s prescriptions were transcribed onto papers/book
prior to serving medication, and 45% incomplete and 30% no documentation of medication administered.
Documentation was haphazard. Therefore, a study was indeed needed to determine the magnitude of this
problem and through a quality process approach, improvements implemented.
• Reinforce the THIS policy in the prescription and documentation of medication served.
• Establish an effective user friendly IT training program with an improved system back-up.
• Transcription of doctor’s prescription was discouraged.
A prospective study (01/05/2005 to 30/10/2005) involving all staff nurses on duty in 3 surgical wards.
All medication, patient’s notes and staff’s questionnaires were reviewed using a formulated format on a
randomly chosen day. A cross sectional descriptive design was utilised.
1)
2)
3)
4)
46% of medication served had incomplete documentation
There was a 100% transcription of doctor’s prescription
3 transcription errors and 1 reported incidence of medication error
81% of the doctor’s prescription adhered to ‘THIS’ policy
Strategy for change
Recommendations were made using PDCA cycle with the head of department’s approval:
1) Several IT related problems were overcome through meetings with nurses, pharmacists, doctors
and IT personnel
2) A documented workflow of training and orientation program for new and existing staff with
emphasis on ‘THIS’ was implemented
3) No transcription of medication prescription was allowed
Effects of change
There was improvement after a month’s implementation.
1) Documentation of medication served improved from 54% to 67%
2) No transcription or prescription and medication error
3) Doctor’s prescription according to ‘THIS’ policy improved from 81% to 95%
The next step
For ‘THIS’ to be well implemented, on-going personnel training is a must to change staff attitude to take
full advantage of IT. With seamless integration and good attitude, hospital wide implementation will be
our next step.
chapter 6
62
OP/2003
Towards Reducing the Incidence of Inaccurate Intravenous
Infusion
Zaida Y, Lin KH, Zauyah G, Noor Hanim R, Juruah H, Asnah D, Raja I,
Suriyanti A, Khatijah M.
Tengku Ampuan Afzan Hospital, Kuantan, Pahang Darul Makmur.
Problem
A need to elevate the quality of nursing care on intravenous infusion by reducing the incidence
rate of inaccurate infusion. Our ultimate aim is to enhance patients’ satisfactions so that the clients
received the intravenous infusion at the prescribed rate for the intended period of time.
chapter 6
Design
A nursing QA committee comprising ten sisters and one staff nurse launched a one-week prospective
and quantitative investigation in February 2002 to verify the occurrence of inaccurate infusions. The
three weeks’ prospective, quantitative, and qualitative studies were conducted in February and June
2002 in eiqht active wards. Two formulated questionnaires were used in this study.
Background and Setting
Nurses are responsible for administering and maintaining the therapy as prescribed. One of the
findings through a random monitoring process in 2001 revealed that a fair number of the intravenous
infusions failed to deliver fluids on schedule with the dangerous consequence of either under or over
infusions.
Eliminating the rate and ratio of inaccurate intravenous infusions. Besides, our mission was the
elimination of inadequacies and weakness in the provision and sustenance of quality nursing care,
knowledge, and compliance of quality nursing care. We were cognizant of the need to enhance
patients’ and staffs’ satisfaction and confidence.
To achieve the goal, several remedial measures were effected an innovative hourly marker on infusion
bottle, conducted CME/motivational talks, delegation of specific assignment, installed wall hooks
and provided ‘5’ hooks, and displayed revised nursing guideline.
Effects of Change
Inaccuracy rate of infusion pi from plunged from 38.4% to 6.6% and occurrence ratio from 1:2.6 to
1:15. The incidence rate of under infusion at 4.2% was higher than that of over infusion at 2.4%.
Survey on 100 nurses showed a significant improvement in knowledge from 51.1% to 80.2%. Staff’s
satisfaction feedback survey indicated 97% concurred that the new system was beneficial to patients.
The patients’ satisfaction survey manifested 98% were satisfied with the nurses’ management of
intravenous infusion.
Lessons learnt
Regular discussions helped to identify, and overcome problems faster and effectively. Awareness of
their role and responsibility, among nurses. Constant monitoring to ensure quality is not comprised.
The incidence rate has become one of the HSA indicators of Nursing Department Tengku Ampuan
Afzan Hospital, Kuantan.
63
OP/2003
Incidence of Thrombophlebitis among Patients Receiving
Intravenous Therapy - Hospital Miri Experience
Agnes SN, Tie SF, Mary G, Ismail A.
Hospital Miri, Sarawak.
Methodology
Data collected by Quality Assurance Unit via standard monthly reporting procedure for thrombophlebitis
among patients receiving intravenous therapy from 1 July 2001 to 30 June 2003 were analyzed
retrospectively and the incidence rate was obtained. A briefing was carried out by matron to staff
involved regarding the need to report all cases-or thrombophlebitis. Prospective study was carried
out after that for first two weeks of the month for two consecutive months, starting from September
2003 to November 2003. The data obtained were analysed and compared with the previous incidence
and the high incidence areas were identified.
Results
The overall incidence of thrombophlebitis reported via standard reporting procedure among patient
receiving intravenous therapy from 1 July 2001 to 31 June 2003 was constant at 0.6%-0.8%.
However, the incidence obtained through prospective study showed an increase in the incidence,
which was 2.62% in the first two weeks of September and 2.29/0 during the same period in October.
Highest incidence of thrombophlebitis was reported In Female Surgical ward, which were 23.0% and
6.8% in September and October respectively. The other area that showed a constantly high incidence
is Peadiatric ward 2, which was 4.2% and 5.0% in September and October respectively. The other
areas that were noted to have fluctuating incidence of thrombophlebitis were Special Unit (8.9% in
September and 0% in October), Orthopedic ward (0% in September and 7.5% in October), Male
Surgical ward (0% in September and 6.8% in October), Peadiatric ward 1 (3.3% in September and
0% in October) and Antenatal ward (2.5% in September and 0% in October).
Conclusions
As a whole, the incidence rate of thrombophlebitis among patients receiving intravenous therapy
in Miri Hospital was maintained at a low level ranging from 0.6%-2.6%. Constant reinforcement
and awareness to all staff involve in the ward had improved reporting of cases as shown during the
prospective study period. Current policy on intravenenous cannula insertion and monitoring must
be maintained and further reinforcement and monitoring at high incidence area will result in further
improvement.
chapter 6
Objective
This study is to determine the baseline incidence of thrombophlebitis reported via standard reporting
procedure among patients receiving intravenous therapy from June 2001 to July 2003 and compare
this with the incidence during study period and also to identify high incidence area, so as remedial
measures can be planned and implemented more effectively.
chapter 6
Chapter 7
Patient Care Related Projects
66
OP/2009
Masa Menunggu Lama bagi Kes Bukan Kritikal di Jabatan
Kecemasan
Mohamed Hisham AS, Umi M, Fazyana MY, Ismail A, Harun S.
chapter 7
Accident & Emergency
Jabatan Kecemasan, Hospital Pontian, Johor.
Kajian Kepuasan Pelanggan menunjukkan hanya 40% pesakit mendapat pemeriksaan Pegawai
Perubatan dalam masa kurang dari 1 jam di Jabatan Kecemasan Hospital Pontian. Kelewatan
mendapatkan pemeriksaan dan rawatan boleh menyebabkan komplikasi kepada pesakit dan
meningkatkan aduan. Pelaksanaan kajian ini bertujuan untuk mengukur masa pesakit menunggu
dan mengenalpasti faktor kelewatan serta usaha-usaha penambahbaikan.
Standard yang ditetapkan ialah untuk mencapai sasaran 90% pesakit mendapat konsultasi Pegawai
Perubatan dalam masa kurang dari 1 jam.
Kajian pra-intervensi telah dijalankan dari Julai hingga September 2007 untuk mengenalpasti masa
menunggu dan faktor penyumbang kelewatan. Data diperolehi dari Buku Pendaftaran pesakit,
waiting time slip dan soal selidik.
Hasil kajian menunjukkan 47% pesakit menunggu kurang dari satu jam. Faktor utama masa
menunggu lama adalah disebabkan oleh Pegawai Perubatan lewat berada di Jabatan Kecemasan
dan pembahagian kerja petugas yang tidak sistematik.
Jadual anggota petugas di Jabatan Kecemasan telah distruktur semula. Seorang Pegawai Perubatan
ditetapkan bertugas mengikut giliran setiap 6 bulan sekali secara aktif/ pasif. Penolong Pegawai
Perubatan dikehendaki membuat penilaian awal (assessment) terhadap pesakit sebelum konsultasi.
Kajian intervensi dijalankan untuk menilai semula keberkesanan usaha penambahbaikan. Hasil kajian
menunjukkan peratus pesakit menunggu untuk mendapat konsultasi Pegawai Perubatan dalam
masa kurang dari 1 jam telah meningkat dari 47% kepada 65.5%.
Langkah Seterusnya
Penjadualan tugas yang sistematik dan deskripsi tugas anggota yang jelas diperlukan bagi
mengurangkan masa menunggu.
67
OP/2007
Reducing the Incidence of Deterioration of Acute Trauma Cases
During Inter-hospital Transfer from Hospital Sungai Bakap
Teo GS, Teh KP, Zaiton M, Maznah MZ, Ong AL.
Hospital Sungai Bakap, Pulau Pinang.
Reducing the percentage of acute trauma patients who deteriorated during the inter-hospital transfer, and
improving the knowledge and competency of staff in monitoring and managing acute trauma patients
during the transfer.
A study was carried out from September 2005 to February 2006 to determine the percentage of trauma
patients who deteriorated during inter-hospital transfers. All acute trauma cases transferred from Hospital
Sungai Bakap to Hospital Pulau Pinang and Seberang Jaya were included in the study. An audit was carried
out on the documentation of monitoring parameters in the referring hospital, during transportation and
on arrival to the receiving hospital. Availability of equipment was monitored through specific recording
book. Staff knowledge and attitude were assessed via questionnaires. Analysis and Interpretation
It was found that 10.1 % of 158 trauma cases had deteriorated during the transportation. The majority of the
patients who deteriorated (8.2% of all trauma cases transferred) were not detected during transportation
because of inadequate monitoring and 1.9% of them were found not appropriately stabilised before the
transfers because they had penetrating injuries and multiple traumas. Poor knowledge and attitude of
staff were identified as the general factors affecting inadequate monitoring and management of these
trauma cases.
Strategy of Change
The interventions instituted included training program on the management of transferring trauma patients
for all staff involved in the transfer of trauma cases and close supervision to ensure adequate monitoring
and management during transfer
Effect of Change
Post intervention studies in April-September 2006 and January–June 2007 showed improvement in the
monitoring of trauma patients during transfer, and the level of staff knowledge and attitude in management
of acute trauma cases. The percentage of acute trauma patients that had deteriorated during transport
reduced from 10.1 % to 5.3%. Undetected deterioration of patients’ vital signs during transfers had
reduced from 8.2% to 0%.
Next Step
Continuous monitoring of the key measures of improvement had contributed to a sustained result. A
similar strategy may be adopted to involve other transferred cases apart from trauma cases.
chapter 7
Following initial resuscitation and stabilisation, acute trauma patients may require transfer for specialist care
in the receiving hospital. Inadequate initial stabilisation, missed or under-treated injuries and inadequate
monitoring during transfer may lead to serious complications. This study was done to determine the
contributory factors and to implement appropriate remedial measures.
68
OP/2007
Improving the Rate of Dry Ambulance Run in Ambulance Service
of Emergency Department Ambulance Service,
Sarawak General Hospital, Kuching
Alexander T, Sarpani K, Zuriah H, Molly S, Anthony R, Colin SJ.
Emergency Department Sarawak General Hospital, Kuching.
chapter 7
Patient satisfaction is the core business of every unit in the hospital. Providing prompt service to our patients
on arrival to Emergency Department is our quality improvement goal. Dry ambulance is an incidence when
the ambulance was called to the scene but come back empty without bringing in any patient or victim.
Dry ambulance run causes wastage of manpower, time and expenses. The incidence of dry ambulance
run in our hospital due to victims brought in by the Rescue 991 or because of flight delay or cancellation
in year 2005 (July until October) was 4.67%. This quality assurance project aimed to verify the incidence,
identify the contributing factors, formulate and implement remedial measures to reduce the incidence of
dry ambulance run.
Reducing the rate of dry ambulance run due to victims brought in by the Rescue 991 or because of flight
delay or cancellation to not more than 2%.
We carried out a retrospective study from 2003 to 2005. We identified the types and main reasons of dry
ambulance run from July to October 2005. Instruction was given to all ambulance crew to explain and write
down the reasons of dry ambulance run in the PHC format (Ambulance Run Sheet). Trial implementation
was carried out from November 2005 to April 2006. The full implementation of the project began in
August 2006.
The contributing factors identified were the absence of a two-way communication between the Emergency
Department and the Rescue 991 team upon receiving an ambulance call, and there was no confirmation
made with the referring hospital, Malaysian Airlines, Air Asia or the Malaysia Airport Authority regarding
the requests before dispatching the ambulance to fetch patients at the airport.
Strategy for Change
Our remedial measures were to first communicate with the Rescue 991 team within 1 minute of receiving
an ambulance call before dispatching an ambulance to the scene. We also made prior confirmation with
the referring hospital, Malaysia Airlines, Air Asia or the Malaysia Airport Authority before dispatching an
ambulance to the airport.
Effects of Change
We managed to reduce the percentage of dry ambulance run from 4.67% (July to October 2005) to
2.52% (July to October 2006)
Next Step
With more effort and cooperation from the Emergency Department staff, we believe our target of not
more than 2% can be achieved. The established Call Centre is recommended to verify all ambulance calls
and we proposed that an ambulance service, manned by paramedics be provided in all Malaysia Airport.
69
OP/2005
High Rate of Repeated Visits to A&E Unit by Acute Asthmatics
Rozita I, Norma S, M. Syauki H, Rohaida AW, Noridin S, Voong FY, Ramli J.
Dungun Hospital, Terengganu.
Hospital staff and patients were assessed on their knowledge on asthma and attitudes towards
disease management. Observation on technique of inhaler use was also carried out. An assessment
was also carried out among staff to see how they manage acute asthmatic patients in A&E Unit.
Poor knowledge of staff as well as lack of training and exposure to clinical practice guidelines (CPG
on management of asthma were factors identified leading to incorrect assessment and subsequent
suboptimal treatment of asthmatic patients. Obvious missed opportunities identified were lack of PEFR
measurement (5.35%) and under-use of systemic steroids in moderate and severe asthmatic attacks
(47.7%). Factors contributing to lack of patients’ adherence to treatment were poor knowledge and
poor attitude.
Strategy for change
Asthma Clerking Sheet was introduced to ensure correct assessment and treatment by staff with
enforcement on systemic steroids usage and PEFR measurement pre and post nebulizer. In addition,
90% of staff were trained and majority of patients were given education through health talks and
pamphlets.
Effects of change
Percentage of repeated visits to A&E Unit by acute asthmatics was significantly reduced from 8.9%
to 3.22%.This success is due to improvement in patients’ and staff’s knowledge; technique of inhaler
use; as well as correct assessment and treatment as recommended in the CPG on management of
asthma.
The next step
To continuously educate patients and hospital staff on the management of acute asthma.
chapter 7
The percentage of patients with acute asthmatic attacks needing two or more visits to A&E within 24
hours is monitored, and targeted to be less than 5%.
Outline of problem
Acute asthmatic attacks have a devastating effect in terms of its significant mortality, alarmingly
negative impact on quality of life, and economic burden. This study aims to reduce the percentage of
repeated visits to A&E Unit of Dungun Hospital by acute asthmatics.
70
OP/2003
Mengurangkan Kegagalan Pengesanan Kad Rawatan
Medikolegal Bagi Pesakit-Pesakit Yang Mendapat Rawatan
di Jabatan Kecemasan Hospital Segamat Kepada 0%
Dul Hadi MJ, Noorasmah WO, Mohd Syakry MS, Mohd Salleh Y,
Farhan A, Karuppiah K.
Hospital Segamat, Johor.
Pengenalan dan Masalah Kualiti
chapter 7
Hospital Segamat mengendalikan lebih 1500 perrnohonan laporan perubatan setahun. Walaupun begitu
kami gagal menyediakan 100% laporan perubatan yang dipohon. Oleh yang demikian tindakan mesti
dilakukan bagi memastikan semua laporan perubatan dapat disediakan.
Standard Pengukuran Kejayaan Langkah-Langkah Pembetulan
Kad mestilah boleh dipantau. Kad mestilah boleh dikesan 100% dalam tempoh tidak melebihi 5 minit.
Laporan perubatan yang memerlukan kad rawatan pesakit luar Jabatan Kecemasan mestilah boleh
disediakan 100% dalam masa yang ditetapkan. Adanya satu proses kerja bagi pengendalian kad-kad
medikolegal.
Metodologi
Satu kajian retrospektif telah dijalankan pada tahun 2000 ke atas semua permohonan laporan perubatan
yang dipohon oleh pihak polis dari Januari 1996 hingga Disember 1999.
Hasil Kajian
Peratus kegagalan penyediaan laporan perubatan adalah kira-kira 9% setiap tahun bagi tempoh 1996
hingga 1999. Sejumlah 83.1% adalah berpunca dari kegagalan mengesan kad rawatan pesakit luar
yang menerima rawatan di Jabatan Kecemasan Hospital Segamat sementara 16.9% pula berpunca dari
kegagalan mengesan Rekod Rawatan Pesakit DaIam. Faktor-faktor yang menyumbang kepada masaalah
adalah Kad rawatan yang sama digunakan untuk semua kes (medikolegal atau bukan medikolegal), sistem
penyimpanan kad rawatan pesakit luar yang tidak teratur, tiada tempat khas untuk simpanan kad-kad
medikolegal, ruang penyimpanan yang tidak mecukupi, kelemahan dalam sistem pengendalian kad-kad
rawatan seperti keselamatan dan lain-lain.
Langkah-Iangkah Pembetulan
Langkah-Iangkah yang diambil bagi melaksanakan projek ini adalah dengan mewujudkan kad khas
medikolegal, menyediakan kaedah pengendalian khas dan terperinci kad medikolegal di Jabatan
Kecemasan, Wad dan Unit Rekod Perubatan termasuk proses kerja, buku despatch, beg keselamatan dan
lain-lain. Pesakit bagi kes-kes medikoleqal didaftar ke dalam komputer. Rak-rak khas bagi menyimpan kad
medikolegal di Unit Rekod Perubatan dan di Jabatan Kecemasan disediakan.
Kesan dari Tindakan Pembetulan
Selepas tindakan pembetulan dilaksanakan selama setahun, kajian semula telah dijalankan pada Januari
2001. Hasilnya ialah kad medikolegal boleh dipantau kedudukannya, 100% kad medikolegal akan
dikembalikan dan disimpan dj Unit Rekod, Kad medikolegal boleh dikesan dalam tempoh kurang 5 minit
di Unit Rekod. Faedah lain yang di perolehi ialah anggota rasa gembira, seronok bekerja dan tidak merasa
tertekan. Imej Jabatan meningkat. Kajian juga telah dijalankan pada tahun 2002 dan 2003. Hasilnya
semua laporan perubatan yang memerlukan kad rawatan pesakit luar Jabatan Kecemasan bagi tempoh
Januari 2001 hingga Ogos 2003 dapat disediakan 100%.
Kesimpulan
Sistem pengurusan yang cekap, pengwujudan kad medikolegal khas, penyimpanan kad yang teratur
memainkan peranan dalam meningkatkan produktiviti dan kualiti perkhidmatan yang diberikan.
Pemantauan yang berterusan berserta kajian-kajian yang berulang adalah penting bagi memastikan
matlamat yang diharapkan dapat terus dicapai. Kami juga bercadang untuk menjalankan kajian terhadap
lain-lain permohonan selain pihak polis.
71
OP/2011
Reducing the Incidence of Ventilator Associated Pneumonia
among ICU Patients
Rozaidah AK, Norlida AB, Fatimah A, Nor Azuwa J, Che Zakiah O,
Dominica Rose J.S. Daniel.
The Malaysian standard for VAP is 15.0/1000 ventilator days and our objective was to reduce it from
40.0 in the first half of 2009 to 15.0 in the same period in 2010.
This is a cross-sectional study involving all ICU patients from January 2009 to December 2010.
Patients’ data were collected through patients’ case notes, admission book, check list, audit sheet
and Malaysian Registry of Intensive Care (MRIC) report.
Five main contributing factors to VAP were identified and analysed. Compliance to Ventilator Care
Bundle (VCB) was good (87 – 100%), yet the incidence of VAP was high (35 – 50/100) ventilator
days.
Strategy for Change
We adopted a holistic approach which comprised increasing staff awareness and improving oral and
bronchial hygiene as well as infection control practices. Our first intervention was to educate our staff
through ICU level Workshops/CNE/CME sessions. Four hourly oral hygiene and measurement of cuff
pressure per shift were made mandatory. Aerosol nebulisers were changed to Metered Dose Inhalers.
The Ventilator Care Bundle (VCB) was reinforced with daily compliance audits. Each patient area was
defined by a 1 meter red line drawn on the floor around each bed. All relevant departments were
notified of tightened infection control in ICU through a letter via our hospital director and a notice to
visitors was put up at the ICU entrance to inform them of how they could help.
Effects of Change
The incidence of VAP dropped to 5/1000 ventilator days between January to June 2010 and further
to 2/1000 ventilator days. A sustainability study showed that this had reduced further to 0.5/1000
ventilator days, thereby reducing the risk of loss of lives and improving patients’ safety.
The Next Step
All corrective interventions will be continued, improved and sustained through reinforcements and
audits. A written oral care protocol will be created and incorporated into our ICU policy. The findings
of this study will also be disseminated to other ICUs.
chapter 7
In caring for the critically ill, we do not want them to develop hospital-acquired complications.
Ventilator Associated Pneumonia (VAP) is the commonest ICU associated infection accounting for
47% of all infections in ICU. Similarly in ICU of Taiping Hospital, it has been persistently high.
Anaesthetics & Intensive Care
Department of Nursing and Intensive Care Unit, Taiping Hospital, Perak.
72
PP/2009
Reducing the High Number of Unnecessary Intensive Care Unit
Bed Booking for Elective Surgery
Soon CC, Farizawati MA, Chew CE, Siti Mariam AM, Amelia A.
chapter 7
Department of Anaesthesia and Intensive Care, Melaka Hospital, Melaka.
Intensive Care Unit (ICU) bed bookings are done for elective surgeries where we anticipate problems
during the post-operative period. Data available showed that more than 70% of elective cases
booked prior to surgery do not end up being admitted, leading to ICU bed wastage. This study aims
to identify the common factors leading to ICU bed bookings and be more selective of patients for
bookings.
The Anaesthesia Department in Hospital Melaka has decided to set the standard of reducing
unnecessary ICU bookings to less than 20%.
Retrospective record review was carried out from May to July 2008 to identify common risk factors for
ICU bed bookings and admission. Interventional study took place from October to December 2008.
Remedial measures were evaluated by monitoring the number of ICU bed bookings and admissions
post operatively.
A total of 66 patients enrolled in this study. Multiple risk factors were identified. Our data showed
that patients with 4 or 5 concurrent risks factors had higher chances for ICU admission. Single risk
factor alone is not a sole reason causing ICU admission post surgery. Booking based on just the
presence of any of the factors lead to false positive indications for ICU booking.
Strategy for Change
We developed a new scoring system whereby only patients who have a risk score of 4 or more will
have an ICU bed booked prior to surgery.
Effects of Change
The new scoring system was applied over a period of 3 months. Total number of unnecessary ICU
booking reduced from 52 to 16 using the new system. This was a reduction of 36 cases (62%
reduction).
The Next Step
The new scoring system was effective and will be applied continuously in our daily practice with
regular reassessment.
73
PP/2009
Mengurangkan Kadar Ventilator Associated Pneumonia di Unit
Rawatan Rapi
Azmin Huda AR, Talhah A, Ropeah A, Noraisyah T, Roslina O,
Mohd Rohaidzal A.
Langkah Utama ke arah Penambahbaikan
Memastikan kejadian VAP tidak lebih daripada standard yang ditetapkan oleh jabatan iaitu tidak
melebihi 20 bagi setiap 1000 hari diventilasi.
Data retrospektif kejadian VAP dari Januari-Disember 2006 telah dikumpul dan faktor penyumbang
peningkatan VAP dikenalpasti. Kajian intervensi dimulakan dari Januari 2007 hingga Disember 2008.
Keberkesanan projek telah dinilai dengan pemantauan kejadian VAP dalam tempoh tersebut.
Masalah utama yang menyumbang VAP ialah tidak mematuhi sepenuhnya protokol Ventilator Care
Bundle dan kurang pengetahuan berkaitan dengannya. Selain itu, penggunaan semula Ventilator
Circuit untuk pesakit lain yang diventilasi.
Tindakan penambahbaikan yang dilaksanakan ialah menguatkuasakan protokol Ventilator Care
Bundle dan mengadakan latihan serta kursus yang berkaitan. Penggunaan Ventilator Circuit pakai
buang (disposable) diimplimentasikan sepenuhnya kepada pesakit diventilasi.
Penurunan kejadian VAP dapat dilihat daripada 18.2 bagi setiap 1000 hari diventilasi (2006) kepada
9.1 bagi setiap 1000 hari diventilasi (2007) dan menurun kepada 6.5 bagi setiap 1000 hari diventilasi
(2008).
Langkah Seterusnya
Projek ini berjaya menurunkan insiden VAP. Perlaksanaan langkahlangkah tersebut telah terbukti
dengan penurunan kejadian VAP dan seterusnya meningkatkan kualiti perawatan terhadap pesakit
yang diventilasi. Pelaksanaan yang berterusan boleh mengelakkan kejadian VAP berlaku.
chapter 7
Kejadian Ventilator Associated Pneumonia (VAP) boleh menyebabkan peningkatan mortaliti dan
morbidity terhadap pesakit yang diventilasi. Bagi tahun 2006 kejadian VAP ialah 18.2 bagi setiap
1000 hari diventilasi. Projek ini bertujuan untuk mengenalpasti faktor-faktor penyumbang kejadian
VAP dan tindakan untuk menanganinya.
Unit Rawatan Rapi, Hospital Pakar Sultanah Fatimah, Muar, Johor.
74
OP/2009
Improving Percentage of Early Goal Directed Therapy
Implementation in Severe Sepsis Patients upon Admission
to General Intensive Care Unit
Shaiful AZ, Marini O, Mohd Fakhzan H, Tuan Nor Azida TA, Nooraini M.
chapter 7
General Intensive Care Unit, Raja Perempuan Zainab Hospital, Kota Bharu, Kelantan.
Early Goal Directed Therapy (EGDT) is an approach that has been proven to improve mortality.
However the implementation rate in our Intensive Care Unit (ICU) was 45%.
EGDT implementation in sepsis patients can be achieved by means of collaborative efforts among
staffs working in the ICU. It can be measured by doing audit on sepsis management during the first
6 hours of admission. The target set is 80% of sepsis patients to have EGDT implemented upon
admission.
A study was done in General ICU to look at the overall implementation of EGDT. Questionnaires were
given to assess the knowledge on EGDT and to look for factors contributing to poor implementation.
The pre-remedial implementation of EGDT was 45%. The contributing factors were poor knowledge
of EGDT, medical officers busy attending to other ill cases in ICU, busy attending to referral in other
wards or A&E and difficult lines insertion.
Strategy for Change
Regular Continuous Medical Education (CME) and continuous training were conducted. Quick
reference of EGDT Chart and Quality Assurance Chart were provided and all nurses were empowered
to help and counter checked EGDT implementation within the first 6 hours of admission. We focused
the training for difficult lines insertion using Ultrasonography. The number of medical officers were
increased to cater for the increased workload.
Effects of Change
EGDT implementation in sepsis patients improved to 70% following remedial measures. In General
ICU, EGDT has been practiced by all the staff. Every sepsis patients will have EGDT implemented upon
admission.
The Next Step
Audit on EGDT implementation has become the department activity. Our next step is to study the
outcome of sepsis patients following EGDT.
75
OP/2007
Reducing Ventilator Associated Pneumonia in General Adult
Intensive Care Unit, Hospital Alor Star
Ahmad Shaltut 0, Chew LS, Md Tarmizi MA, Dahaga Y, Maziah E,
Noor Asmah A, Sharifah V, Meriam V, Norma S.
A reduction in the rate of VAP to below national benchmark, which is 10.1 per 1000 ventilator days,
i.e. the 50th percentile of National Nosocomial Infection Surveillance-NNIS.
The duration of our study was from March 2005 until May 2007. Our preliminary data was from
March until June 2005 and the implementation of remedial action was from July until October 2005.
We evaluated the remedial actions three times over 3 years; November 2005 until January 2006;
September 2006 until January 2007; and March 2007 until May 2007, respectively.
The most important contributing factors to the high incidence of VAP identified were the poor
knowledge, compliance and practice of aseptic technique and hand washing; and cross colonisation
contributed by health care personnel, families and visitors. Other minor factors included poor patient
hygiene and integrity of ventilator used to ventilate patients.
Strategy for Change
For the remedial measures, we focused on knowledge, compliance and practice of basic infection
control policy to healthcare personnel; strict use of the standard precautions to reduce and prevent
transmission of organisms via healthcare personnel, families, and visitors and maintain high integrity
of ventilator used for patient.
Effects of Change
The VAP rate gradually declined after the remedial action to 14.4 per 1000 ventilator days by the
end of 2005, 8.4 in 2006 and 9.6 by the end of May 2007. These rates were below the national
benchmark which is 10.1 per 1000 ventilator days.
Lessons Learnt and Next Step
The remedial measures implemented were successful in reducing VAP rate, reduce cost for antibiotic
and improve the quality of care of ventilated ICU patients. Ensuring continuity of the remedial
measures will sustain improvement. We will continuously be looking at the latest evidence-based
literature to strive for new target which is “Ideal or zero tolerance to VAP”.
chapter 7
In 2004, a multiple one day prevalence study on Ventilator Associated Pneumonia (VAP) in 14 state
hospitals Intensive Care Unit (ICU) was conducted and ICU Hospital Alor Star was noted to have the
highest incidence (44.2 per 1,000 ventilator days). The incidence in 2003 and 2004 was 27.6 and
26.4 per 1000 ventilator days respectively and they were higher than the national benchmark. The
objective of this study was to identify the contributing factors to the problem, formulate remedial
measures based on cost saving patient safety solutions and to reduce the overall incidence of VAP.
Hospital Alor Star, Kedah.
76
OP/2005
Towards Achieving a 0% Cancellation of Elective Cases
in the Operating Theatre
Quek, Salimi MS, Shireen SJ, Kamarulzaman T, Jenny T.
chapter 7
Department of Anesthesia and Intensive Care, Seremban Hospital.
Objective
The objective of the study is to evaluate the effectiveness of a change in our work process in reducing
cancellations of elective cases in operating theatre on the day of surgery.
Methodology
The study was conducted in two phases, each phase was carried out over one month period. The
first phase was to identify the number of elective cases cancelled in the recovery room on the day
of surgery and to make recommendations for improvement. The second phase was to evaluate our
intervention whereby the Anesthetic Medical Officers were to inform the Anesthetic Specialists all
cases that they had seen in the ward and posted for surgery for the following day, for re-evaluation
and their opinion.
Results
There was no statistical difference in the demographic characteristics of patients included in the
study between phase one and two. The first phase showed a cancellation rate of 2.5%, out of a
total of 385 cases listed for surgery. The causes for cancellation were due to concurrent medical
problems comprising of uncontrolled hypertension (10%), abnormal ECG changes requiring further
investigation (20%), anemia (10%), hypoglycemia (10%), acute exacerbation of asthma (10%),
hyponatremia requiring correction (10%) and two patients with upper respiratory tract infections
(20%). The second phase showed a cancellation rate of 3.5%. The causes for cancellation in this phase
were hyperglycemia (16.68%), uncontrolled hypertension (8.33%), upper respiratory tract infections
(25%) and a case of fluctuating level of consciousness (6.33%) which after CT scan turned out to be
a subdural cerebral haematoma. In the first phase, the percentage of unavoidable cancellations 20%
as compared to 33.3% in the second phase. These were cases that we could not be postponed the
day before, even after consultation with the Anesthetic Specialist, due to the nature of the causes.
Conclusion
Further efforts need to be taken to achieve a 0% cancellation of elective cases in the operating
theatre on the day of surgery in order to improve the quality of service. These include availability
of patients’ investigation results the day before surgery when they are seen during pre-medication
rounds by the Anesthetic Medical Officer, re-assessment of patients on the morning of surgery by the
Medical Officers of the respective departments during their morning rounds, and either optimization
or cancellation of the cases deemed unfit after consultation with the Anesthetic Medical Officers/
Specialists before patients being wheeled to the operating theatre.
77
PP/2005
Improving Time in-between Elective Cases, Main Operating
Theater, Hospital Melaka
Ho WN, Juriah, Rohani, Zainal A.
The indicator for the study is the percentage of elective cases delayed by more than 20 minutes for
Orthopaedic surgeries and 10 minutes for other surgical disciplines. An improvement would be noted
as less cases being delayed.
A cross sectional study was carried out in March to September 2004 with a post remedial studying
May 2005. Data was collected by special forms, filled by staff nurses, indicating the time in between
elective cases and the reasons for delays.
The preliminary results showed that 70% of cases were delayed because patients had not arrivedin the OT, with 15% waiting for surgeons and 11% waiting for the anesthetists. In total, 6.2% of
elective cases was delayed.
Strategy for Change
Following this, elective cases were called earlier to OT. An OT manager was appointed to improvethe flow of elective cases with the availability of doctors, staff and equipment coordinated. Problems
related with wards and surgeons were brought up at OT committee meetings to be resolved amiably.
Effects of Change
With the remedial measures in place, a repeat study showed that 50% of cases delayed because
patients were not in OT. The total case delayed was reduced to 3.3%.
The Next Step
There is a need to find better ways on how to ensure patients are timely wheeled to the OT. A
reminder telephone call to the ward for elective case to be sent to OT is a feasible and low cost
approach to reduce the delays. Monitoring the causes of delays must be continued and reported
regularly. On the other hand, efforts need to be made to review why elective patients take time to
reach OT.
chapter 7
Outline of Problem
There was a perception of delay in between elective cases in the main Operating Theatre (OT),
Melaka Hospital, leading to lost OT time. This topic was chosen as it affected the OT image with
loss and wastage of OT time leading to cancellation of cases, and dissatisfaction among surgeons
and patients. A study was carried out in the main OT of Hospital Melaka involving elective cases
with anaesthesia care from March 2004 to May 2005. The aim of the study was to identify the main
factors leading to the delay and to find ways to overcome it. The factors that were thought to have
led to the problems were patients not available, staff not available, equipment not available and delay
in room cleaning.
Department of Anesthesiology, Melaka Hospital.
78
OP/2009
Reducing Wound Infection Rate for Diagnostic Skin Biopsy in
Dermatology Clinic
Tang JJ, Kong SH, Khairul Nizam
Tuanku Bainun Hospital, Ipoh, Perak.
Diagnostic skin biopsy is commonly done to assist dermatology diagnosis. It can be complicated by
wound infection and delayed the healing process. Multiple risk factors can increase the risk of wound
infection.
chapter 7
Dermatology
Our monthly census in 2008 showed post-biopsy wound infection rate was around 10%. This study
aimed at reducing the rate to the national indicator standard of less than 2%.
A cross sectional study was conducted from October to November 2008 to assess the wound infection
rate and to identify the contributing factors. A data collection form was used to collect demographic
profile and skin biopsy process. A post-biopsy photo was taken to determine the technique. Wound
outcome was assessed during suture removal to determine the infection rate. Implementations of
remedial measures were carried out from December to February 2009. Infection rate was reassessed
from March to April 2009.
Pre-remedial infection rate was 20%. Important risk factors identified include choice of post operative
topical dressing, poor wound closure technique, site of biopsy below waist, lack of wound care
counseling, bigger punch size used and improper procedure room. The ABNA was 18%.
Strategy for Change
A seminar on proper skin biopsy technique was conducted and a protocol was formulated. Immediate
post operative dressing was standardised. Skin biopsy above the waist and use of smaller punch size
were recommended. Wound care counseling and pamphlet on wound dressing were given to all
patients. Changes to procedure room were made.
Effects of Change
Wound infection rate was reduced from 20% to 6.7% following remedial actions.
The Next Step
Our skin biopsy wound infection rate has dropped to 0% in May 2009. There is a need for continuous
monitoring of wound infection rate and to sustain the remedial measures.
79
PP/2005
Reducing Non-Attendance at Dermatology Clinic, Ipoh Hospital
Chan LC, Lachtmi A, Meenakumari S, Kamariah Y, Agnes H.
Department of Dermatology, Ipoh Hospital, Perak.
Outline of problem
Outpatient appointments that are not kept are a drain on the health service resources in term of
economy and manpower. It adversely affects clinic productivity and lengthens appointment waiting
list.
The non-attendance rates, before and after implementation of remedial measures was analysed. The
main causes for non-attendance were forgetfulness, being busy and out station travels.
Strategy for change
Patients were educated on the importance of keeping to their appointments. If they were unable
to keep to their appointments, they were advised to cancel or change it before the appointed date.
Effects of change
The proportion of non-attendees had been significantly reduced from 22.6% to 17.0% (p= 0.0006).
The achievable benefit not achieved (ABNA) have also narrowed from 10.5% to 5%. A significant
attitude change in the patients was noted.
The next step
Incorporation of the remedial measures into the routine practice of the department will contribute to
further improvement and sustained results.
chapter 7
A study on the non-attendance rate was done based on registration and appointment records. A
survey using questionnaires was done to identify the reasons of non-attendance. Remedial measures
were then implemented and a re-evaluation study was conducted.
Dermatology
The key performance measure was the non-attendance rate at the Dermatology Outpatient clinic,
which was targeted at 12% and below.
80
PP/2005
Reducing Defaulter Rate among Leprosy Patients Receiving
Multi-drug therapy (MDT) at Department of Dermatology
Kuala Lumpur Hospital
Aziz S, Gangaram HB, Hussein SH.
Department of Dermatology, Kuala Lumpur Hospital.
Introduction
Leprosy (Hansen’s disease), a chronic debilitating disease, is now curable with the advent of multi-drug therapy
since 1985. However, success of the treatment requires patient’s full compliance for the total duration of
treatment which is 1 year for paucibacillary (smear negative) and at least 3 years for multi-bacillary (smear
positive) Hansen’s disease. Unfortunately, patients tend to default treatment and this undermines the success of
the Leprosy Elimination Programme.
Outline of Problem
chapter 7
Dermatology
Every year we have 30 to 50 new patients of Hansen’s disease, mainly from the Klang Valley and some from
the border of Pahang. Due to Malaysia’s robust economy, it has attracted many immigrants from neighbouring
countries, mostly contract workers with daily wages.
Key Measure for Improvement
Low defaulter rate of patient with leprosy will reduce transmission and help eliminate/eradicate the disease. A
standard of not more than 10% defaulter rate was set as a target to be achieved.
All patients with leprosy on follow up since 1993 at the Hansen Clinic, Department of Dermatology, Kuala
Lumpur Hospital were included in this study. We retrospectively assessed the defaulter rate among patients
with leprosy on multi¬drug therapy (MDT). A defaulter is defined as a patient who fails to take medication as
prescribed for 3 consecutive months, as indicated by failure to come for follow up.
In a pilot study in 1993, the defaulter rate of Hansen patients on multi-drug therapy was 42.2%. Among the
reasons were poor knowledge of the disease by patient or family, side-effects of the drugs and inability to attend
clinic as they are daily paid workers. Moreover, the majority of the patients were migrant workers with changing
places of employment and no fixed abode. Thus untreated patients became a reservoir which infected others
causing further spread of the disease.
Strategy for Change
After the pilot study, the reasons for the shortfall were identified. Remedial measures to improve patient’s
compliance and understanding of the disease through health education using patient information pamphlets,
audiovisual aids and individual and group counseling were implemented. Appointments were given according
to patient’s convenience. Stable patients without complications were allowed to collect WHO blister pack
containing anti-leprosy treatment at specified intervals not exceeding 2 months.
Effect of Change
After institution of the remedial measures, there was a gradual reduction in the defaulter rate. From 1994 to
1997 the defaulter rate went down by half from 42.2% to 22.2%, 16% and 20%, respectively. As education
level and patient understanding of the disease increased, we achieved our target of less than 10% defaulter
rate by the year 1998 and were even able to reach 3% in 2002 and 2003. However, the rate increased to 9.5%
in 2004 and this emphasises the need for continuous monitoring so that deterioration can be detected early.
The Next Step
Having achieved the 10% target, the next step is to further reduce the defaulter rate to <5% and subsequently
< 1 % towards zero defect. Although we have achieved the WHO standard of prevalence rate of < 1 per
10,000 and incidence rate of <1 per 100,000 population, proper implementation of MDT regime and good
patient compliance plays a major role if we want to eradicate this disease, and no patient should default their
medication if we wish to achieve this goal.
81
PP/2003
Patient Education and Counselling in the Management of
Psoriasis - Towards Better Patient Compliance
Gangaram HB, Hussein SH.
Department of Dermatology, Hospital Kuala Lumpur, Malaysia.
The Department serves about 30,000 patients per year, mainly from the Klang valley. New cases with
psoriasis account for about 5% of the total.
Improving patients’ knowledge on psoriasis will lead to better patient compliance in management
and disease outcome.
Design
Patients on follow-up for at least 6 months are recruited to answer a self-administered questionnaire
on psoriasis. An arbitrary standard of 80% of patients scoring 75% or more marks is set as the quality
target. Following a pilot study in 1992, remedial measures were instituted and monitoring done
annually from 1995 onwards.
There was an improvement in performance from 28% in 1992 to 86.6% in 2002. A dip in 1998 is
probably due to slight slack in counseling and poor patient understanding. Over the years patients
understanding of their disease has improved, especially on the different therapies available.
Effects of change
Patients’ knowledge on psoriasis improved from 28% in 1992 to 86.6% in 2002. Understanding of
disease also improved, especially on the different therapies available.
Lessons learnt
The study demonstrated some “gaps” or misconceptions in knowledge on psoriasis which could
hinder better patient care and outcome. Monitoring is very important to detect any deterioration in
our as well as the patients’ performance.
The next step
Further studies would be conducted to determine whether improvement in knowledge would lead
to better disease control.
chapter 7
Rationale for study
Despite advances in therapy, psoriasis continues to be a chronic skin disorder characterised by
exacerbations and remissions. Besides impairing the Quality of life, it also has financial consequences
for the patient and the health services. Knowledge of psoriasis will allow patients to participate
more in their treatment and control and to avoid aggravating factors. To achieve this, patients must
understand their disease, hence the importance of education and counseling.
Dermatology
Problem
Inadequate knowledge of psoriasis patients of their disease will lead to poor patient compliance in
management and control of this chronic disorder.
82
OP/2009
Iron Chelation amongst Thalassaemics: A Need for Reappraisal
Shahannim I, Norhasni MZ, Jamaluddin M, Mohammad Zamri K, Hazimah Y,
Zarini J, Huzaimi N, Mohd Zamri MH.
Tuanku Fauziah Hospital, Kangar, Perlis.
Iron overload in transfusion-dependent thalassaemia patients causes morbidity and mortality.
chapter 7
Haematology
To improve the number of patient initiated on iron chelation, with a standard set at > 80% and to
improve the number of patients compliant to iron chelation with standard set at > 60%.
A cross sectional study was conducted at Day Care Thalassaemia Clinic Hospital Tuanku Fauziah with
96 registered thalassaemic patients. The study was conducted in two phases. First phase was from
1 July to 30 September 2006 and the second phase was from 1 September 2007 to 30 November
2007.
Strategy for Change
Multifaceted interventions which included using local anaesthesia and smaller needle to reduce pain
of injection, providing users manual, CD and starter kit to facilitate the procedure for administering
medication. Motivational talk and counseling session was also organized. Compliance of patients
improved through house call or visit and training of staff.
Effects of Change
There was an increased in percentage of thalassaemic patients initiated on iron chelation from 53%
to 89%. Compliance rate improved from 17% to 79%.
The Next Step
Multifaceted interventions used to address patient’s concern and difficulties, contributed to the
success of iron chelation therapy.
83
PP/2009
Preventing Febrile Transfusion Reactions in Thalassaemia
Patients
Hlaing AA, Abd Kadir Z, Awaluddin R, Harun A, Shahi Noor Z.
Transfusion Medicine Unit, University Malaya Medical Centre, Kuala Lumpur.
Febrile reactions are not life threatening but make patients uncomfortable and costly in terms of
medical, nursing and laboratory investigations. It is necessary to stop the transfusion immediately and
measures taken to exclude dangerous adverse reactions.
There was a high incidence of febrile reactions when using standard products with bedside filtration
resulting in patient discomfort and transfusion disruption. Pre-storage leucodepletion however has
been described as effective in reducing these reactions.
Strategy for Change
The quality problem was chosen based on a patient satisfaction survey, and pre-storage leucodepletion
was introduced as the remedial action. Freshly collected red cells units were filtered within 24 hours
using specific filters in the blood centre. A small stock of leucodepleted units are available at all times
and issued without delay according to the daily requests.
Effects of Change
The incidence of transfusion reactions had decreased from 5.8% to 0.1%. A patient feedback
revealed that 98% of the patients preferred pre-storage leucodepletion to bedside filtration with
reason of less reaction and interruption to transfusion.
The Next Step
The remedial actions proved effective in reducing the incidence of febrile reactions thus providing
a safe and timely experience for thalassaemia patients. Routine quality checks to ensure that the
process meets the specifications will prevent future febrile reactions from occurring.
chapter 7
Retrospective analysis of data collected from 539 transfusion episodes during 2006 indicated that
febrile reactions occurred in 5.8% of the episodes. A prospective interventional study was conducted
from June 2007 and the number of transfusion reactions was followed up until December 2008.
Haematology
Febrile transfusion reaction (FNHTR), normally affects 1-2% of transfused patients. Reduction in the
rate to less than 0.5% was set as a standard for the quality assurance target.
84
PP/2011
Adherence Programme to Improve Treatment Response
in HIV Treatment-Naïve Patients at Infectious Disease Clinic
Chow TS, Low LL, Zuhaila MI, Cheang LF, Asma A, Zakiah K, Norlizawati S
Penang Hospital, Penang.
chapter 7
Infectious Disease
Highly Active Antiretroviral Therapy (HAART), a combination of at least 3 drugs from at least 2 different classes of
antiretrovirals (ARVs), is used for treating Human Immunodeficiency Virus (HIV) disease. Adherence to complex
HAART is critical as it is one of the major determinants to maintain sustainable virological suppression, hence
prolonging patients’ survival. Levels of adherence below 95% have been associated with poor virological and
immunological response. Therefore, it is crucial to identify and overcome barriers that lead to non-adherence
in order to sustain and prolong virological suppression.This study aimed to improve adherence in all new HIV-1
infected patients on HAART at the Infectious Disease Clinic Penang Hospital .
In this study, we measured the improvement in adherence by studying the record of attendance to Adherence
Clinic and also the pill counts from every visit. The indicator is the percentage of patients newly started on
HAART at 24-weeks post HAART with adherence of ≥ 95% and the standardwas 100% Number of patients with adherence ≥ 95% X 100%
Total number of new HIV-1 infected patients on HAART
A retrospective study was done from 2005-2007 as a situational analysis. Subsequently post-remedial measures
were undertaken with a new cohort from April 2008 to December 2009. Patients’ consents were obtained
before being enrolled into the study. All data were recorded in the patients’ medication file and the Antiretroviral
Therapy Monitoring Record.
During the pre-remedial period, a few factors which might contribute to non adherence were identified, namely
complexity of the HAART regime (73.1% of patients were on non-combination pills), poor counseling for
adherence (no adherence clinic), lack of communication between health care providers and patients (no helpline
available after office hour) and lack of reviews in between appointments to meet the clinicians (4-6 months).
Strategy for Change
To improve patients’ compliance and adherence as well as knowledge about disease and therapy, the study
implemented a 10-visit adherence programme in between the visit to the clinician. In the programme, pill counts
were performed, regime of combination pills was prescribed, counseling sessions including education were given
and tested at the end of the program, contact numbers of health care providers (including a 24-hour emergency
contact) were given out. The programme involved clinicians, pharmacists counselors and nurse counselors.
Effect of Change
Defaulter rates had significantly reduced from 17% (pre-remedial) to 9.1% After remedial measures were
undertaken. Patients had easier access to advice from physicians and pharmacist counselors with the provision
of a contactable emergency number and also the 10-visit adherence programme. A simplified regime was also
achieved in 70% of patients compared to 26.9% In pre remedial analysis.
The Next Step
The programme will be continued and the implementation of the 10-visit adherence programme in retroviral
patients on HAART especially in the first 2 years of therapy in the clinical setting will be practiced in all Infectious
Disease Clinics throughoutthe country. The inclusion criteria would be extended to also include treatmentexperienced HIV patients.
85
PP/2005
Reduction of Methicillin Resistant Staphylococcus Aureus (MRSA)
Infection in Alor Star Hospital
Norhasmaliza MN, Juita G, Siti Rohani R, Siti Norma S, Dahaga Y, Maziah E,
Azizul A, Law GC, Mahsuri AH.
Alor Setar Hospital, Kedah.
Outline of problem
Reduction of MRSA infection rate could be achieved through proper practice of hand washing and aseptic
procedure, improve knowledge and skilled staff, proper cleansing in the wards, good patient hygiene and
avoid overcrowding of wards. Standard set for the MRSA rate is less than 0.3%, less than the current
national standard of 0.5%. Staff knowledge was assessed by using questionnaires. Practices of aseptic
procedures and hand washing were observed by using a designed checklist. Standard set for all variables
should be 80% or more.
Infectious Disease
MRSA infection rate in Alor Star Hospital was 0.8 % (31 cases) in January 2003, the highest compared to
the other 13 state hospitals in Malaysia. MRSA causes infection leading to morbidity and mortality. The
aim of this study is to reduce the MRSA infection rate, thus lessen patients’ suffering, expenditure and
workload. The main factors contributing to high MRSA rate were poor knowledge and practice of aseptic
technique, hand washing, poor patient hygiene and crowded wards.
A prospective study was carried out. All nosocomial infection cases admitted to Alor Star Hospital for year
2003 were included in the study. Data were collected in three phases. A self-administered questionnaire was
formulated to assess knowledge regarding aseptic technique and hand washing Checklist was designed
specifically for observing proper hand washing technique, proper aseptic technique, ward cleanliness and
patient hygiene.
The findings revealed the average rate of MRSA was 0.6%. MRSA infection was the highest in ttIe
Orthopedic wards. The results showed that only 15.5% practiced proper aseptic technique and 49.2%
practiced proper hand washing. Good knowledge, practicing proper hand washing and aseptic techniques
in performing procedure are key measures for improvement.
Strategy for change
Several Workshops on Nosocomial Infection were conducted. The emphasis was on proper aseptic
procedures and proper steps of hand washing. The Infection Control Nurse demonstrated the procedures.
Link-nurses were appointed and trained to supervise other personnel. Efforts were taken to ensure good
patient hygiene, ward cleanliness and avoid overcrowding.
Effect of change
As a result of increased awareness among health care workers, 84% practiced proper aseptic technique
compared to only 15.5% before the remedial action taken. Good hand washing practices also increased
from 49.2% to 86.7%. Even the hospital support service staff showed commitment towards ward
cleanliness with an increased of 58% through observational study.
The next step
Through continuous educational sessions, monitoring and supervision, a good work culture can (be
developed and sustained. MRSA infection rate in Alor Setar Hospital declined to 0.28% in December 2003
and consistently remained below 0.3% till now, thus reducing nosocomial infections.
chapter 7
86
OP/2009
Optimisation of Glycaemic Control of Diabetic Patients in a
Medical Outpatient Department
Mithali A@Jacquline S, Che Sukinah H, Teh S, Abinash K, Nor Azilawany CS,
Hassan Zaini S, Azraf A, Mohamad R.
Medical Outpatient Department, Sultan Abdul Halim Hospital, Sungai Petani, Kedah.
The control of diabetes was not satisfactory despite the resources available. Our preliminary study
revealed that only 29% of 141 patients had good glycaemic control (HbA1c < 7.0%).
chapter 7
Medical
We aim to achieve 30% of patients with HbA1c ≤ 6.5% (optimum glycaemic control).
Retrospective analysis on glycaemic control of patients was conducted from January to October
2007 to identify the contributing factors. Interventional study took place in 2008 and the cohort
was followed until 2009. The effectiveness of remedial measures were assessed by monitoring the
percentage of the patients with optimum glycaemic control in 2008 and 2009.
12.1% of the patients had optimum glycaemic control. The most important contributing factor to
low percentage of patients with optimum glycaemic control were patients’ inadequate knowledge
and poor compliance to treatment amongst patients.
Strategy for Change
The frequency of health education given to patients were increased. A multidisciplinary team
was established by developing a one stop centre for patients with diabetes. Results of study were
communicated to all staff. The latest Clinical Practice Guideline was distributed to all medical officers.
Effects of Change
The percentage of patients with optimum glycaemic control had improved to 15.3%, subsequently
to 20.6% and 27% in February 2009. The achievement was sustained in May 2009 (28.6%). The
ABNA was 1.4%.
The Next Step
We aim to increase the percentage of patients with good glycaemic control by employing strategies
such as emphasizing self blood glucose monitoring, focusing on patients with poor glycaemic control
and conducting home visits to patients. We would also like to propose glycaemic control as the Key
Performance Indicator for Department of Medicine.
87
PP/2009
Improving Provision of Diabetic Care at Diabetic Clinic
Koay BS, Tan HY, Lee KF, Pang YS, Saw AK, Tan SM, Siti Zauyah Y,
Nurul Zarini BH, Maktar M.
Sungai Bakap Hospital, Penang.
A prospective study was carried out from January-February 2008 on the percentage of patients who
achieved the targeted DCQA score. Re-evaluation was carried out from October 2008 - February
2009.
Only 1.6% of patients achieved good score before intervention. The contributing factors were
inadequate clinic adherence, lack of counseling or knowledge, provider accessibility and systemoriented service, and improper diabetic monitoring.
Strategy for Change
One-stop multidisciplinary team approach was provided. The remedial measures included patient
reminder and defaulter tracing system, checklist, regular monitoring and patient counselling. These
were implemented from April-October 2008.
Effects of Change
The percentage of patients with good DCQA score increased from 1.6% to 65.1%. A further reevaluation proved the result was sustainable (62.3%).
The Next Step
The remedial measures improved the provision of diabetic care. The DCQA score can serve as an
objective and holistic tool to assess the provision of diabetic care at primary care level. We hoped that
DCQA Score could be applied in other clinics.
chapter 7
This study aims to improve the provision of diabetic care at diabetic clinic via system-oriented service,
effective delivery and defaulter tracing system. The outcome was measured by Diabetic Care Quality
Assurance (DCQA) Score which was designed by incorporating the essential elements in improving
the provision of diabetic care. The aim is to achieve 60% of patients with good DCQA score.
Medical
A preliminary cross sectional study in 2007 showed only 63% of patients have HbA1c done in the
past one year, and 16% of them have HbA1c<6.5%. The defaulter rate was 45% and the patients’
knowledge was inadequate. Delay in the management of poor glycaemic control will increase
morbidity and mortality. A proper care delivery and monitoring system can be formulated to improve
the weaknesses identified.
88
OP/2009
Reducing Waiting Time at a Warfarin Clinic in a Medical
Outpatient Department
Siow KY, Choo WS, Gun SC, K. Sreeraman, Zaharimah, Wan Shaariah.
Department of Medicine, Tuanku Jaafar Hospital, Seremban, Negeri Sembilan.
Waiting time at the Warfarin Clinic is a major setback as 80% of patients had to wait for 2 to 3 hours
before the PT/INR is sorted out. This quality assurance project aimed to identify the contributing
factors, formulate and implement remedial measures in reducing the waiting time at the Warfarin
Clinic.
chapter 7
Medical
The indicator for waiting time is 80% of the patients to be seen within 60 minutes and 100% to
be seen in 90 minutes. The waiting time is the time taken for the patients’ PT/INR to be reviewed by
doctors after registration at the counter.
Retrospective record review was conducted from April to May 2005 to identify the contributing
factors to the long waiting time. An interventional study was carried out from January to April 2007
and was re-evaluated in July 2007.
It was noted that only 14%(7) of patients were seen in 60 minutes, 6%(3) were seen between 60 to
90 minutes and 80%(40) of patients were reviewed after in more than 90 minutes.
Strategy for Change
The remedial measures taken include forming the PT/INR Fast-Track whereby patients have an
express queue for themselves, individual blood-tubes sent to laboratory immediately, screening at
the counter, setting up a dedicated warfarin clinic with at least 3 doctors reviewing the PT/INR results
and staggering of appointments.
Effects of Change
The waiting time was reduced, 65.8% of patients were reviewed in comparison to 14% prior to
remedial measures. ABNA was reduced from 66% to 14.2% within the 60 minutes waiting time and
from 80% to 12.4% for the 90 minutes waiting time. The re-evaluation study showed that 88% and
995 were reviewed within the 60 and 90 minutes waiting time respectively.
The Next Step
The project can be implemented for other clinics.
89
OP/2005
Door-to-Needle Time for STEMI Patients in HKL,
How good are we?
Jeyaindran S.
Department of Medicine, Kuala Lumpur Hospital.
Problem
World wide STEMI, causes approximately 10 million deaths annually and is a leading cause of death in Malaysia. Better
understanding of the pathophysiology of the disease has shown that rapid diagnosis and prompt treatment can reduce
cardiac mortality.
Design
Since September 1996 all STEMI (acute myocardial infarction cases which fulfilled the WHO criteria) patients admitted
to the Coronary Care Unit (CCU) of Hospital Kuala Lumpur (HKL) have been included in an ongoing clinical audit.
Special audit forms were used to collect the demographic data, cardiac risk factors, time of onset of chest pain, time
thrombolysis was started, the type of STEMI and the reasons for delay in thrombolysis.
Although in the CCU in Kuala Lumpur Hospital we have consistently been able to achieve both NIA indicators, it was
felt that in keeping with international standards we should aim for a “Door -to-needle time of <30 minutes” in > 70%
of our STEMI patients.
A situational analysis done in 1996 revealed an in-hospital case fatality rate of 15.19%, only 35.18% of all STEMI
patients were thrombolysed and of these only 59% were thrombolysed within 30 minutes. It was noted that due to a
multitude of reasons, thrombolysis was not routinely done in the Emergency Department and this resulted in delays in
both the diagnosis and definitive treatment.
Strategy for change
Various changes were implemented which included the development of a new STEMI clerking format and training of
the doctors and nursing staff of the Emergency Department in the diagnosis and treatment of STEMI patients.
Effects of change
A repeat audit six months later in March 1997 showed the “door-to-needle time of <30 minutes” had risen from 59%
to 96% (p<0.001). As a result of the success of our center in exceeding the NIA targets repeatedly, the Health Ministry
is using our STEMI form for the basis of a home grown IT real time internet based NIA audit toot. This tool was piloted
in HKL in August 2003 and is now being used in several other hospitals in the Klang Valley.
As this is an ongoing audit of all cases of STEMI, our analysis of 204 consecutive STEMI cases admitted to the COO in
HKL, over a ten (10) month period between September 2003 and May 2004, using our newly developed IT internet
based NIA audit tool, showed that the “door-to-needle time <30 minutes” had dropped from 96% to 69%, still short
of the >70% target we had set.
The next step
An analysis of the data showed that the commonest reason for delay in starting thrombolysis was non-specific ECG
changes (67%). This was because 56% of the patients with an acute STEMI presented to the emergency department
within three (3) hours of onset of chest pain. At this early stage of an acute STEMI, the ECG is often non-specific and
all of the currently available cardiac biomarkers are not specific nor are they sensitive enough to pick up myocardial
damage at such an early stage. To overcome this, we are conducting a head-to-head study, comparing a new cardiac
biomarker against the conventional biomarkers to establish if it is indeed a more specific and sensitive tool. Our
preliminary data shows that it appears to be so.
chapter 7
Many landmark clinical trials have shown that the faster blood flow is restored, the greater the reduction in mortality.
This has resulted in evidence-based medicine which now forms the basis of international STEMI guidelines including
our 2001 Malaysian Clinical Practice Guidelines on Acute Myocardial Infarction. These guidelines form the basis of
selecting the following two quality indicators in the National Indicator Approach (NIA) of the Ministry of Health’s Quality
Assurance programme for Patient Care; “the myocardial infarction case fatality rate «30%)” and “the percentage of
STEMI patients receiving thrombolysis within one hour of presentation to the emergency department (> 70%)”. The
international bench mark for the efficiency of treatment at any particular hospital is the “door-to-needle time”.
Medical
90
OP/2003
The Review of In-Patient Investigation Results Received
After Discharge in Balik Pulau Hospital
Wong LW, Sharif A, Ku Saad N, Abd Rahman H, Zainan A,
Hamid SI Ismail J, Yusaf AR.
Balik Pulau Hospital, Penang.
Problem
This study was designed to identify factors contributing to the lack of review of in-patient investigation
results returning after discharge and to institute remedial measures so that management can be
improved.
chapter 7
Medical
A 71 bedded district hospital with no specialist. Certain investigations require analysis in the general
hospital. High patient turnover increases number of results returning after patient has been discharged.
All returning results are seen by the doctor. Issuing follow-up appointments to patients with pending
investigation results on discharge. Improving review rate of results with patients during the follow-up
appointment to 80%.
2 prospective studies were done. Data collection was through record reviews. Study lasted 6 months.
For preliminary studies, 76.3% results were reviewed by the doctor, 71.3% were issued follow up
appointments and 12.5% patients had their results reviewed on follow up. This was below the
acceptable level.
The remedial measures included a) compulsory ruling to review all results, b) introducing a patient
discharge summary, c) rubber stamp to facilitate recording information pertaining to pending results,
d) issue follow-up appointments to patients discharged with pending results.
Effects of Change
In the post-remedial study, all results were reviewed by the doctor. 90.1 % patients received a follow
up appointment. Patients who had their results discussed during follow up increased to 52.2%.
Lessons Learnt
The changes were effective. Introducing the patient discharge summary helped circumvent the
problem of misplaced outpatient summary cards.
91
PP/2003
Kelewatan (Melebihi 72 Jam) Menghantar Rekod Pesakit Discaj
dari Wad ke Unit Rekod
Norate S, Intan AS, Syarifah H, Mardziah H, Norfaiza H.
Hospital Kampar, Perak.
Latar belakang
Aduan dari jabatan lain terhadap kelewatan dalam penyediaan laporan perubatan, melambatkan
siasatan pons dan bukti mahkamah. Selain itu, ia menyusahkan pesakit untuk mendapatkan rawatan
susulan dan gagaI memenuhi garis panduan Patient Care Service National Indicator Approach, KKM.
Langkah untuk penambahbaikan
Kumpulan bersetuju supaya langkah-Iangkah penambahbaikan diambil agar kelewatan melebihi
72 jam menghantar rekod pesakit ke unit rekod dapat dikurangkan. Dengan adanya tindakan
penambahbaikan, kerja-kerja lebih kemas dan sistematik, mempercepatkan summary rekod pesakit,
memudahkan rawatan susulan dan memberi perkhidmatan lebih berkesan.
Strategi perubahan
Kumpulan ini telah mengambil langkah penambahbaikan berikut: (a) peringatan memenuhi protokol
Pegawai Perubatan dan Garis Panduan QAP-NIA (indikator 53) kepada semua Pegawai Perubatan (b)
kad pesakit luar disimpan di Unit Kecemasan (c) inovasi checklist pesakit discaj dari wad (d) inovasi
kad biodata/rawatan pesakit (e) catitan cop x-ray di belakang Borang Daftar Masuk Wad (f) rekod
pesakit discaj untuk temujanji dihantar ke Unit Rekod dan dipinjam semula oleh wad (g) tatacara
biling yang baru semasa pesakit discaj.
Kesan perubahan
Perubahan yang dilaksanakan telah dapat mengurangkan kadar kelewatan (melebihi 72 jam)
menghantar rekod pesakit discaj dari wad ke unit rekod daripada 24% kepada 0.8%, menjimatkan
kos operasi dan masa serta meningkatkan hasil kerja.
Pengajaran
Projek ini dapat melahirkan anggota yang lebih proaktif, inovatif dan bertanggungjawab untuk
mencapai matlamat jabatan dan KKM. Selain itu, ia dapat memupuk Budaya Korporat KKM.
chapter 7
Rekabentuk
Kumpulan yang terdiri daripada anggota Unit Rawatan Pesakit Dalam telah ditubuhkan dan
mengenalpasti masalah kelewatan (melebihi 72 jam) menghantar rekod pesakit discaj dari wad ke
unit rekod sebagai masalah utama. Mesyuarat telah diadakan setiap minggu dan menggunakan
teknik-teknik QA cycle dengan dibantu oleh fasilitator.
Medical Record
Permasalahan
Keperluan untuk mengurangkan kekerapan kelewatan (melebihi 72 jam) menghantar rekod pesakit
discaj dari wad ke Unit rekod supaya rnencapai standard Kementerian Kesihatan Malaysia (KKM) iaitu
hanya 5% kelewatan dibenarkan.
92
OP/2007
Reducing Continuous Ambulatory Peritoneal Dialysis Peritonitis
Rate in Hospital Tuanku Ja’afar, Seremban
Shanmu K, Norilah K, Shaariah W.
chapter 7
Nephrology
Hospital Tuanku Ja’afar, Seremban.
Continuous Ambulatory Peritoneal Dialysis (CAPD) peritonitis is a serious problem which can cause
sepsis leading to death. It causes distress to patients due to hospitalisation and increase in the cost
of treatment. Patients may lose confidence in this modality. In the CAPD Unit patients are trained to
do the exchange procedure and continue to do the four exchanges per day in their home. Repeated
episodes of peritonitis can cause patients on CAPD be transferred to haemodialysis. However, the
peritonitis rate can be reduced with possible adjustment made to the procedure room, better division
of work for staff and thorough assessment of patients prior and during CAPO training. The success
in a CAPD programme is dependent on the CAPD peritonitis rate. Our CAPD peritonitis rate for 2004
was 1: 21.4 per patient month.
The CAPD peritonitis rate is calculated using the Peri Rate Programme. Our target for CAPD peritonitis
rate is 1:35 per patient month.
A cross-sectional study was carried out in July 2004. All patients on the CAPD programme in the
hospital were recruited for the study. The remedial measures were identified and implemented in
January 2005. There was a ‘break’ period from January to June 2005 to allow us to be accustomed
to the remedial measures. Following that, data was collected and analysed at a six- monthly cycle
until June 2007.
The high CAPD peritonitis in our hospital was contributed by congestion in the CAPD room, poor comorbidities factors of the patients and their negative attitude, and shortage of staff.
Strategy for Change
The improvement in the CAPD peritonitis rate was contributed partly by the changes in the structure
of the CAPD room through the extension of the nephrology unit. However, we felt that the changes
made with regard to the negative attitude of patients, staff rotation and training to patients were
more crucial than the structural change. Better division of work for staff, flexibility in training of
patients and regular home visit schedule proved beneficial.
Effect of Change
After the implementation of remedial measures, the CAPD peritonitis rate had improved from 21.4
per patient month to 35.0 per patient month at the second cycle and the results continued to
improve subsequently.
Lessons Learnt and the Next Step
We planned to reinforce the remedial measures in our daily practice, and to share our experience in
reducing peritonitis rate with other CAPD centres, especially during the CAPD seminars.
93
OP/2011
Meningkatkan Peratusan Kepatuhan Terhadap Perawatan
Pesakit dengan Infusi Intravena di Wad Obstetriks & Ginekologi
Nancy B, Sania L, Diviki T, Anita M, Zabidah J, Rusti T, Jockina M.
Indikator yang dikenalpasti adalah peratusan kepatuhan penjagaan perawatan pesakit dengan
infusi IV mengikut SOP dengan standard lebih 80%.
Semua Jururawat U29 di Wad O&G dan pesakit dengan infusi IV diambil sebagai sampel kajian.
Kajian dilaksanakan dari 1 hingga15 Disember 2010. Borang soal selidik digunakan untuk
mengkaji pengetahuan jururawat berkaitan perawatan pesakit dan menilai keberkesanan
pemberian penerangan kepada pesakit sebelum dan semasa pemasangan infusi IV. Senarai
semak digunakan untuk menentukan dan memerhati cara perawatan yang diberikan.
Didapati daripada sejumlah 110 jururawat, 20% dikenalpasti kurang pengetahuan berkaitan cara
mengira titisan infusi IV. Faktor lain mempengaruhi ketidakpatuhan terhadap perawatan pesakit
infusi IV adalah beban tugas yang tinggi, tiada semakan regim, melayan pesakit, kurang
pemantauan, regim kurang jelas dan salah pengiraan titisan/kalibrasi oleh jururawat. 75% pesakit tidak diberikan penerangan sebelum pemasangan infusi IV.
Strategi yang dilaksanakan termasuklah mengadakan sesi ceramah dan pembelajaran berterusan
dari wad ke wad berkaitan Prosedur Infusi Intravena; bengkel memantap cara pengiraan infusi IV
regim; program berstruktur kepada jururawat lantikan baru atau baru pindah dan memantapkan
kecekapan pemantauan klinikal. Mesyuarat bersama Ketua Jabatan berkaitan penyediaan
regim tepat dan jelas turut diadakan. Memantapkan pemberian penerangan kepada pesakit
mengenai penjagaan infusi IV secara tidak langsung memberikan peranan/kuasa kepada pesakit
untuk melibatkan diri bersama jururawat dalam menjaga infusi IV.
Selepas enam bulan, pelan penambahbaikan telah meningkatkan peratusan kepatuhan terhadap
perawatan pesakit dengan infusi IV daripada 69% meningkat kepada 87% dan melepasi sasaran yang ditetapkan.
Langkah Seterusnya
Sesi pembelajaran berterusan, pemantauan indikator setiap 6 bulan dan berterusan untuk pengekalan
dan peningkatan kepatuhan kepada SOP. Jururawat perlu komited, supaya ia menjadi amalan
budaya perawatan.
chapter 7
Pemilihan Peluang untuk Penambahbaikan.
Sebilangan 20-40% pesakit yang dimasukkan ke Wad Obstetriks & Ginekologi (O&G) dan 100%
pesakit yang menjalani pembedahan, dirawat dengan infusi intravena (IV). Hasil audit bagi
tiga tahun berturut-turut 2008-2010 menunjukkan pencapaian Wad O&G hanyalah mematuhi
Standard Operating Procedure (SOP) sebanyak 65-69% dan tidak mencapai sasaran yang ditetapkan
oleh Unit Kejururawatan, Jabatan Kesihatan Negeri Sabah.
Obstetrics & Gynaecology
Hospital Wanita dan Kanak-Kanak, Kota Kinabalu, Sabah.
94
OP/2011
Improving Time Interval from Decision to Caesarean Delivery
for Fetal Distress Cases
Yuzainov A, Nurul Khairiyah K, Norul Akhma AH, Rahmah N, Norraihan H,
Suriwati I.
chapter 7
Hospital Seberang Jaya, Penang.
A retrospective analysis in the Obstetrics and Gynaecological (O&G) Department, Seberang Jaya
Hospital revealed that only 24% of babies with fetal distress were delivered within 30 minutes (via
caesarean section) from July to December 2007. This can result in an increase in perinatal morbidity
and mortality. This study intended to improve the rate of babies delivered with fetal distress within
30 minutes.
This study aimed to re-engineer the process involved from decision making to delivery of baby. A
standard of more than 70% of babies delivered within 30 minutes was set.
A prospective study (pre-remedial) was carried out from April to May 2008. The staff were assessed
on their knowledge on the urgency to deliver babies with fetal distress using self-administered
questionnaires. A data sheet on the time sequence from decision for caesarean section till delivery of
baby was designed.
6.25% of babies were delivered within 30 minutes during the pre-remedial study. Delay in preparing
and sending patient to OT was among the major contributing factors identified.
Strategy for Change
Seminars and drills were carried out to improve staff knowledge on the urgency to prepare patient
for caesarean section. Delay in sending patients was attributed to lengthy report writing. Hence a
simplified nursing report form was created to expedite the process. A caesarean section kit was also
innovated to expedite preparation of patient.
Effects of Change
The rate of babies with fetal distress delivered within 30 minutes increased from 6.25% (pre-remedial)
to 46.9% (3rd cycle). There was also an improvement on staff knowledge from 18% (pre-remedial)
to 95% (3rd cycle). ABNA was reduced from 63.8% to 23.1%.
The Next Step
The simplified nursing report form and caesarean section kit were adopted for other cases of
caesarean section. The improvement in the re-engineering of the work process will also be shared
with other hospitals in our country.
95
OP/2011
Increasing Lower Segment Caesarian Section without
Post Partum Hemorrhage
Nor Jumizah AK, Lim KY, Faridah MY, Wan Mazlina WR, Maziati M,
Suhainiza S, Norleeza MN.
We set a standard of LSCS without PPH at 90%.
A cross sectional clinical study was carried out from July 2008 to December 2009. Data were
obtained from maternal notes and questionaires. The rate of LSCS without PPH were calculated by
incident of LSCS without PPH divided by total LSCS multiplied by 100. The research tool used was
self administered questionnaire.
Our verification study showed the incidence of LSCS without PPH was only 83.5%. PPH in LSCS was
associated with delay in calling for help by the junior doctors, surgery related factors, uterine factors
and inappropriateness of measures taken to prevent PPH as well as lack of staff knowledge and
urgency.
Strategy for Change
The remedial measures taken were training module on LSCS for medical officers, emphasis on early
call for help by medical officers, LSCS training module, CME sessions for doctors and paramedics and
application of safe surgery protocol. Patients were prepared for surgery in accordance to their risk
factors and cases were delegated to surgeons based on risk, seniority and experience of the surgeon.
Effects of Change
The incidence of LSCS without PPH increased from 83.5% to 92.5 %.There was an increased in
awareness of calling for help early and knowledge of staff had also improved .
The Next Step
The remedial measures carried out had been effective, thus it shall be applied constantly and
improvement will be made along the way. Our next aim is to carry out an observational study on
‘Surgery related reasons of PPH in LSCS’ which will assist us in improving the remedial actions
implemented in this QA study.
chapter 7
2006-2008 statistics had shown that post partum haemorrhage (PPH) was one of the major problems
faced by the Obstetrics and Gynaecology Department in Hospital Kemaman, which contributed
towards the increased morbidity and mortality rate of pregnant mothers. The aim of this study was
to identify the contributing factors and to reduce the incidence of PPH in Lower Segment Caesarian
Section (LSCS).
Department of Obstetrics and Gynecology, Kemaman Hospital, Terengganu.
96
PP/2011
Improving Admission Time at a Maternity Patient Assessment
Centre
Mohd Azri MS, Lim GL, Puziah Y, Mohd Nasir O, Mohammad Faidzol T.
chapter 7
Sultan Abdul Halim Hospital, Sungai Petani, Kedah.
Admission of obstetrics patients through the Patient Assessment Centre (PAC) becomes a major
workload to the Obstetrics and gynaecological (O&G) Department, Sultan Abdul Halim Hospital
(HSAH). A preliminary study on the magnitude of this issue revealed that only 6% of obstetric patients
were admitted to the wards within one hour, another 94% of patients were stranded in PAC for up
to more than 2 hours. The aim of this study was to identify the contributing factors that cause long
admission time at PAC and to formulate appropriate remedial measures to overcome it.
Our aim was to achieve 75% of patients sent to the Antenatal Ward within one hour.
The data were collected for pre and post remedial period, mainly the time started and time finished
at every stage of care at PAC and the time interval between each stage and the stage before it.
During the pre remedial study period, only 8.4% of patients managed to be transferred to the
Antenatal ward from PAC within 1 hour. Registration process and lengthy clerking were the two main
factors for long admission time.
Strategy for Change
Several strategies had been planned to overcome each problem. Continual meetings and orientation
of the staff at PAC were carried out.
Effects of Change
After the first reevaluation period, 67.2% of patients in PAC managed to be transferred to their
respective wards within 1 hour. Greater improvement was observed during the 4th re-evaluation
period where we achieved 71.6%. The time intervals for all stages were also reduced.
The Next Step
We hope to achieve the target of 75% of patients admitted to the Antenatal Ward from PAC within
1 hour. Although the target has not been achieved, there is promising result from the measures
implemented and the next step is to sustain current achievement and formulate new strategies to
achieve the target.
97
PP/2011
Reducing the Incidence of Third Degree Tear in Obstetrics
& Gynaecology Department
Molen A, Myat SY, Lily D, Chanic B, Landsee DM, Juliana DJ, Abby B.
Department of Obstetrics and Gynaecology, Bintulu Hospital, Sarawak.
Record reviewed from January 2007 to December 2009 revealed that there was high incidence of
third degree tear among primigravida and non-antenatal cases.
Mothers admitted from January to June 2010 were interviewed to identify weaknesses during
antenatal check-up. Nurses conducting deliveries were supervised. Intervention was carried out from
July to December 2010. Remedial measures were evaluated by monitoring all high risk mothers.
Among 1515 deliveries from January to June 2010, multiple contributing factors were identified. Data
showed that primigravida/nulliparity, mothers with history of big baby/previous tear and non antenatal mothers were at risk. We realised that preparation and process of delivery were not properly
done due to lack of knowledge regarding proper delivery technique.
Strategy for Change
Strategies implemented were coordinating with Maternal and Child Health Clinic staff to impart
proper education, close supervision, regular Continuous Nursing Education, appropriate perineum
protection, appropriate time for episiotomy and no sweep and stretch.
Effects of Change
The strategies were applied and there was a reduction from 72 (2%) in 2009 to 23 (0.7%) incidences
in 2010. During the monitoring period January to June 2011, there was further reduction to 6 (0.4%)
incidences. From this study, we learned that ante-natal education and good delivery technique may
reduce the incidence of 3rd degree tear. Staff became more committed, knowledgeable and skillful.
The Next Step
The strategies were effective and will be continuously practiced in our daily activities.
chapter 7
The team had decided to set the standard of not more than 1% incidence of third degree tear among
total number of vaginal deliveries per year.
Hospital Bintulu is the referral centre where maternal problems are anticipated. Data showed that
mothers experiencing third degree tear had not attended antenatal education/clinic. The study aim
was to identify the risk factors and implement measures to reduce the incidences.
98
PP/2011
Delay in Induction of Labour with Oxytocin
Nik Azi Azuha NH, Norhayati A, Norizah M, Saluwani AH, Nuraini M.
chapter 7
Obstetrics and Gynaecology Department, Raja Perempuan Zainab II Hospital , Kota Bharu, Kelantan.
Patients planned for induction of labour (IOL) with intravenous (IV) Oxytocin have to wait for a
long time before induction is started, hence delaying labour initiation. This subsequently can give
rise to poor maternal and perinatal outcomes and may cause distress to patients and relatives. A
retrospective study revealed that the majority of cases were delayed and initiated after 12.00 noon.
This study aimed to identify the contributing factors for and to reduce the delay in induction of
labour.
The team set a standard of 80% cases for IOL to be started before 12.00 noon in anticipation of
adverse or poor maternal and perinatal outcomes. Should these occur, then it is preferable to be in
the daytime.
A verification analysis was done from November to December 2009 to identify the factors for the
delay in IV oxytocin initiation. A cross-sectional study was carried out from January to May 2010.
Remedial measures were implemented and the results analysed.
A total of 50 cases were evaluated for this study. Every step of the process of care was studied. Before
remedial measures were implemented, only 35% of patients had IV Oxytocin initiated before 12.00
noon. The delay between the decision for induction and the initiation of IV Pitocin in the labour room
was mainly associated with the absence of a systematic approach in guiding the caretakers in dealing
with cases for IOL.
Strategy for Change
Induction has to be carried out as early as possible in order to anticipate any adverse outcomes
related to the procedure. We had developed a strategy towards managing patients for IOL by
introducing induction beds/ rooms, induction sheet, induction board, and organising Continuous
Medical Education for the staff.
Effects of Change
Implementation of remedial measures had resulted in dramatic improvement in every step of the
induction process, whereby 77% of patients were initiated on IV Oxytocin before 12.00 noon,
compared to 35% previously. We had a better outcome of delivery and a more satisfactory perinatal
outcome by the reduction in the number of emergency caeserian section.
The Next Step
This new strategy of change is effective and will be applied continuously in our daily practice with
regular re-assessment.
99
PP/2011
Mengurangkan Kadar Kejadian LSCS Wound Breakdown
Anna T, Masni L, Lena C, Chua YL, Jeanyfer L, Mohd FA, Lucina L.
Memastikan insiden LSCS Wound Breakdown kurang dari 15% dalam tempoh kajian selama 6 bulan.
Kajian berbentuk irisan lintang dijalankan dari bulan Julai - Disember 2010. Subjek utama adalah
semua ibu yang menjalani pembedahan LSCS. Data diperolehi melalui borang soal selidik dan
senarai semak yang diisi oleh Pegawai Perubatan, anggota Wad Materniti, Unit Dewan Bedah, Klinik
Kesihatan Ibu dan Anak dan semua Klinik Desa di Daerah Tenom.
Kadar LSCS wound breakdown meningkat dari 40.60% (Julai-Disember 2009) kepada 43.75%
(Januari-Jun 2010). Punca masalah ini adalah tahap pendidikan yang rendah, amalan pantang larang
serta adat resam yang tidak seiring dengan perubatan moden. Anggota kesihatan yang kurang
pengalaman dalam perkhidmatan, pendidikan kesihatan yang tidak seragam dan masalah kualiti
udara Dewan Bedah juga menjadi punca insiden ini berlaku.
Perhatian diberikan kepada memantapkan perlaksanaan pendidikan kepada anggota kesihatan
seterusnya kepada ibu, agar mereka memahami cara penjagaan luka LSCS di rumah. Kaedah
pemantauan luka LSCS juga diperkemaskan dengan mewujudkan senarai semak dan melakukan
lawatan rumah oleh anggota kesihatan. Dewan Bedah juga ditutup sementara bagi kerja pembersihan
dan penyelenggaran.
Insiden LSCS wound breakdown Hospital Tenom berjaya dikurangkan dari 43.75% kepada 13.64%.
Langkah Seterusnya
Amalan, pengetahuan dan kerjasama antara anggota kesihatan serta fasiliti yang lengkap adalah
penting bagi memastikan perkhidmatan yang selamat dan berkualiti. Kaedah pemantauan yang
berkesan juga diperlukan bagi memudahkan urusan mengesan masalah serta mengukur prestasi
penambahbaikan yang telah dilakukan.
chapter 7
Lower Segment Caesarian Section (LSCS) merupakan pembedahan yang dilakukan terhadap ibu yang
mempunyai masalah melahirkan anak. Oleh kerana jangkitan boleh berlaku, maka proses persediaan
dan perlaksanaannya perlulah mengikut prosedur yang telah ditetapkan. Kajian ini dilakukan bagi
melihat keberkesanan langkah yang telah diambil bagi mengurangkan kejadian LSCS wound
breakdown di Hospital Tenom.
Hospital Tenom, Sabah.
100
PP/2009
Improving Pregnancy Rate of Intra Uterine Insemination
M. Zulkifli MK, S. Norfaizah W, Maznah M, Kamariah Y, M. Nasir TA.
chapter 7
Sultanah Nur Zahirah Hospital, Kuala Terengganu, Terengganu.
The procedure of Intra-Uterine Insemination (IUI) was simple but encouraging measures provided
proper selection of cases, adequate pre-procedure preparation and effective implementation of the
procedures were carried out. Findings from the scientific researches verified it. This quality assurance
project was to revisit our current practice and performance followed by implementation of changes
to improve it.
The rate of pregnancy (regardless the outcome) were used to measure the success of IUI and the
standard was more than 10%.
Four audit cycles using data collection format were done for a period of two years (June 2007 - March
2009). Thirty cases were audited in every cycle. The content includes the patient characteristics, the
completeness of the pre-procedure investigations as well as the favouring criteria towards achieving
pregnancy.
The pregnancy rate was only 6.6% (10.2% in 2006). The main missed opportunities were inappropriate
cases, sperm inadequacy and unconducive number of dominant follicles. The percentage of favourable
endometrium and fallopian tube was satisfactory but may be improved.
Strategy for Change
The main changes instituted were a preparation of guideline for proper selection of cases and
dedicated IUI clinic followed by regular case auditing. The guideline for ovarian stimulation and
insemination had been revised and strengthened.
Effects of change
The interventions were able to reduce the rate of missed opportunities and the percentage of
pregnancy had exceeded the standard set of 10% (12.5%).
The Next Step
Regular revision of the service is one of the key to success especially those related to the new services
or procedures. New innovation will be added continuously.
101
PP/2009
Reducing the Incidence of Rejected Laboratory Specimens from
Obstetrics Wards
Dorien H, Nancy B, Christina M, Juria S, Felecia L.
The project aimed at reducing the percentage of rejected laboratory specimens from 13.5% to 5.0%.
This target was based on the standard agreement between the Hospital and Medical Laboratory in
2008.
All documents of the rejected specimens were analysed, whilst the knowledge and practice of
relevant personnel were tested, observed and analysed.
The research noted the lack of knowledge of staff on handling the specimens which include wrong
blood taking technique and poor labeling procedures.
Strategy for Change
Remedial measures were implemented for three months and these include a structured orientation
programme for house officers and medical officers on blood taking procedures and handling of
laboratory specimens. Standardised labelling stickers were introduced and daily monitoring on
rejected specimens were done by head of units.
Effects of Change
Evaluation was done in June 2009. The percentage of rejected specimens was reduced from 13.5%
in January 2009 to 4.4% in June 2009.
The Next Step
Continuing education and strict supervision managed to improve the knowledge and practice of staffs
on handling of specimens. The next step will be working towards maintenance of the achievement
for the next six months and to reduce the standard of the indicator to 0%.
chapter 7
High percentage of rejected laboratory specimens from Obstetric Wards, Women and Children
Hospital, Likas was identified as a quality problem. A total of 225 laboratory specimens (13.5%) were
rejected out of 1664 specimens taken in January 2009. Laboratory test results are important because
it serves as a guide on decision for patient’s treatment, especially for those with life threatening
conditions. Delay in decision making may endanger patient’s life and may lead to patient or family
dissatisfaction.
O&G Department, Women and Children Hospital, Likas, Sabah.
102
OP/2007
Re-Engineering of Low Risk Birthing Centre
Nor Anita A, Ghazali I, Mohd Azam M.V, Nurhazinat V, Anna Liza R, Ganesh
R, Sudesan R, Norliza I, Hjh Khatijah K, Azizah M, Rodiah A, Azizah C.D,
Rahimah O.
chapter 7
Department of Obstetric and Gynaecology, Hospital Tengku Ampuan Afzan, Kuantan.
Low risk pregnancy can safely be managed by qualified nursing midwife at alternative birthing centre
without the presence of medical practitioners. However, these birthing centres do not receive good
response from the public and some obstetricians do not believe in the concept of low risk delivery.
In June 2004, Low Risk Birthing Centre (LRBC) was reopened but the delivery was less than 10% in
the first 3 months. This study was conducted to determine the factors that lead to low deliveries rate
and to consider re-engineering the system without compromising the safety of pregnant mothers
and their babies.
To determine the factors for low delivery at LRBC, to propose remedial actions and reevaluate the
effectiveness of changes made.
A retrospective data was collected in September 2004 to verify the low delivery rate and to identify the
root of the problem. This was followed by a prospective cross-sectional study conducted in October to
December 2004, to determine the effectiveness of remedial action undertaken. Subsequently studies
were carried out in the following years to monitor sustainability of the remedial actions carried out.
The contributing factors identified were failure of staff to adhere to the obstetric admission policy,
lack of promotion of LRBC by health centres and lack of knowledge and confidence among the
nursing staff in handling cases at LRBC.
Strategy for Change
The remedial measures taken included reviewing admission criteria for delivery, designing a new
Standard Operating Procedure, an introduction of “Admission Cardiotocogram” to ensure satisfactory
fetal wellbeing, a specialist to supervise in the screening of cases, provision of 4 beds for pre labour
stage, availability of doctors at Patient Admission Centre (PAC) to assist nursing staff for intrapartum
complications, re-educating nursing staff and increasing promotion about LRBC at community clinics.
Effects of Change
The number of deliveries at LRBC increased exponentially to 13.7% after implementation of remedial
actions in October - December 2004. It continued to rise to 19.8% and 24% in the subsequent
studies. The maternal and perinatal mortality was 2.2 and 2.7%, respectively which were lower than
prior implementation.
Next Step
The use of LRBC can be optimised to help reduce congestion in hospital labour wards, without
compromising the safety of both mother and her baby. Remedial action such as modification of
selection criteria had increased the deliveries at this centre. Further remedial measures such as
providing in-house medical officer 24 hours at PAC, ambulance stationed 24 hours to shuttle patient
to high risk labour ward and providing analgesia e.g. ENTHONOX may also contribute to improved
quality of care in LRBC.
103
OP/2007
Towards Reducing the Risk of Retained Swab after Perineal
Repair in Hospital Sultanah Nur Zahirah
Mohd Zulkifli MK, Fadhilah H, Mohd. Nasir TA, Salmah S, Rokiah A.
The rate of compliance to the steps of preventing retained swab (derived from literature-clinical
guidelines) was used to measure improvement.
Four completed audit cycles and surveys using questionnaires were done for a period of one year and
6 months (January 2006 - July 2007). One hundred procedures were audited in every cycle. Surveys
involving 60 respondents in the first round followed by 30 respondents each for the subsequent
rounds were carried out.
The most common reasons for failure to comply the steps of preventing retained swabs were lack
of knowledge about proper handling of swab, lack of, awareness of safe practice, unavailability of
Standard Operating Procedure (SOP), no structured dissemination of information, swab counting
policy not in place and insufficient supervision.
Strategy for Change
The main changes instituted were preparation of SOP for perineal repair, availability of perineal
suturing kit, distribution of pamphlets, increasing the frequency of supervision and regular session of
providing information.
Effect of change
The intervention was able to reduce risk of retained swab as shown by increased compliance to
preventive steps from only 41 % in January 2006 to 95% in July 2007.
Lessons learnt
Reducing the risk of retained swab in all hospitals is possible if the above strategies are in place.
chapter 7
Incidents of retained swab in maternity department are frequently been reported. Findings from the
enquiries confirmed that our current practice of perineal suturing is not without risk of retained swab.
However little information is available on the reasons and what to do to prevent retained swab. This
quality assurance project is to evaluate our current preventive measures followed by implementation
of a strategy to improve it.
Hospital Sultanah Nur Zahirah, Kuala Terengganu.
104
OP/2005
Episiotomy Wound Breakdown, How to Overcome It?
Rusnah A, ML Foo, Sotinah T.
Kluang Hospital, Johor.
Outline of problem
chapter 7
Episiotomy wound breakdown at the Obstetric & Gynaecology Unit, Hospital Kluang was noted to be
on the rise from 1 case in September 2003 to 6 cases in October and 4 cases in November. Episiotomy
wound breakdown not only causes emotional stress to patients and their family, but it adds physical pain,
increases admissions to the ward, increases cost to the patients and hospital, and decreases trust of public
towards quality of care provided by the hospital.
Cause and effect analysis of the problem identified factors such as staff not adhering to aseptic technique,
suturing not done as per guidelines, lack of experience in suturing, lack of knowledge on care of episiotomy
wound, uncooperative patients and type of sutures used.
A “model of good care” (MOGC) was developed which stressed on correct aseptic technique, correct
suturing technique, types of sutures used and health education. Evaluation on staff skills was performed
using a structured checklist. A standard was set for staff nurses to perform at least 5 - 10 episiotomies per
month so that suturing skills improves. All patients with episiotomies were to be given health education on
care of episiotomy wound. A pamphlet on care of episiotomy wound was developed.
Shortfall in quality was observed from analysis of data obtained from the monthly monitoring of episiotomy
wound breakdown. To assess the attitude, practice and skills of the staff nurses (26 nurses), structured
checklists were used to identify areas of shortfall for all staff nurses and community nurses working in
the labour wards by direct observation. The same checklist was used to compare the performance of the
nurses after implementation of MOGC and monitoring the number of episiotomy wound breakdown was
done continuously. Nurses suturing episiotomies recorded each episiotomy suturing performed.
53.6% of the nurses had less than 3 years experience whilst 46.4% had more than 3 years experience
working in the labour wards. 61% of nurses did not wash their hands before wearing glove and suturing
episiotomies. 28.5% did not prepare sterile field and 7% of staff did not give health education to patients.
After the intervention, the percentage of nurses not washing their hands had reduced from 60.7% to
7.1%. There was a reduction in wound breakdown from 2.2% to 0.5%.
Strategies for change and effects of change
All nurses were made aware of availability of MOGC and the need to adhere to it. Continuous nursing
audit by the ward quality team, to ensure correct practiced were carried out. Results of audit were made
known to staff during ward meeting. Documenting procedures done in log book was made compulsory.
Nurses working in the labour wards were required to perform at least 5 to 10 episiotomies per month.
Patients with episiotomies were given health education and pamphlet on care of wound. The infection
control nurse monitored every wound breakdown and notified the nursing sister-in-charge. With the
support and cooperation from the Hospital Director, O&G Specialists, other doctors and all nursing staff,
the number of episiotomy wound breakdown had reduced from 11 cases (September to November 2003)
to 2 cases (January to March 2004).
The next step
Experienced staff and practicing a correct technique had contributed to the decreased number of
episiotomy wound breakdown. To ensure that the good practice is being maintained, regular monitoring
and feedback mechanism must be in place.
105
PP/2005
Improved Screening of Distress Newborn to SCN
Norhafizah MA, Noryazlina MA, Kwok GK, Chua TH.
Department of Obstetric & Gynaecology, Batu Pahat Hospital, Johor.
To improve the screening of distress newborn to SCN, the indicator was the number of failure to diagnose
distress newborn 1 hour after delivery from postnatal ward over the number of all admissions to SCN x
100%. The standard set was less than 10%.
A retrospective cross-sectional study was conducted in the Department of Obstetrics & Gynecology, Batu
Pahat Hospital, Johor from January until December 2003. Data of all admissions of term distress newborn
after 1 hour of life that were diagnosed as distress from postnatal ward and admitted to SCN were
collected and their records analysed. The variables on category of staff, documentations, staff knowledge
and experience, delay in response by doctor and attending NRP course were studied. Questionnaires were
designed to assess working experience and knowledge.
There were 114 cases of newborn admitted to SCN in 2003. The number of distress newborn failed
to be diagnosed was 27. The indicator was 23.6% which was 13.6% higher than the standard. The
contributing factors identified were; poor documentation in labour room and postnatal ward (100%), lack
of knowledge (65.8% had poor grade) and lack of experience (66.7% had less than 1 year experience in
Labour room or SCN).
Strategy for change
‘Low risk newborn observation’ checklist was introduced in the labour room and postnatal wands. CME on
‘Care of Newborn’ was given by the Paediatrician and Nursing Sisters in-charge. After a week of exposure,
all staff underwent a post test assessment. NRP was organized by Paediatric team on July 2005.
Effects of change
After implementation of the remedial actions, the incidence of failure to diagnose distress newborn had
reduced to 10.75%. The ABNA has improved tremendously from 13.6 to 0.75%. The staff knowledge
improved after the CME (only 7.1% had poor grade). In monitoring the effect of change, data were
collected again from January until June 2005. Failure to diagnose distress newborns further reduced to
3.38%.
The next step
There was a sustainable quality improvement evidenced by the results above. In ensuring the problem will
not recur, all staff should adhere to the guidelines. For the new staff, it is compulsory for them to attend
the ‘Care of Newborn’ CME.
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Distress newborn is characterised by rapid grunting respiration, cyanosis and retraction of tile intercostals
muscle on inspiration. In Hospital Batu Pahat the incidence of distress newborn detected at postnatal ward
is high, 20 - 30% from all admission newborns to Special Care Nursery (SCN). All term newborns are to be
observed in the labour room for at least 1 hour. Failure to diagnose distress newborn especially during the
first hour after birth and sending babies to postnatal can lead to morbidity and mortality. The causes of
failure to diagnose distress newborn are lack of knowledge and experience, and improper assessment or
not adhering to protocol or guidelines. The general objective of this project is to improve the screening of
distress newborn to SCN, in order to reduce morbidity and mortality. The specific objectives are to identify
the possible causes of failure in diagnosing distress newborn, determine the magnitude, implement the
necessary remedial measures and evaluate their effectiveness.
Outline of problem
106
PP/2005
Active Management of Obstetrics Hypovolaemia
M. Zulkifli MK, Rohana I, Zahar AZ.
Department of Obstetrics & Gynaecology, Kuala Terengganu Hospital.
Outline of problem
Many women are dying unnecessarily due to irreversible hypovolaemia secondary to obstetric haemorrhage.
Thus, obstetric hypovolaemia is a good indicator of quality of maternal care. This study is to assess our
current performance in relation to shortfall in quality (SIQ), followed by implementation of the strategies
for change in order to ensure effective management of obstetric hypovolaemia and its sustainability.
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Management of obstetrics haemorrhage forms an important part of the critical O&G services. Blood
coagulopathy is one of the major avoidable complications leading to maternal morbidity/mortality. Active
management will ensure rapid and uncomplicated recovery, thus preventing serious morbidity and reducing
mortality. There are many missed opportunities which include delay in recognition, inadequate treatment,
ineffective/delay in resuscitation and inadequate clinical monitoring. There are ample opportunities to
improve - early recognition, identification/elimination of risk factors, prompt/well organised resuscitation,
effective Red Alert System and timely/appropriate decision to arrest bleeding. The indicator chosen was
“the percentage of obstetrics hypovolaemia complicated by coagulopathy”.
A cross-sectional study was carried out in the postnatal ward involving 54 cases of obstetrics hypovolaemia
managed in Hospital Kuala Terengganu (HKT) from 1 April to 30 September 2003 (6 months). Data were
collected from maternity cards/relevance case records. After implementation of remedial actions, reevaluation was carried out, involving 31 samples from 1 February to 30 June 2004 (5 months). Subsequently,
52 monitoring cycles followed the first cycle from 1 November to 31 December 2004 (2 months) and the
second from 1 May to 30 June 2005 (2 months).
Analysis & interpretation
The incidence of coagulopathy (DIVC) from 1 April to 30 September 2003 was 68.5%. Majority was due
to post-partum hemorrhage following vaginal delivery. Only 88.9% had adequate clinical monitoring and
94.5% of them were recognised late (blood pressure was less than 90/60). There was failure to identify
risk factors in 36.6% and 14 cases did not receive adequate medical treatment. Red alert was not activated
in 9 cases, 5 cases were not well stabilised before intervention and there were delay in getting blood for
11 patients. More than half of the patients had complications with post-operative fever being the most
common complication.
Various remedial actions were carried out which included strengthening of the departmental maternal
audit, CMEs, monitoring system (usage of gauze count chart, small white board monitoring tool) and
introduction of new strategies (regular drill, action card and alarm system), as well as enhancing the
effectiveness of red alert system.
Effect of change
Analysis showed that the percentage of late detection was reduced, adequate clinical monitoring
had increased, the risk factors were being successfully identified and there were fewer occurrences of
missed opportunities. As a result, the percentage of coagulopathy had reduced from 68.5% to 29.0%.
The standard set of less than 30.0% had been achieved. Subsequent re-evaluations showed that the
improvement was sustained.
Conclusion
There was SIQ in the process of management of obstetrics hypovolaemia in HKT. After remedial actions,
the incidence of coagulopathy had reduced and the standard of less than 30% had been achieved. This
performance was sustained in subsequent re-evaluations.
107
OP/2005
Incidence of Post Partum Hemorrhage
Hasrina H.
Tawau Hospital, Sabah.
A prospective study was conducted to assess the common practices in handling patients with a high
risk of developing PPH. A questionnaire was filled up by doctors and nurses on risk stratification anti
preventive measures undertaken for each selected patient.
Only 60% of patients with high risk of PPH received maintenance intravenous (IV) pitocin 40u for
6 hours post delivery and only 20% patients received intra-muscular (IM) syntometrin during the
delivery of the anterior shoulder.
Strategy for change
Formal and bedside teaching sessions were given to doctors and nursing staff on the identification of
patients at risk of PPH and preventative actions to be taken in anticipation of PPH. Copies of the PPH
Training Manual were made available in the wards. Effects of change
After implementing the strategies for change, there was an improvement in the use of 1M
syntometrine during the delivery of the anterior shoulder (to 40%) and IV pitocin 40 unit post delivery
of patients with high risk of PPH (to 100%). Overall, the incidence of PPH was also reducd to 1-2
cases per month.
The next step
Continuous education of medical personnel in reinforcing good process of care should continue as it
significantly contributes towards reducing the incidence of PPH.
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Remediable measures are chosen in which their improvement will reduce the incidence of PPH.
Outline of problem
40% of patients who came to deliver in Tawau Hospital were found to be high risk of developing Post
Partum Hemorrhage (PPH). The incidence of PPH was 4-6 cases per month in 2004 and this happened
easily due to inadequate preventative measures undertaken and mis-management of the third stage,
following deliveries conducted by inexperienced staff.
108
OP/2005
Unsatisfactory Pap Smear Yield
Sharmini Diana P, Shamsul AH, U Pandian, Malliga Devi, Noraini H.
chapter 7
Seberang Jaya Hospital, Penang.
Outline of Problem
There is a problem of increasing number of unsatisfactory Pap smear results in this unit. This can lead
to delay in the diagnosis and treatment of abnormal smear and cervical cancer. Patients would be
dissatisfied and inconvenienced due to repeated Pap smear tests. This would also incur an increased
cost to patients and hospital.
Unsatisfactory Pap smear may be due to lack of knowledge and skills of our health care providers.
The patient factors may be incorrect timing and poor self-preparation. Poor packing of slides can also
lead to broken slides. Poor knowledge on fixation can result in unsatisfactory smears.
This study hopes to improve the knowledge, skills and competency of staffs and patients in order to
improve the Pap smear yield. Hence, to reduce the number of unsatisfactory Pap smear results.
A descriptive cross sectional study was conducted from 1 to 31 July 2003. Re-evaluation was carried
out twice. Patients were assessed for their knowledge on preparation and timing of Pap Smear.
Assessment of knowledge and skills of staff was also conducted. These were carried out using
questionnaires and observational survey.
Poor knowledge of staff (40%) was identified as one of the factors leading to poor timing and patient
preparation. There was also a lack of knowledge in fixation of slides (1%). Lack of knowledgedf
patients (20%) about timing and self preparation was one of the contributory factors.
Strategy for Change
Intervention activities included retraining of all staff by specialist. A new patient information pamphlet
was designed which included information on timing and preparation for Pap smear examination.
Supervision of fixation of smears was enhanced.
Effects of Change
The number of unsatisfactory Pap smear has been reduced from 14% to 4.76%. Staff and patient
knowledge has improved. Achievable benefits not achieved were reduced from 9% to 0%.
The Next Step
The experience gained from this study has shown the need to identify key problems and institute
practical remedial measures which could be complied and sustained in order to provide continuous
quality improvement. We have adopted this indicator as our Hospital Specific indicator and the quality
of Pap smears has been sustained as evident by our 2004 result which is 3.87%.
109
OP/2005
Inappropriate Waiting Time in Maternity Patient Assessment
Centre
Hamidah O, Mohamad Farouk A, Annie N.
The smooth flow of patients can be ensured with the following measures: an efficient triaging system,
competent staff performing initial assessment, precise clerking, supervision of and access to senior
personnel. More than 70% of patients should be seen within the acceptable waiting time which was
taken as s 2 hours.
A preliminary, prospective cross-sectional time motion study was conducted between the 6 and 15
September 2004. The time interval for each stage of patient care was analysed.
Only 53% of patients spent less than 2 hours in PAC. The main factors were delay in house-officer
clerking and lengthy clerking.
Strategy for Change
The main interventions taken were the assignment of a resident medical officer and keeping of
patient records in PAC.
Effects of Change
78% of patients spent 2 hours or less in PAC. The time intervals for most of the stages were reduced.
There was less number of complaints received.
The Next Step
The next step is to evaluate the appropriateness of care, which will include proper triaging, competency
of staff attending to the patient, accurate documentation and avoidance of unnecessary admissions.
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Outline of Problem
Being a busy maternity unit, the Patient Assessment Centre (PAC) is constantly congested with
pregnant mothers. This resulted in long waiting hours, causing discomfort, anxiety and complaints. At
times, crucial time needed for maternal and fetal monitoring was compromised resulting in near-miss
events. Occasionally, adverse perinatal outcome occurs. The possible causes are too many patients,
inexperienced and inadequate staff.
Department of Obstetrics and Gynaecology, Tengku Ampuan Rahimah Hospital, Klang, Selangor.
110
OP/2005
To Reduce the Waiting Time for Antenatal Patients to Get
Admitted to the Maternity Wards at Sarawak General Hospital,
Kuching
Dayang Jakiah AY, Loh W, Rafiah B, Kueh MH, Jeniffer M, Norliza Y.
Labour Ward, Sarawak General Hospital, Kuching.
chapter 7
Outline of Problem
Labour Ward is an admission centre for all antenatal patients who are either in labour or referred for
admission with other problems. All patients have to undergo the process of admission in Labour Ward and
that should not take more than 60 minutes. When a decision for admission has been made the patients
should be admitted to the Maternity Wards within 10 minutes. In January 2005, 58% of the patients had
to wait for more than 70 minutes before they could be accepted by the Maternity Wards and in May 2005,
80% had to wait for more than 70 minutes. The delay in accepting patients was due to non-availability of
beds in the Maternity Ward.
The key measure for improvement is the time taken for admission to the Maternity Ward. Based on
existing resources, a target that 90% of patients should be able to be admitted within 70 minutes, was set.
A time motion study on waiting time was carried out. All antenatal patients with 22 weeks gestation were
included in the study and antenatal patients who are admitted directly to labour ward and those who
require emergency intervention were excluded.
Pre-study data was collected from 1 May 2005 to 31 May 2005.
Post-study data was collected from 1 July 2005 to 31 July 2005.
80% of the patients had to wait more than 70 minutes for beds to be available in the Maternity Wards.
Unnecessary occupancy of beds by patients who had already been discharged contributed to the nonavailability of beds for new patients. 30% of the patients who were fit for discharge stayed on because
their babies were not fit for discharge. 20% of the patients were unable to go home because their babies’
G6PD results were not ready. Another 20% of the patients were waiting for their husbands to fetch them.
Other contributing factors were the rigid policy of bed allocation for patients’ placement. Even though
there were beds available in the ward, but if those beds were allocated to postnatal or operation cases,
antenatal patients could not occupy these beds.
Strategy for Change
Increasing the availability of beds will reduce patients’ waiting time. Hence, factors contributing to the nonavailability of beds were identified and remedial measures were implemented. Beds were made available
by ‘free bed occupancy’ policy, instituting a Planned Discharge practice and improving G6PD Screening
services. Medical and House officers were reminded on the Planned Discharge practice and nurses were
encouraged to practice flexible bed allocation. G6PD issues were addressed by having discussions with the
Hematology Unit, Pathology Department, on screening and dispatch schedules.
Effects of Change
The percentage of patients who were admitted within 70 minutes increased from 20% to 70%.
The Next Step
This is an on going project and the next step is to further narrow the ABNA gap with the intention of
achieving zero ABNA gap.
111
OP/2003
Effect of Non-Compliance to Standard Operating Policy Relating
to Referral of Potential Obstetric Patients in Premature Gestations
to the Neonatal Intensive Care
Ng P.
Hospital Universiti Kebangsaan Malaysia.
Introduction
Correct hand-over of all in-patients that may require premature delivery to the NICU department.
Outline of Problem
In utero and ex-utero transfers will occur when the NICU was unable to take further referrals. Regular
handover of potential in-patients will avoid acceptance of ex-utero transfers from other hospitals and
allow time for transfer of existing in patients when all NICU spaces were found to be taken up.
A prospective daily count of the number of existing in-patients at risk of suspected preterm delivery in
our antenatal wards and patients known to the NICU was carried out over a 2 week period to determine
the percentage of updating that was occurring. A count of the number of in-utero and ex-utero transfers
coming in and out of our hospital was also carried out during this time to see if there was any potential
effect of discrepancy between the number of patients known to the obstetric and neonatal departments.
A spot questionnaire on random members of staff was also carried out to determine the level of awareness
of the standard operating policy and to see if staff answering the questionnaire carried this out.
Discrepancies between the number of in-patients with preterm gestations that could have required delivery
and the number of patients who were updated in NICU were noted, being as high as 7 patients on some
days. Lack of compliance of the standard operating policy resulted to unnecessary in/ex-utero transfers
following acceptance of ex-utero transfers from other hospitals into our NICU department.
Strategy for Change
Measures to improve awareness of this policy through re-emphasis on policy, improvement of communication
between both departments, enforcing policy by specialists working in each department.
Effects of Change
Better communication between the 2 departments and compliance to the Standard Operating Policy will
ensure that existing inpatients requiring premature delivery will be ensured of a place for their babies
in the NICU and have a lower risk of being transferred out in the event of lack of space. The Neonatal
Department will be able to limit ex-utero transfers from other hospitals when there are already many
potential bookings for these spaces from within the same hospital.
The Next Step
This audit will be carried again to see if the measures have been effective in ensuring better compliance to
the policy of handover of these patients and to see if the number of in-utero and ex-utero transfers can
be minimized from this.
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Key measures for Improvement
A policy was agreed upon between the Obstetric and Paediatric Department to ensure daily handover of
potential Obstetric patients requiring premature delivery to the neonatal intensive care unit (NICU).
112
OP/2011
Meningkatkan Tahap Penglihatan Pesakit Ambliopia
di Klinik Oftalmologi
Farawahida Kasmira F, Nur Liyana I, Nurul Ain MZ, Abdul Mutalib O,
Mazliana A, Maizun MZ, Laila A.
Jabatan Oftalmologi, Hospital Kuala Krai, Kelantan.
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Ophthalmology
Ambliopia boleh berlaku pada pelbagai peringkat umur dan jika tidak dirawat awal boleh
menyebabkan kebutaan kekal. Peningkatan tahap penglihatan (VA) di kalangan pesakit Ambliopia
yang komplians terhadap rawatan pengatupan boleh mencapai 77%. Seterusnya, meningkatkan
komplians terhadap rawatan pengatupan akan meningkatkan VA pesakit Ambliopia.
Untuk menilai VA dan mengenalpasti faktor yang menyumbang kepada VA di kalangan pesakit
Ambliopia yang menjalani rawatan dan seterusnya menjalankan tindakan penambahbaikan bagi
meningkatkan VA kepada 77%. Komplians dinilai dengan memakai kaca mata beralat refraksi
terkini, membuat rawatan pengatupan 2 jam sehari dan menghadiri temujanji.
Kajian bermula Jun 2009 hingga Mac 2011. Maklumat diperolehi dengan menggunakan borang
soal selidik, buku temujanji pesakit dan kad rawatan pesakit. Kajian penilaian keberkesanan tindakan
penambahbaikan dijalankan terhadap pesakit dan kakitangan klinik.
Analisa dan Interpretasi
Peningkatan VA ialah 12% manakala faktor penyumbang kepada VA pesakit Ambliopia ialah kurang
pengetahuan tentang rawatan, waktu sekolah yang panjang (lebih 7 jam), tidak faham arahan
pengatupan, tidak yakin kepada rawatan pengatupan, tidak memakai kaca mata dengan ralat
refraksi terkini dan gagal menghadiri temujanji yang ditetapkan.
Menyediakan Prosedur Operasi Terpiawai (SOP) pengendalian pesakit Ambliopia, menjalankan
aktiviti pendidikan kesihatan dan meningkatkan kemudahan sistem temujanji.
Kesan Perubahan
Kajian menunjukkan VA pesakit Ambliopia telah meningkat kepada 78% dengan peningkatan
komplians terhadap rawatan pengatupan.
Langkah Seterusnya
Memastikan pengendalian semua pesakit Ambliopia mengikut Prosedur Operasi Terpiawai (SOP) serta
mempertingkatkan aktiviti pendidikan kesihatan dan program saringan penglihatan di peringkat
tadika, sekolah rendah serta projek komuniti sebagai langkah pencegahan Ambliopia.
113
PP/2011
Reducing the Percentage of Clinical Progression of Severe
Non-Proliferative Diabetic Retinopathy Cases to Proliferative
Diabetic Retinopathy Stage Over 1 Year in an Ophthalmology
Department
Adeline ML Khaw, Chariya Eh Chot, Ng SL, Rosli A.
Department of Ophthalmology, Hospital Taiping, Perak.
This project was divided into 4 parts. A retrospective analysis was done over a 2 year period (January
2007 to December 2008) to identify contributing factors (n=12). Remedial measures have been
carried out since January 2009. Evaluation on its effectiveness was carried out from March 2009 to
April 2010 (n=20). A sustainability review was held from June 2009 to July 2010 (Part 1, n=20) and
August 2010 to April 2011 (Part 2, n=15).
Four contributing factors were identified namely, long waiting time for new cases, poor glycemic
control, low number of referrals to nearest clinics for better glycemic control and delay in initiating
Laser Treatment.
Strategy for Change
Remedial measures included starting Laser Treatment at Severe NPDR stage, strict supervision of
learning doctors during Laser Treatment, giving appointment to new patients with diabetes within
6 weeks, lifestyle modification counselling and referring of patients with poor glycemic control
(FBS > 10mmol/l) to the nearest clinic. These measures involved all doctors and paramedics in our
department.
Effects of Change
There was a significant reduction in the percentage of clinical progression of Severe NPDR cases
to PDR stage from 67% in 2007, 70% in 2008 to 10% in March 2009 until April 2010. A lower
percentage of 5% was recorded in our Sustainability Review period (Part 1) and similarly 6% in Part 2.
The Next Step
This project had raised awareness among our doctors to be more vigilant in DR cases. We had started
introducing monthly Fundus Camera screening programme in nearby government clinics.
chapter 7
We aimed to reduce the above percentage of 50.2% to 20%, based on the target set by our
department.
Ophthalmology
Selection of Opportunities for Improvement Diabetic Retinopathy (DR) is a microvascular complication of patients with diabetes. Those who have
Severe Non-Proliferative DR (Severe NPDR) are at high risk (one year risk of 50.2%) of progressing
to Proliferative DR (PDR) with subsequent poor visual outcome due to vitreous haemorrhage and/or
retinal detachment. This study was carried out to identify the contributing factors, develop effective
remedial measures and thus, delay the progression of this potentially blinding complication.
114
PP/2011
Re-Engineering the Cataract Surgery Wait-Time Strategy
Shubhashini Y, Poh EP, Gong VHM, Kogilavaani J, Kasturi R, Che Sam AK,
Normadiniatul SMH, Nur Fazlina MN.
Department of Ophthalmology & Medical Social Unit,Hospital Raja Permaisuri Bainun (HRPB), Ipoh,
Perak.
chapter 7
Ophthalmology
Cataract surgery wait-time has important clinical, public health and health policy considerations. Delay
in cataract surgery reduces patient’s quality of life (QOL), increases risk of lens-related complication
and is associated with poorer outcome. There was a mean cataract surgery wait-time of 23 weeks for
patients with mature cataracts in the Department of Ophthalmology, HRPB, Ipoh.
This QA project identified the contributing factors and introduced remedial measures to reduce the
cataract surgery wait-time for patients with mature cataracts to 8 weeks.
A cross-sectional study was conducted from January to March 2009 followed by a prospective study
from January to March 2010 to evaluate the effectiveness of remedial measures.
The rate of surgery within 8 weeks was 26.7%. The mean time for approval of intraocular lens (IOL)
was 3 months. The contributing factors were no proper prioritisation of cataract surgery wait-list,
high postponement rate, financial constraints, defaulters and lack of awareness on the need for
second eye surgery.
Strategy for Change
Remedial measures taken were prioritising wait-list for patients with mature cataract to a maximum
wait-time of 8 weeks. All patients with uncontrolled medical or ocular conditions were admitted to
be stabilised and operated. A special medical social unit referral for IOL with approval within 4 weeks
was established. Patients with second eye mature cataract were listed directly for surgery within 8
weeks postoperatively.
Effects of Change
There was a significant shortening of the cataract surgery wait-time for patients with mature cataract
from 23 weeks to 8 weeks from January to March 2010. The ABNA was overcome. The remedial
measures were successful in prioritising cataract surgery wait-list.
The Next Step
Continuous implementation of remedial measures will ensure improvement in the quality of our
cataract surgery service.
115
OP/2007
Improving the Rate of Postoperative Endophthalmitis after
Cataract Surgery in the Department Of Ophthalmology,
Hospital Ipoh
Poh EP, Syarifah Faiza SMD, Liaw KT, Najihah MS, K.Pannirselvi,
Izuan Shukri MA.
Department of Ophthalmology, Hospital Ipoh.
Retrospective analysis of the incidence of endophthalmitis from January to December 2005 identified
the contributing factors. Prospective interventional study took place from January to June 2006.
The effectiveness of remedial measures was evaluated by monitoring the incidence of postoperative
endophthalmitis in year 2006.
The major contributing factors identified were irregular intraoperative sterility practices and inadequate
surgical skills. Other minor factors included preoperative patient preparation and poor postoperative
patient care. Strategy for Changes
The remedial measures taken included stringent preoperative assessment, strict supervision of learning
surgeons, compulsory intraoperative isolation of eyelashes, conjunctival sac and Povidone irrigation,
and distribution of postoperative care instructions leaflets given to patients during preoperative
counseling. These remedial measures were applied to all cataract surgeons and paramedics working
in the Ophthalmology clinic and ward who are directly involved with cataract surgery.
Effects of Changes
A significant reduction was observed in the rate of postoperative endophthalmitis from 0.64% to
0.15%.
Next Step
This quality assurance project succeeded in reducing the incidence of postoperative endophthalmitis.
The remedial measures taken proved effective in reducing the overall rate thus improved the quality
of care of cataract patients. Ensuring continuity of the implemented remedial measures will prevent
future postoperative endophthalmitis complications from cataract surgeries.
chapter 7
Reduction in the rate of postoperative endophthalmitis to less than 0.3% by the standard set at the
local level for the quality improvement effort.
Ophthalmology
Selection of Opportunity for Improvement
Postoperative endophthalmitis is a devastating event which can cause irreversible blindness. The
incidence rate in year 2005 was 0.64%. This quality assurance project aims to identify the contributing
factors, formulate and implement remedial measures to reduce its incidence.
116
PP/2007
Reducing the Incidence of Long Transportation Time of Patients
from Orthopaedic Ward to the Operation Theatre
Chuah CK, Mohd Redduan MA, Lydia LYC, Irene PCP, Ekie @ Suzanna J,
Rozimawati M.
Department of Orthopaedic, Sarawak General Hospital, Kuching, Sarawak.
chapter 7
Orthopaedic
Much time was wasted in transferring patients from the ward to the operating theatre (OT). This
caused many complaints either from anaesthetists, specialists, or patients. Half (47%) of the delay (of
more than 20 minutes, as time taken from OT call till patient entered OT’s door) were recorded during
August to September 2005. Consideration had been taken into from the beginning till a patient
entered the OT. This quality assurance project aimed to identify the contributing factors, formulate
and implement remedial actions to correct the situation.
To reduce the incidence of long transportation time, from the time the nurse in the ward being
informed to transfer the case to arrival at OT’s door. The team targeted a transportation time of no
more than 20 minutes.
A 20-minute cut-off time was decided based on analysis of data collected over a 4-week duration
(19 August to 15 September 2005). The transportation time consisted of the following components:
5 minutes to have the nurse-in-charge in the ward informed of the readiness of the OT, another 10
minutes to prepare patient in the ward and fulfil the checklist requirement for transferring, and the
final 5 minutes for travel time from the ward to the OT.
It was reported that the ward staff were occupied with their respective duties. One example of delay
was caused by difficulty in transferring patient from bed to trolley due to different heights of the bed
and trolley. Special care was also needed, thus longer time taken, for patients with external fixation
or skeletal traction.
Strategy for Change
SOP (standard operating procedure) circulars on model of good care approved by the Heads of
Department were distributed to respective wards and implementation carried out. All staff were
trained or re-educated on the SOP in their respective areas. Patients’ education and reassurance were
given accordingly.
Effects of Change
The delay of transporting patients from ward to OT (longer than 20 minutes) had significantly being
reduced from 47% to 13%.
The study had successfully achieved its objectives. The delay in transporting patients from ward to OT
was greatly reduced. This is attributed to good teamwork among the staff. With this methodology,
an overall masterplan on the SOP should be drawn up to improve the quality of health care service.
117
OP/2003
Meningkatkan Peratusan Siap Laporan Perubatan Ortopedik
Dalam Masa 4 Minggu Kepada 80%
Mohd Uzuman NA.
Hospital Kuala Terengganu, Terengganu.
Masalah
Mempercepatkan penyediaan laporan perubatan merupakan satu tuntutan dari pesakit yang ingin membuat
tuntutan dari pihak insuran. Ia juga adalah salah satu indikator yang menunjukkan kualiti perkhidmatan
selain dari merupakan indikator SKT Pengarah Hospital. Terdapat juga pesakit yang mengadu kelewatan
penyediaan laporan perubatan kepada Birro Pengaduan Awam. Hasil kajian menunjukkan pencapaian
penyediaan laporan perubatan kes ortopedik yang dapat diselesaikan dalam tempoh 4 minggu hanya
55.0%.
Mengesyorkan tindakan pemulihan dalam mempercepatkan tempoh penyediaan laporan perubatan,
menentukan keberkesanan tindakan pemulihan. Memastikan kadar laporan perubatan yang dapat
disediakan dalam masa 4 mingg.u mencapai sekurang-kurangnya 80%.
Latarbelakang
Satu pasukan gabungan diantara anggota Jabatan Rekod Perubatan dan Jabatan Ortopedik telah
ditubuhkan bagi mengkaji dan mencari jalan mempercepatkan tempoh penyediaan laporan perubatan
dari Jabatan Ortopedik. Pasukan ini telah bermesyuarat dua minggu sekali dan menggunakan kaedah
Continuous Quality Improvement dalam menyelesaikan masalah ini.
Orthopaedic
Tujuan
Kajian prospektif bagi semua permohonan bulan September 2002 telah dijalankan. Sebanyak 92
permohonan lengkap bagi kes Ortopedik telah berjaya dikaji. Pemantauan dibuat pada bulan Januari dan
Julai 2003 bagi menilai keberkesanan tindakan remedi.
Tindakan Remedi
Perbincangan dengan Ketua Jabatan Ortopedik (30/12/02) mengenai kelewatan laporan perubatan
menghasilkan, Pre-format diperbaiki, agihan fail permohonan kepada Pegawai Perubatan yang berkenaan
dilakukan terus pada hari fail diterima, laporan diberi kepada Pegawai Perubatan yang berminat sahaja
(oleh ketua jabatan), laporan prestasi pencapaian laporan perubatan dihantar ke Ketua Jabatan Ortopedik
setiap 2 bulan, surat peringatan dihantar kepada Ketua Jabatan selepas 10 hari dari tarikh hantaran fail,
surat peringatan dihantar ke wad atau Ketua Jabatan bagi BHT yang masih belum diterima, buku kawalan
pergerakan BHT disediakan di wad ortopedik, pemantauan kedudukan/pergerakan faH sering dilakukan,
Sistem Failing diubah menggunakan nombor Kad Pengenalan, Hantaran fail permohonan dan laporan
yang siap ditaip dilakukan setiap hari tanpa dikumpul, menyediakan bilik kajian di Jabatan Rekod untuk
kegunaan pegawai perubatan bagi tujuan penyelidikan menggunakan BHT. Remedi baru dilaksanakan
pada bulan Jun 2003 melibatkan pengagihan dibuat.
Kajian Penilaian Semula
Kajian prospektif menilai keberkesanan remedi yang dilakukan bagi permohonan bulan Januari 2003
menunjukkan jumlah permohonan siap dalam tempoh 4 minggu ialah 75.9%. ABNA telah dapat
dikurangkan dari 25% kepada 4.1%. Kajian kedua yang dilakukan ke atas permohonan pada bulan Julai
2003 menunjukkan pencapaian telah mencapaian standard yang ditetapkan iaitu 80%.
Kesimpulan
Proses penyediaan laporan perubatan memerlukan pemantauan dibuat secara berterusan. Pengurusan
masa amatlah penting di setiap peringkat proses. Format khusus perlu disediakan untuk memudahkan
penyediaan laporan perubatan. Satu tempat perlu disedaikan di Jabatan. Rekod Perubatan bagi Pegawai
Perubatan menyediakan laporan perubatan untuk mempercepatkan proses penyediaan laporan perubatan
dan mengelakkan kehilangan rekod perubatan pesakit.
chapter 7
Metodologi
118
PP/2011
Reducing Central Venous Line Related Blood Stream Infections
among Paediatric Oncology Patients
Yeoh SL, Tan PY, Suhaila R, Azimah A, Nor Hafiza R.
Paediatric Oncology Unit, Paediatric Department, Hospital Pulau Pinang, Penang.
A high rate of catheter related blood stream infection (CR-BSI) in paediatric oncology patients may
lead to increased mortality, morbidity, patient dissatisfaction and higher financial cost.
chapter 7
Paediatrics
To educate caretaker on central venous line (CVL) care and ensure that staff follow the MOGC. A
target to reduce our CR-BSI rate to <10 per 1000 catheter day was set as standard.
A retrospective study was done in January 2010 to determine the CR-BSI rate in ward C3. Questionnaires
and checklists were used to identify possible contributing factors. A prospective interventional study
was done from July 2010 till January 2011 and effectiveness of remedial measures was evaluated.
Pre-remedial survey showed that our CR-BSI rate was 14.6 per 1000 catheter day in January 2010.
The reasons identified for this high rate included insufficient knowledge of staff and caretakers in
CVL care and hand hygiene, poor compliances to guideline of CVL flushing and dressing and < 80%
of patient with proper skin preparation prior to CVL insertion.
Strategy for Change
Our remedial actions included ensuring that patients were free of skin problems and had bathed
prior to CVL insertion, only allowing house officers trained in paediatric oncology to do ward C3
calls, training all new C3 oncology staff in CVL care, checking compliance to guideline of CVL care
regularly, ensuring caretakers had adequate knowledge in CVL care and hand hygiene and providing
pamphlets on CVL care to all caretakers.
Effects of Change
At the midterm review in November 2010, the compliance to model of good care had improved
though not ideal. Incidence of CR-BSI in January 2011 was 9.7 per 1000 catheter day.
The Next Step
These measures can be introduced in paediatric daycare and district hospital that manages paediatric
oncology cases to ensure optimal CVL care.
119
OP/2007
Reducing Hypothermia in Post Caesarian Newborn Admitted to
Neonatal Intensive Care Unit in Hospital Tuanku Fauziah
Shahannim I, Jamaluddin HM, Asmidar A, Nurhidayati AH, Chiang SL,
Vinayakam P, Zarinah A, Tarmizawati T, Azizul A.
Paediatric Unit, Hospital Tuanku Fauziah, Kangar, Perlis.
A cross sectional study was conducted from 1 April to 30 May 2005 (pre-intervention phase) and
from 1 November 2005 to 28 February 2006 (post-intervention phase) in Operating Theatre (OT) and
NICU in HospitaLTuanku Fauziah, using a standardised form to document the information needed.
The distance from OT to NICU in our hospital, inadequate level of knowledge of hypothermia among
the staff, and poor communication between transporting and receiving teams were among the
factors identified to contribute to the problem.
Strategy for Change
The focus of the intervention was on improving communication between transporting and receiving
teams, controlling temperature of local environment in OT, NICU and during transportation,
implementing an efficient transportation process, providing Continuous Medical Education (CME)
session to improve knowledge of hypothermia and organising more Neonatal Resuscitation
Programme (NRP) courses for staff involved.
Effects of Change
Two sets of data were collected with a total of 45 and 47 newborns during the pre intervention
and post intervention phases, respectively. There was a reduction in the incidence of hypothermia
among post caesarian newborn in NICU from 31% (pre-intervention) to 9% (post intervention),
which marked a successful outcome of the intervention.
An organised effort to maintain thermal protection for the newborns should be given a priority in
our hospital in order to provide quality care for post-caesarian newborns. We aim to maintain this
notable achievement and to extend the intervention to delivery room so that more newborn will
benefit from it.
chapter 7
The aim of this study is to reduce the incidence of hypothermia in newborns admitted to the
Neonatal Intensive care Unit (NICU) after caesarian deliveries. The aim was to reduce the incidence of
hypothermia to less than 10%.
Paediatrics
Hypothermia in newborns during routine postnatal resuscitation is a worldwide issue, occurring with
associated morbidity and mortality. The newborns in Hospital Tuanku Fauziah (HTF) also faced the
same hazard.
120
PP/2007
Prevention of Low Apgar Score Baby in Hospital Kluang
Foo ML. Gan SC, Rusnah A, Latifah A.
Hospital Kluang, Johor.
Incidence of low Apgar score in Kluang Hospital was noted to be on the rise from 4 cases in May 2006 to
8 cases in October 2006. It causes emotional distress to mothers and their families, increases the risks of
perinatal morbidity and mortality to baby, and decreases public trust towards quality of care provided by
the hospital.
chapter 7
Paediatrics
Cause and effect analysis of the problem identified factors such as failure of staff to follow the available
Standard Operating Procedure (SOP), delayed admission of pregnant mothers to hospital, lack of
communication between staff, patient and doctor, and lack of skills among staff in managing antenatal,
intrapartum and postpartum care.
A model of good care was developed which stressed on the correct procedures for screenig for admission,
interpretation of Cardiotocogram and improvement of knowledge and skils during intrapartum and
postpartum management.
Shortfall in quality was observed from analysis of data obtained from the monthly rnonitoring of incidence
of low Apgar score. Staff’s attitude, practice and skill were assessed before and after implementation of
remedial measure. Structured checklists were used to identify areas of shortfall in the screening room,
maternity ward and labour room.
Almost three quarter (71.4%) of staff did not immediately inform doctors about cases being admitted,
60.7% staff did not practice proper history taking and 28.6% staff at screening did not do physical
examination and urine analysis. About a third of staff (37.5%) delayed in informing doctors about
abnormalities encountered during antenatal or intrapartum care. After the intervention, the percentage of
nurses who did not inform doctor during admission reduced to 0% and those not practicing proper history
taking reduced to 10.7%.
Strategy for Change
All nurses were made aware to adhere to the procedures. Continuous audit with the use of a structured
checklist and evaluation by team members to ensure correct practice were carried out and results made
known to staff during ward meetings. Nurses were required to attend at least 80% of sessions for
continuous education conducted by the Obstetrics and Gynaecology Unit.
Effects of Change
The number of low Apgar score baby reduced from 34 cases (May to October 2006) to 11 cases (January
to June 2007). A drop in percentage from 2.10% to 0.70%.
Compliance to SOP and sharing knowledge via effective communication prevent high incidence of low
apgar score in babies. Regular monitoring and feedback must be the practice.
121
PP/2007
Meningkatkan Kualiti Rawatan Kes Acute Gastroentritis
di Wad Kanak- Kanak Hospital Muadzam Shah
Mahanim, Haizul Ikhwan M, Nik Mohd Irwan Z, Nurul Ashiqin AH,
Rusni Y, Zubaini A.
Hospital Muadzam Shah, Pahang.
Pemilihan Peluang Penambahbaikan
Pada tahun 2005, Hospital Muadzam Shah telah mencatatkan kematian kanak-kanak di bawah urnur
5 tahun yang tinggi disebabkan oleh kerana gastroenteritis (AGE). Oleh itu, kajian ini dijalankan bagi
mengenalpasti faktor menyebabkan kelemahan dalam perawatan kes AGE di hospital ini. Objektif kajian
ini ialah untuk meningkatkan kualiti perawatan kes AGE di kalangan kanak-kanak di Hospital Muadzam
Shah.
Semua kanak-kanak menghidap Gastroenteritis di Unit Pesakit Dalam Hospital Muadzam Shah pada Jan
2005-Jun 2006 telah dimasukkan dalam kajian ini. Pilihan hanya dibuat kepada kanak-kanak yang tinggal
di Mukim Muadzam Shah, berusia 12 tahun ke bawah.
Analisis Dan Interpretasi
Hanya 31 kes memenuhi perawatan berkualiti daripada 66 kes AGE biasa. Hanya 45 kes dirawat mengikut
CPG. Hanya 4 Pegawai Perubatan (60%) yang tidak mematuhi perawatan mengikut CPG.
Menyediakan sesi continuing medical education terutama kepada Pegawai Perubatan dan Paramedik,
disamping memberi peluang attachment untuk Pegawai Perubatan dengan Pakar dalam Bidang Pediatrik.
Penyediaan protokol, carta alir dan garis panduan kepada Pegawai Perubatan. Menyediakan bahan
pendidikan kesihatan untuk Pameran dan Khemah Kesihatan, serta menjalinkan kerjasama dengan
anggota kesihatan di Klinik Kesihatan untuk memantau semua kes yang dirujuk
Kesan Perubahan
la dapat dilihat pada perbandingan Pemeriksaan Pesakit mengikut CPG. Selepas Penambahbaikan, peratus
kepatuhan rawatan kes AGE menunjukkan peningkatan sebanyak 35% pada peringkat kedua dan 41
% peringkat ketiga. Hasil baik juga dapat dilihat pada peningkatan jumlah pesakit yang sihat dan dapat
didiscaj awal, dengan itu mengurangkan jangkamasa tinggal di wad yang ketara selepas penambahbaikan.
Pelajaran yang Diperolehi dan Langkah Seterusnya
Sebelum kajian dibuat didapati peratus kes AGE yang dirawat mengikut CPG hanyalah sebanyak 60%.
Selepas penambahbaikan terdapat peningkatan sebanyak 86%. Selepas kajian, 2 faktor utama penyebab
kepada permasalahan iaitu pemeriksaan yang tidak optima oleh kakitangan dan ketidakpatuhan terhadap
rawatan mengikut CPG. Selepas perubahan dilakukan, hasil yang diperolehi ialah peningkatan kepatuhan
rawatan mengikut CPG sebanyak 26%, peningkatan jumlah kes yang sihat dan didiscaj 10.2%, serta
pengurangan jangkamasa tinggal di wad bagi kes AGE. Oleh itu, cadangan perubahan yang telah diambil
perlu diteruskan untuk rnencapai standard 100% pada masa akan datang.
chapter 7
Menentukan standard dan indikator untuk menentukan perawatan yang berkualiti iaitu jumlah kes yang
mematuhi pemeriksaan dan rawatan mengikut Clinical Practice Guidelines (CPG) yang disediakan oleh
Kementerian Kesihatan, dibahagikan dengan jumlah kes AGE yang dirawat. Selain daripada itu, Carta Alir
Kerja dan Model of Good Care juga digunakan dalam kajian ini.
Paediatrics
122
OP/2007
Improving Platelet Transfusion Care in Paediatric Haemotopoietic
Stem Cell Transplantation Patients in Pusat Perubatan Universiti
Malaya, Kuala Lumpur
Indra Jeyajothi R, Suzila S, Rashida K, Sakdiah B, Fatimah D, Siti Baniah AD,
Lim SL, Saniah S.
Pusat Perubatan Universiti Malaya.
chapter 7
Paediatrics
Multiple platelet transfusions in haemoto-oncology patients, undergoing haemotopoietic stem cell
transplant, increase the risk of transfusion complications. Apheresis platelet products are believed
to be able to reduce these complications. This project identified contributing factors to the low
production of apheresis products, formulated and implemented remedial measures to increase
production.
Providing volunteer apheresis platelet products to at least 95% of platelet requests from the paediatric
stem cell transplant unit.
Retrospective analysis of laboratory records over a 6-month period was carried out in 2003 to assess
the platelets requested, supplied, and the causes of poor production of apheresis products.
The records showed that random platelets were often issued to stem cell transplant patients as there
were insufficient volunteer plateletpharesis donors.
The strategies carried out to obtain adequate apheresis donor population were improving donor
knowledge of apheresis, increasing commitment of donors, proper scheduling of appointments, and
maintenance of an electronic database of donors. To achieve the objective, the targets were set to
conduct 50 procedures a month, ensuring a dedicated donor pool of 150 volunteer donors and a
functioning electronic database of donors.
Effects of Change
The donor recruitment doubled and an apheresis donor pool of 150 was achieved. Apheresis platelet
products supplied to paediatric stem cell transplant patients increased by 90%. By 2005, 94.5% of
all platelet requests were supplied with apheresis platelet products.
Next Step
As complications from multiple platelet transfusions can be reduced by using apheresis platelets
rather than random platelets, the plan is to increase its production and extend the supply of apheresis
platelets to all hemato-oncology patients.
123
OP/2005
Improving Thalassaemia Care in Paediatrics
Hasmawati H, Maznisah M, Pauziyah K, Rositah R, Latifah S, Hasmah P.
Raja Perempuan Zainab II Hospital, Kota Bharu, Kelantan.
Outline of problem
Thalassaemia patients requiring blood transfusions are often managed in active wards, causing management
delay, prolonged hospital stay and school absenteeism. The objective of the study is to improve care
provided to thalassaemia patients so that we can reduce the length of hospital stay and identify factors
contributing to prolonged stay to be able to institute necessary strategies of change.
Only 21.4 % of patients stayed less than 8 hours and 40% of patients missed school for more than 2 days.
The contributing factors for longer stay were delay in being seen by doctors and unavailability of blood.
Other factors were admission of thalassaemia patients to active wards, no dedicated personnel taking
charge of transfusion and late blood sampling.
Strategy of change
Specific staff in convalescent Wad 4 was assigned to attend to’ all thalassaemia patients. Health education
was given to patients. Patients were encouraged to come for blood sampling a day prior to transfusion.
Effects of change
Post intervention monitoring showed a reduction in hospital stay. The percentage of patients staying less
than 8 hours in the hospital increased from 21.4% to 58.6%. Only 6.7% children missed school for more
than 2 days and 12 patients had agreed to be treated with Desferral.
The next step
The intervention had shown an improvement of 37.2%. Efforts such as a Day-care Centre, interdepartmental team work, increasing awareness among parents should be continued to further improve
care of thalassaemia patients.
chapter 7
A one-month prospective study was carried out on all thalassaemia patients admitted to the hospital. Data
on patients’ management were collected and questionnaires were distributed to patients anti doctors.
Paediatrics
Using the model of good care, the process of managing thalassaemia patients was improved. The
percentage of patients receiving blood transfusions who stayed in hospital within 8 hours was monitored.
A standard was set for at least 85% of patients should stay less than 8 hours in the ward.
124
PP/2011
Mengurangkan Ketidakseimbangan Badan di kalangan
Pesakit Warga Tua di Wad Kronik
Mike C, Fung Z, Tay LH, Nandi Dewi R, Mariani A.
chapter 7
Physiotherapy
Unit Fisioterapi, Hospital Mesra Bukit Padang, Sabah.
Penurunan kefungsian diramal pada kadar penurunan 5%-10% untuk setiap dekad hidup setelah
usia 30 (Sanders, 1995). Kementerian Kesihatan Malaysia (KKM) menetapkan warga tua adalah
berumur 60 tahun ke atas. Di Hospital ini, terdapat 40 orang pesakit geriatrik yang ditempatkan di dua
wad kronik. Terdapat 22 orang pesakit geriatrik berada dalam program Fisioterapi. Statistiks hospital
menunjukkan, terdapat peningkatan terhadap pesakit jatuh disebabkan masalah keseimbangan
badan (balance) di kalangan pesakit geriatrik. Sehingga Mei 2010 sahaja, telah terdapat 5 kes jatuh
berlaku di Hospital Mesra Bukit Padang. Projek ini dijalankan bagi mengenalpasti punca masalah yang
menyebabkan kelemahan keseimbangan di kalangan pesakit geriatrik ini, seterusnya mengenalpasti
program pemulihan untuk pesakit ini.
Indikator kajian adalah mengurangkan peratusan pesakit yang mempunyai masalah keseimbangan
badan (balance) sehingga 60%.
Satu kajian berbentuk deskriptif telah dijalankan pada Mei 2010 dengan sampel kajian seramai 22
orang yang berada dalam program Fisioterapi. Setelah penilaian dijalankan 7 orang pesakit telah
dikeluarkan daripada kajian disebabkan masalah seperti tidak memahami arahan dan tidak berupaya
untuk berdiri. Kajian dijalankan secara soalselidik, temubual dan penilaian fizikal.
Setelah kajian dilakukan, didapati hanya seorang mempunyai keseimbangan badan yang baik dan
14 orang mempunyai masalah keseimbangan badan. Faktor penyumbang adalah kelemahan otot
(93%), kurang koordinasi (67%), kesan teraputik ubat (33%), dan masalah gait (13%).
Langkah penambahbaikan seperti latihan kekuatan otot, koordinasi dan keseimbangan, gait, aktiviti
rekriasi dan pendidikan kesihatan telah diimplemintasikan.
Selepas implementasi, pesakit yang mempunyai masalah keseimbangan badan berkurang daripada
93.3% ke 66.6%.
Langkah Seterusnya
Walaupun sasaran 60% tidak tercapai, terdapat peningkatan terhadap pengurangan pesakit
geriatrik yang mempunyai masalah keseimbangan badan. Pada masa akan datang, program ini akan
diperluaskan kepada pesakit geriatrik yang lain bagi mengelakkan risiko jatuh di kalangan pesakit
geriatrik di hospital ini.
125
OP/2009
Recurrent Referral for Low Back Pain to Physiotherapy
Department
Yew SF, Chin Mary, Norhanim O, Haslizawati SM.
Physiotherapy Department, Penang Hospital, Penang.
High rate of recurrent referrals within 6 months from onset of first episode of pain leads to increase
workload for physiotherapists, reducing contact time for other patients, increased cost, reduced
productivity and low morale among patients and physiotherapists.
The major causes of recurrent referral were no proper discharge care plan, no assessment using
Oswestry scale before discharge, no emphasis and empowerment of patients on self care and failure
to identify long term risk and distress (yellow flags).
Strategy for Change
Extra guidance, motivation and supervision to all physiotherapists were carried out. Training and
awareness on persuasive skills, were given. The use of Model of Good Care and Care Protocol was
emphasized. Home Exercise Program was explained within 3 sessions of treatment followed by
complete discharge care plan. Pamphlets on proper back care were also given to the patients.
Effects of Change
Cases of recurrent referral dropped from 17% in 2007 to 5.8% in the 2nd cycle January - December
2008 and to 4.8% in the 3rd cycle January - May 2009.
The Next Step
Implementation of Model of Good Care, Care Protocols and patients’ education reduce the rate of
recurrent referral. The study was continued in 2009 and the same strategy will be applied to patients
with Osteoarthritis of the knees.
chapter 7
Data was collected using a checklist and by interviewing the patients.
Physiotherapy
The objective of the study was to reduce the rate of recurrent referral for low back pain and to instill
a holistic management of low back pain to prevent recurrent referrals.
126
PP/2011
Reducing Frequency of Readmission of Patients with
Schizophrenia after Last Discharge
Ruzita J, Dandaithapani T, Muslim AR, Rasidi D, Rozali I, Basiah A,
Afidayati A.
Department of Psychiatry, Tuanku Fauziah Hospital, Kangar, Perlis.
chapter 7
Psychiatry
Readmission is commonly used as an outcome and quality indicator for inpatient services. Schizophrenia
was found to be the most commonly diagnosed mental illness among those readmitted into the
psychiatric ward. The aims of this study were to reduce the frequency of readmission of patients with
schizophrenia after last discharge from the psychiatric ward, Tuanku Fauziah Hospital (HTF) and to
look for factors that may contribute to this problem.
We decided to set the standard of rate of readmission of patients with schizophrenia within 6 months
of last discharge to less than 25% in keeping with our national indicator for psychiatry.
All the psychiatric cases that were admitted into the psychiatric ward from 2008-2009 were identified
and their case notes were traced and reviewed. 80 patients with schizophrenia that were admitted
to the psychiatric ward from January-June 2010 that fulfilled the inclusion criteria were interviewed
using a guided questionnaire.
There were 390 psychiatric cases admitted into the psychiatric ward in 2008 and 386 cases in 2009.
Of these, 246 cases (63.08%) were schizophrenia cases in 2008 and 277 (71.80%) in 2009. Of the
246 schizophrenia cases admitted in 2008, 93 (37.80%) of them were readmitted within 6 months
of previous discharge. Of the 277 schizophrenia cases admitted in 2009, 97 of them (35.02%) were
readmitted within 6 months of previous discharge. The rate of readmission of the schizophrenia
patients from 2008 to 2009 ranged from 10.02% to 12.80% higher than the standard.
Strategy for Change
In this study, medication non-adherence and multiple social problems were the most important
factors related to frequency of readmission. Psychoeducation was given to improve their knowledge
and reduce treatment non-adherence. Home visit services were strengthened to ensure the continuity
of treatment and to empower support from the caregivers.
Effects of Change
There was a reduction in the rate of readmission of schizophrenia patients after last discharge from
35.02% to 25.61% post intervention. Providing psychoeducation and psychosocial care reduced the
readmission rates among schizophrenia patients.
The Next Step
More studies are needed in this field as it will help in the provision of care in our mental health
patients particularly schizophrenia and also those caring for them.
127
OP/2009
Improving the Effectiveness of Retrieval of Psychiatric
Follow-Up Defaulters
Segaran R, Majitol S, Maria S, Stephen S, Mohd Daud D.
Mesra Hospital, Bukit Padang, Sabah.
Psychiatric patients defaulting follow-up is a serious issue; breaching the continuity of care. In Hospital
Mesra, the effectiveness of defaulter tracing was a problem, as only 50% of cases were retrieved
whilst the remaining 50% were lost or untraceable. Untraced defaulters left without treatment have
widespread repercussions, as they risk relapse, becoming psychotic and posing serious danger to the
safety of both their families and public.
Findings revealed 16 causative factors impeding effective retrieval and of these, 74.6% involved work
process errors of commission or omission that were remediable.
Strategy for Change
Remedial strategies included comprehensive documentation of patient`s contact information, psychoeducation for patient and family, re-referral of out-station cases and the long acting depot therapy
to address non-compliance issue.
Effects of Change
Although post-remedial outcome of 59.5% did not confer to the set standard of 60%, the reduction
of ABNA from 8.14% to 0.6% translated into significant cost savings and improved follow-up
adherence.
The Next Step
Remedial measure was found effective and was proposed to the hospital`s clinical stakeholders and
thereafter incorporated as critical pathway to manage defaulters. To ensure effectiveness, the relevant
work process parameters would be closely monitored and re-audited to gauge level of sustenance.
chapter 7
This study was conducted in 2 phases, a baseline evaluation followed by a post-remedial phase. The
study sample consisted of 111 defaulters admitted during January - March 2009 and assessed using a
structured questionnaire which among others, to explore the specific factors related to poor retrieval.
Psychiatry
Key indicator for this study was measured by improvement in retrieval rate of defaulters. The standard
set was not less than 60% of defaulters retrieved.
128
PP/2009
Preventable Falls amongst Long Stay Patients in Psychiatric
Wards in a Government Hospital
Maria K, Fatimah S, Bong R, Zamahari M.
Sentosa Hospital, Kuching, Sarawak.
chapter 7
Psychiatry
Falls are preventable incidence responsible for morbidity, immobility and mortality amongst older
patients leading to prolong hospitalisation, higher health care cost, public complains and potential
litigation issues.
These are aimed to minimize shortfall in quality. Vigilant assessment on daily living activities,
appropriate usage of bilateral bed rails, ward physical layout orientation, introduction to inmates who
enjoy pushing people, instilling good civic culture through “love thy neighbours” education program,
placing higher risk patients nearer to staff counter, close monitoring of drugs side effect, frequent
review of medication, assistance on activities of daily living.
A descriptive cross sectional study was conducted from January to December 2004. Inclusion
criteria was psychiatric wards long stay patients. Self administered questionnaires for assessing staff
knowledge on fall prevention and observational checklist on prevention techniques were used.
The analysis revealed an existing problem of falls in a public hospital. In January to December 2004
there were 24 incidences of fall. 12(50%) elders, 11(45%) had previous fall and 1(4.1%) fell while
sleeping. Among them, 12(50%) had unsteady gait probably due to medication side effects.
Strategy for Change
Awareness on national standard of zero incidence, protocols on daily living activities assessment, risk
assessment, fall prevention checklist, weekly safety audit, do root cause analysis on incident, and
mitigate way forward by implementing key measures.
Effects of Change
Two incidences in January to December 2005; 3 in January to December, 2006, as compared to 24 in
2004. This reduced usage of lotions, swabs, gauze and plasters to dress lacerations and antibiotics to
prevent infections. Two verbal complaints from relatives in 2004; none in 2005 and 2006.
The Next Step
Improvement in staff report writing and documentation skills, more competent in patients’ care,
expressed better job satisfaction and harmony as blaming culture no longer exist. We plan to
standardize the practice to other hospitals in the state.
129
PP/2007
Ke Arah Meningkatkan Kesinambungan Rawatan Pesakit Mental
di Klinik Lawatan Pakar Psikiatrik, Hospital Kuala Nerang
Norizan A, Munizam AM, Juhairoh MS, Yong PW, Hashimi NO, Norliza A.
Hospital Kuala Nerang, Kedah.
Peluang untuk Penambahbaikan
Kehadiran pesakit mental untuk mendapatkan rawatan susulan di Klinik Lawatan Pakar Psikiatrik, Hospital
Kuala Nerang adalah di paras bawah 90% mulai bulan Julai 2004 dan serendah 47.8% pada bulan
Disember 2004
Meningkatan kehadiran perawatan pesakit mental melalui pengurusan Klinik Lawatan Pakar Psikiatrik
yang efektif untuk, meningkatkan kesedaran pesakit dan waris, sistem mengesan kes keciciran yang
efektif, pengurusan pesakit yang efektif dan mengatasi masalah pengangkutan pesakit ke klinik.
Kajian prospektif telah dijalankan mulai Mei 2005 hingga Disember 2006 (20 bulan). Pengumpulan data
implementasi untuk 3 bulan diadakan dari Mei hingga Julai 2005. Pesakit mental yang telah diberi tarikh
temujanji dan hadir pada sesi klinik pada bulan Jun dan Julai 2005 (42 orang) ditemuduga dengan borang
soal selidik berpandu. Kad rawatan, buku rekod temujanji, buku daftar kedatangan pesakit bagi pesakit
yang telah datang pada sesi klinik dari bulan Januari hingga Jun 2005 (163 orang) dlsemak untuk data
yang diperlukan.
Psychiatry
Tren kehadiran pesakit dari Januari hingga Jun 2005 dalam lingkungan 51.7% ke 85.2% dengan purata
kedatangan 69.4% sebulan berbanding dengan 90% seperti standard yang ditetapkan. Faktor utama
yang dikenalpasti adalah, sistem mengesan keciciran pesakit yang efektif (0%), meningkatkan kesedaran
pesakit dan waris (30%), pengurusan klinik yang efektif (42.2%), pengurusan pesakit yang efektif 56.2%
dan masalah pengangkutan pesakit ke klinik (76.2%).
Strategi berikut telah dilaksanakan. Kes cicir temujanji dikesan melalui telefon atau hantaran surat
peringatan dalam masa seminggu serta lawatan ke rumah oleh ahli pasukan perkhidmatan kesihatan
mental komuniti yang baru diwujud; pendidikan kesihatan kepada pesakit dan waris dan perbincangan
dengan ahli keluarga semasa sesi klinik; memberi taklimat kepada staf supaya merekodkan butir-butir
pesakit ke dalam kad rawatan, buku temujanji, kad temujanji dan dokumen lain dengan lengkap; petugas
diberi tunjuk ajar oleh pakar psikiatrik dan dihantar attachment ke Jabatan Psikiatrik Hospital Alor Star
untuk mempertingkatkan pengetahuan dan kualiti rawatan; serta pesakit cicir temujanji yang bermasalah
pengangkutan dibekalkan dengan ubat-ubatan semasa lawatan ke rumah, sekiranya perlu.
Kesan Perubahan
Perubahan dapat dikesan selepas 2 fasa (3 bulan setiap fasa) implementasi strategi penambahbaikan
dilaksanakan. Tren kehadiran pesakit telah meningkat dari purata 69.4% kepada 87.1%. Sistem mengesan
keciciran telah meningkat dari 0% kepada 100%, kesedaran pesakit ditingkatkan dari 30% kepada
80.2%, pengurusan klinik yang efektif meningkat dari 42.2% kepada 100%, pengurusan pesakit yang
efektif meningkat dari 56.2% kepada 100% dan masalah pengangkutan pesakit ke klinik yang dapat
diatasi, meningkat dari 76.2% kepada 89.7%.
Pelajaran Diperolehi dan Langkah Seterusnya
Dengan implementasi tindakan penambahbaikan dan pemantauan berterusan kehadiran pesakit mental
yang bertemujanji ke klinik telah dapat ditingkatkan sebanyak 17.7%. Implementasi strategi pemulihan
yang berterusan dengan penilaian 2 kali setahun diperlukan sebagai langkah seterusnya.
chapter 7
130
PP/2009
Improving Percentage of Lens Exclusion in Routine Head
Computerised Tomography Examination
Asmah O, Salmah A, Saw YH, Nordiana M, Mairuzsazali Z, Rasmaria AR,
Hussin A, N Diana D, Ram Piari HD, Mohd Razin O, Ahmad Zalizan Z.
Tuanku Fauziah Hospital, Kangar, Perlis.
A substantial radiation to the lenses of the eyes during head Computerized Tomography (CT)
examinations may lead to an increased potential risk of cataract leading to patient visual impairment.
Thus, lens exclusion in routine head CT examination is crucial.
chapter 7
Radiology
The most effective way in reducing the potential radiation damage to the lens is by avoidance of
direct irradiation during the examination. This is achieved by looking at percentage of lens excluded
from total examinations with the standard of > 85% selected from literature review.
A retrospective pre-remedial study to assess the magnitude of the lens exclusion and the possible
contributing factors in routine head CT examination was carried out. Subsequently, a prospective
postremedial studies were carried out to evaluate the outcome after the institution of the remedial
measures.
In the pre-remedial study, only 65% of the samples had their lenses excluded. The contributing
factors were identified.
Strategy for Change
Appropriate modifications of CT protocol of head examination may significantly reduce dose to the
lens of the eyes. Several changes applied including fixing the CT table height, using a dedicated head
padding, setting the baseline at the supraorbital and patient in “chin tucked-in” position. These
changes were written and incorporated into CT operating guideline and radiographers were trained
over a period of one month.
Effects of Change
In the post-remedial study, 96% (n=96) of the samples have their lenses excluded with improvement
of 31%. Thus, with the application of the changes, avoidance of direct irradiation of the lenses was
achieved and effectively reduced potential radiation damage
The Next Step
We will carry out continuous monitoring of the practice to sustain the performance and random
evaluation studies. We hope to develop Hospital Specific Approach (HSA) Indicator at 90% lens
exclusion for routine head CT examination.
131
PP/2007
Meningkatkan Peratus Radiograf Servikal Lateral Erect
yang Sempurna
Sazali S, Rizali MN, Salmah A, Mutiah S, Rushelawati K, Rozairie ZC,
Mohd SWAG.
Jabatan Pengimejan Diagnostik, Hospital Tuanku Fauziah, Kangar, Perlis.
Kajian pengumpulan maklumat dilaksanakan selama sebulan pada tahun 2005. Juru x-ray
yang melaksanakan semua pemeriksaan radiograf servikal lateral pada tempoh tersebut telah
melengkapkan borang penilaian yang disediakan.
Didapati hanya 57% daripada radiograf servikal lateral yang dihasilkan adalah sempurna. Kegagalan
untuk merangkumi keseluruhan servikal vertebra adalah satu faktor yang menyumbang kepada
masalah ini. Kesemua radiograf yang tidak sempurna adalah berkaitan dengan saiz pesakit yang
besar dan leher yang pendek. Strategi Penambahbaikan
Aplikasi teknik baru yang boleh mengatasi masalah pesakit yang gemuk dan berleher pendek telah
dilaksanakan. Perubahan baru ini melibatkan pemeriksaan dijalankan dalam keadaan duduk di atas
kerusi, pesakit diarahkan menjangkau palang kerusi di bawah untuk merendahkan bahu dan titik
pemusatan bim ditinggikan ke aras external auditory meatus.
Kesan Perubahan
Selepas pelaksanaan penambahbaikan, didapati bahawa peratus penghasilan radiograf servikal
lateral yang sempurna telah meningkat dari 57% ke 90%.
Pelajaran yang Diperolehi dan Langkah Seterusnya
Teknik baru ini telah dimasukkan ke dalam prosedur kerja jabatan dan pemantauan dilaksanakan
secara rawak untuk memastikan penghasilan radiograf servikal lateral sempuma. Seterusnya teknik
baru untuk menghasilkan radiograf sempurna untuk servikal lateral pesakit trauma dalam posisi
supine akan diusahakan.
chapter 7
Penghasilan radiograf servikal lateral erect yang sempurna boleh diperolehi sekiranya pemeriksaan
dilaksanakan pada pesakit dengan betul, mempunyai imej faktor dedahan yang baik dan merangkumi
keseluruhan servikal vertebra. Target yang diharapkan ialah untuk mendapat radiograf yang sempurna
melebihi 80%.
Radiology
Penghasilan radiograf servikal lateral erect sempurna adalah penting agar keseluruhan vertebra
servikal dapat dianalisis dan sebarang abnormaliti dikenalpasti. Kegagalan untuk menqenalpasti
masalah servikal vertebra boleh mengakibatkan penglibatan saraf tunjang.
132
PP/2007
Audit on Portable Radiography Done after Office Hours in the
Diagnostic Imaging Department Hospital Raja Perempuan
Zainab II
Aniyah MJ, Noor Hasnita IM, Azhan M, Hazrol AA.
Department of Diagnostic Imaging, Hospital Raja Perempuan Zainab II, Kota Bharu Kelantan.
chapter 7
Radiology
Portable radiography is time consuming and produces poor film quality. It gives higher radiatien doses
to patients and people in the vicinity. Chances of repetition of examination are high, leading to higher
cost. Therefore it is imperative that the number of examination is reduced and its use is optimised.
Inadequate assessment of patients, lack of awareness of criteria for request, lack of awareness of
higher radiation and low quality image produced and lack of experience of requesting doctors are
among factors which may contribute to unjustified and higher number of requests for portable
radiography. Radiographers or radiology doctors who receive vague or unjustified requests should
clarify the indication with the requesting team/ doctor. This however is not usually done.
To reduce the number of after office hours portable radiography use only to those patients with clear
indication. The standard set was 15% or less. Process of Gathering fnfotmation
Data sheet was filled by radiographer on the day of examination. Questionnaires were also given
to the requesting doctors. Assessment of patient’s condition was done both by observation by the
radiographers at the time of examination and from the clinical history on the request forms. The
number of examinations performed after office hours were obtained from the registration book.
Percentage of portable radiography done after office hours was 37%. The contributory factors
leading to this were requests made by junior doctors (83.4%), lack of awareness of criteria for
portable radiography (13.3%), lack of awareness of higher radiation of portable radiography (13.3%),
unjustified requests/indications (8.6%) and unjustified requests/ indications which were not clarified
(81.2%).
Strategy for Change
Modification of the process of care was done by introducing a format for request of portable
radiograph which should be filled up by the requesting doctor. This format also served as a reminder
of the indications and disadvantages of portable radiography. Continuous medical education sessions
for doctors and radiographers were conducted.
Effects of Change
There was a reduction in the number of portable radiography done after office hours to 23.7% and
more of them with justifiable requests.
Close cooperation between radiology staff and requesting doctors, and proper education of staff
can result in optimal use of portable radiography. Continued implementation is needed to achieve
sustainability in quality and we have incorporated these changes as part of our departmental policy.
133
OP/2005
Ensuring Production of Optimally-exposed Radiographs
Ahmad ZZ, Sazali S, Salmah A, Saw YH, Rushelawati K, Marlina M,
Rozairie ZC, Mutiah S.
Tuanku Fauziah Hospital, Perlis.
Outline of Problem
The main bulk of the workload in the Department of Diagnostic Imaging, Tuanku Fauziah Hospital is
production of plain radiographs (3300 to 4000/month). Though the reject rate was consistently below
5.00% (2.50% to 4.90%), radiographs with suboptimal exposure (over and under exposed) made up
60% of the total rejected films. These radiographs had to be repeated, causing an increase in production
cost, waiting time and workload of radiographers. Human, mechanical and technical factors were noted
to be the main contributors to this problem.
1. Elimination of inter-observer bias to ensure that only optimal radiographs are released. This can
be achieved by producing an objective guideline (Optimal Exposure Chart) for reference in approving
radiographs and applying a counter-check system (Consensual Evaluation) in evaluating radiographs.
2. Reduction of production of suboptimal radiographs by creating an exposure chart guide for
reference to radiographs.
A prospective study was done from 16 April to 6 May 2004, applying the “Optimal Exposure Chart” and
“Consensual Evaluation” methods to verify the true intensity of the problem after elimination of interobserver bias.
With elimination of inter-observer bias (application of “Optimal Exposure Chart” and “Consensual
Evaluation”), the rate of production of radiographs with suboptimal exposure was higher, 31.5 radiographs
in every 1000 radiographs produced.
Strategy of Change
An exposure guide chart called “Ray 2 Chart” was invented to overcome this problem. This chart was
produced by collecting all exposure factors for various examinations which produced radiographs with
optimal exposure and classified/arranged them in proper tables/charts. The chart identified the range of
suitable exposures that should be given according to patient’s size, presence of POP and the site of interest.
Effects of Change
With the application of “Ray 2 Chart”, the rate of production of radiographs with suboptimal exposures
had been reduced from 31.5 to 12.5, 18.2, 14.4, 9.1 and 7.2 films for every 1000 radiographs for August,
September, October, November and December 2004, respectively.
The Next Step
The application of “Ray 2 Chart”, “Optimal Exposure Chart” and “Consensual Evaluation” has been
applied in the work process. Further improvement can take place by adding exposure factors for new
views.
chapter 7
The main objective is to ensure that only radiographs with optimal exposure are released to the clinicians.
This can be achieved by:
Radiology
Objectives and Key measures to Improvement
134
PP/2005
Towards Reducing Sub-standard Portable Chest Radiographs
in Adult
Norie Azilah K, Zainun A.R, Mohamad Sufian J, Liom SL, Khairul Anuar I.
Department of Diagnostic Imaging, Tengku Ampuan Afzan Hospital, Kuantan, Pahang.
Problem
There is a need to reduce sub-standard portable chest radiographs in adults. Sub-standard
radiographs may result in missed diagnosis, repeat examination, increase cost, increase workload,
which subsequently may lead to poor patient management.
chapter 7
Radiology
Background
Portable radiographs are common x-ray investigations requested in this department. They account
for 12% of total workload and portable chest radiographs alone accounts for 60% of total portable
radiographs done in this department.
Design of Study
Using the Quality Assurance Cycle, a cross-sectional study was conducted from 14 January 2004 to
30 January 2004 and the study found that there were 40% sub-standard portable chest radiographs
in adults. The contributing factors were then identified and remedial measures implemented.
The main objective was to reduce the number of sub-standard portable chest radiographs. The specific
objectives were to improve the quality of portable chest radiographs, identify the contributing factors
and causes of sub-standard radiographs and to implement remedial measures.
Strategy for Change
No primary marker, poor positioning and poor collimation were the main contributing factors round
for the causes of sub-standard portable chest radiographs. The actions were focused on the target
group and the model of good care was emphasised. In April 2004, action was taken to reduce the main
causes of sub-standard radiographs which include providing a primary marker for the radiographers,
placing the marker on the portable machine, providing a checklist for the radiographer to produce a
standard radiograph, obtaining assistance from ward staff to position ill patients, conducting regular
CME with scoring system and regular auditing of portable chest radiographs.
Effects of Change
The effects of change took place in mid of April, May and June and the percentages of sub-standard
portable chest radiographs were reduced from 40% to 14%, 10% and 6%, respectively.
The Next Step
Regular quality auditing and continuous monitoring is the key factor to maintaining the standard of
portable radiographs.
135
PP/2005
Audit on Defaulters for Special Radiographic Examinations
in Diagnostic Imaging Department
Fairos AM, Zuraina B, Hazrol M, En. Mat Wi J.
Raja Perempuan Zainab II Hospital, Kota Bharu, Kelantan.
Problem
High incidence of defaulters for special radiographic examinations in diagnostic imaging department.
A prospective study over one month duration was conducted and samples taken from registration
appointment book for special radiographic examinations. Questionnaires were filled by the staff
during reappointment date or via telephone.
The results showed 15.1% defaulters. The main reason was lack of information regarding the
examination that is to be undergone by the patients.
Strategy for Change
A new system has to be created to give further information regarding the special radiographic
examinations. Our remedial actions were (1) Discharged patients from the ward were given pamphlet
and checklist, (2) A reminder from department to ward or dime to inform the patients one day prior
to appointment date, (3) Maximise the usage of counseling room for IVU, (4) A short documentary
video which shows various activities within the department, including the special radiographic
examinations played from a television near the counter during peak hours, (5) Modified checklist
was given to all patients during appointment day, (6) Patient contact number was included in the
appointment book and (7) Departmental level continuous medical education to radiology staff in
order to improve their knowledge and skills.
Effects of Change
The percentage of defaulters for special radiographic examination was reduced from 15.10% to
8.96%.
The Next Step
Continuous implementation will reduce the percentage of defaulters for special radiographic
examinations in Diagnostic Imaging Department, Raja Perempuan Zainab II Hospital.
chapter 7
To minimize the percentage of defaulters for special radiographic examination and to identify the
causative factors leading to high incidence of defaulter for special radiographic examinations.
Radiology
Background
Special radiographic examinations constitute about 6.2% of total special examinations workload in
the Diagnostic Imaging Department, Raja Perempuan Zainab II Hospital, defaulters causing delay in
the appropriate management to patients and subsequently increase morbidity and mortality.
136
PP/2005
The Human Factor in X-Ray Film Rejection
John BJ, Edward L.
Department of Diagnostic Imaging, Duchess of Kent Hospital, Sandakan, Sabah.
chapter 7
Radiology
Problem
In a radiographic examination, the incidence of rejected films due to its poor diagnostic value (and
thus to be discarded) incurs loses in terms of cost, longer working process, longer waiting time and
more importantly, additional radiation dosage to patient when x-ray examination is repeated. The
factors contributing to the rejection are basically due to human error. Other minor attributes are
faulty equipments, x-ray accessories and dark room factors.
Design
A 10-month retrospective study was undertaken and data was collected from the records of the
‘Reject Film Analysis’ which is one of the national quality indicators monitored under the National
Indicator Approach (NIA) for the Radiology Department. All of the rejected films are accounted for
the reasons of reject identified and recorded accordingly.
All general radiographic examinations done by radiographers on patients from the wards (including
mobile x-ray), Accident and Emergency Department, Specialist Clinics and Out Patient Department
and the Radiology Department, Duchess of Kent Hospital, Sandakan were included in the study.
Strategy for Change
The major contributing factor for the rejection was human errors (80.3%). Hence, the Radiology QA
Team focused on the implementation of remedial measures on 5 areas which they predicted could
reduce the film rejection contributed by human errors and achieve a baseline of 65% human error
rejection rate. Effects of Change
Post implementation of strategies study done from July to September 2004 proved a decline of
20.16% of human error rejection rate, thus achieving the modest target of a baseline indicator of
65%.
Lessons Learnt
With the implementation comes the awareness on the need of a continuous QA monitoring program
within the department. Undeniably, human attitude still contributed towards the rejection of X-ray
films. Constant supervision and monitoring, regular auditing of rejected films, coupled with training
and counseling of staff can further reduce reject film rate. Even though the cost saving is insignificant,
the more important issue here is the avoidance of unnecessary radiation doses to patients as a result
of repeat X-rays, reduced patient waiting time and the prompt and accurate diagnosis that can be
derived from consistently optimal quality radiographs.
137
OP/2003
Compromised Patient Safety by being Inappropriately Attended
to during Radiological Imaging in Hospital Seremban
Raj T, Robiah MN, Chiang MG, Amin SA, Zakiah AR, Ranatunga L, T. Rajeswary,
Hasri A, M. Santa Devi, A. Vasanta, Halimah M.
Seremban Hospital, Negeri Sembilan.
Objective
This quality assurance (QA) study had the objectives of assessing the existence of the problem of compromised
patient safety by being inappropriately unattended during radiological imaging in Seremban Hospital, identifying
the factors that lead to the existence of this problem, and to implement interventional measures that would lead
to the problem being resolved and improving patient safety during such processes.
Results
The QA study proved the existence of the problem with 31 cases being detected during the Phase 1 of the
study. The majority of the cases were from the A&E Department (55%), with the remaining being from surgery,
orthopaedics and general medicine. Absence of a protocol for good practice guidelines in the transport of ill
patients for imaging, lack of adequate trained staff, poor communication between radiographers and requesting
departments, and lack of triaging priority at the radiology department for imaging were identified causative
factors. Interventional measures were implemented for the Phase 2 study. The results of the % of the A&E
cases being inappropriately accompanied increased from 55.5% to 87.5%, lack of communication with the
radiographers for A&E cases increased from 11.7% to 14,2%, achievement of imaging time within 15 minutes
improved from 20% to 54.1% for the A&E cases. The results of Phase 2 study however were compromised by
the small population sample procured during the period of one month of the Phase 2 study.
Conclusions
Patients being sent for imaging in Seremban Hospital are at risk of compromised safety during the process
of transport due to absence of procedural guidelines, failure of requesting physicians to also indicate
appropriate patient escort during process, inadequate appropriate manpower resource and management,
insufficient communication access between requesting clinical service providers and radiographers, and the
lack of formal triaging priority at the radiology department. While the establishment of procedural guidelines
and communication modalities such as pager were interventions that could be established, human resource
management and procurement remain unresolved issues, in spite of management notification and action. The
consequences on compromised patient safety are occurrence of further morbidity, threat to life, patient and
family distress, and as well as the medicolegal liability of Seremban Hospital. These demand that this problem
be addressed and resolved without undue delay in a proactive manner, rather than reacting to medicolegal
negligence suit.
chapter 7
A QA study group was formed consisting of Seremban Hospital staff, including the Radiology Department
staff. A preliminary discussion was done and a literature search conducted for recommended standards of
patient safety during transportation for radiological imaging. There were however none found on the internet
search using Pubmed and MSN search engines. A questionnaire for problem identification and causative factors
was formed. It was conducted in a randomized manner by the radiographers from the 01 July till 05 August
2002, accumulating a sample of 31 patients. Identified intervention measures of the need for procedural
guidelines, trained and adequate accompanying staff for patient during transport, improve communication
access to radiographers via pager and telephone, and triaging of patient priority for imaging by radiology staff
at counter were then implemented in second phase of the study from 26 August till 25 Sept 2002. These were
only targeted for implementation in A&E patients, with the remaining hospital units being used as controls.
There was however failure of procurement of adequate appropriate staff for the A&E department, and this was
reflected in the subsequent results. A sample of only eight patients were obtained during the time period of the
intervention implementation phase, but this had to be time limited for purposes of preparation of presentation,
as well as being not relevant in pursuing further without succeeding in procurement of the human resource
intervention required.
Radiology
Method
138
PP/2003
Meningkatkan Kadar Radiograf Dada “Portable” yang Optima
Mohd. Romzi AR.
Jabatan Radiologi, Hospital Kuala Terengganu, Terengganu.
Pengenalan
Pemeriksaan x-ray dada portable dilakukan di wad-wad atau unit kecemasan bagi kes pesakit kritikal.
Pemasalahan ini adalah serius selepas satu pilot study yang dilakukan menunjukkan peratusan
radiograf yang optima hanya 47.4% berbanding dengan standard yang telah ditetapkan oleh
International Standard Ministry of Health iaitu 90%. Kajian dan tindakan perlu dilakukan segera bagi
meningkatkan kualiti imej radiograf ke tahap yang optima.
chapter 7
Radiology
Objektif
Meningkatkan kadar penghasilan radiograf portable dada yang optima.
Metodologi
Kajian secara retrospektif dilakukan ke atas 108 keping radiograf untuk mengesahkan dan mencari
faktor penyebab kepada pemasalahan ini. Tindakan penambahbaikan dilakukan untuk mencapai
standard berdasarkan kriteria imej yang telah ditetapkan. Kajian semula selepas penambahbaikan
dilakukan ke atas 100 keping radiograf.
Keputusan
Kajian menunjukkan kadar radiograf yang optima adalah 64.7%. Kajian selepas penambahbaikan
ke atas 100 keping radiograf menunjukkan kadar radiograf yang optima adalah meningkat kepada
89%. Kesemua lima faktor radiografik yang dikenalpasti sebagai penyebab utama kepada imej yang
suboptima menunjukkan peningkatan, iaitu faktor dedahan (84%), tiada artifak (88%), posisi toraks
yang simetrikal (60%), dan kolimasi (25%).
139
OP/2003
The Effectiveness of Hysterosalpingography Appointments in
Kuala Lumpur Hospital: A Study Using Continuous Quality
Improvement Method
Mastura T, Ali N, Aintan I.
Kuala Lumpur Hospital.
Problem
To determine the effectiveness of appointment given for HSG examination by the Obstetrics &
Gynaecology (O&G) department/clinic and to study the role and reason for cancellation of HSG cases
done in the Diagnostic Imaging Department of Kuala Lumpur Hospital.
To determine the effective way of giving HSG appointments.
To reduce the rate of cancellation of the examinations.
To minimise avoidable reasons for cancellation of the HSG examinations.
Using a Plan-Do-Study-Act cycle for guidance, the team decided that the staff of the Diagnostic
Imaging Department should give appointment for HSG. Appointment should be given on any
working day from Monday to Friday limiting 1 - 2 cases per day. For patients with regular menstrual
cycle, appointment should be given within 10 days of the next menstrual cycle. For patients with
irregular menstrual cycle, the patients themselves should call the Diagnostic Imaging Department
for an appointment once they have their menses. Printed preprocedure instructions and counseling
should be provided to the patients by the radiographer / nurse / doctor in charge of the examination.
Effects of Change
Patients’ turn-up rate for appointments Improved from 66.04 % to 97.45%
Rate of cases that were done had increased from 54.29% to 88.54%
Cancellation rate for the examinations had reduced from 45.71% to 9.15%
chapter 7
All HSG examinations in Kuala Lumpur Hospital were requested by the O&G specialists. The staff
nurse in the O&G clinic of Kuala Lumpur Hospital gave the appointments for every Wednesday,
limited to 4 patients per day. The patient turned up for the examination on the appointment day in
the Diagnostic Imaging Department. The Diagnostic Imaging Department’s doctor performed the
examination.
Radiology
Design
A multiprofessional team was established to collect data on the effective way of giving HSG
appointments. Data was collected using a self-prepared survey form that was required to be filled by
the staff nurse / doctor in charge of the examination. Patient that failed to turn up for the examination,
cancellation of cases and reason for cancellation were recorded.
140
OP/2003
Audit on the Turnaround Time in CT Scan Examination in
Patients with Improper Preparation
Nijhar S, Udin A, Zulkarnaini MN, Rahimah O.
Hospital Kota Bharu, Kelantan.
Problem
A need to reduce the number of CT examinations delayed and postponed due to improper patient
preparation.
chapter 7
Radiology
Design of Study
We established an interprofessional team comprising 4 members within the department. A prospective
study was carried out to tackle the issue of improper patient preparation. We used the continuous
quality improvement methodology.
Background
CT scan examinations constituted 23% of the total special examinations workload in our department.
The high radiation dosage and long duration of examination makes it significant.
To reduce the turnaround time in CT examinations in patients with improper preparation. To improve
the knowledge of patients and staff concerned regarding preparations for CT examinations.
The team decided to tackle 3 subgroups namely; inpatients, outpatients and radiology departmental
staff. This was done by (a) Modifying the model of care for in-patients, (b) Giving discharging inpatients a second explanation on necessary preparations, (c) Posting a notice at the CT room reminding
accompanying staff to ensure all preparations have been done, (d) Improving counselling sessions,
(e) Formulating a Patient Comprehension Feedback Form to assess patient’s understanding of the
explanations, (f) Improving the Prednisolone Intake Guidelines and finally (g) Holding continuous
medical education (CME) sessions for Radiology Department staff.
Effects of Change
The percentage of CT examinations delayed and postponed due to improper preparation was reduced
from 26% to 3.49%.
141
PP/2003
A Delay in the Patients’ Waiting Time for Plain X-Rays in the
Radiology Department, Queen Elizabeth Hospital
Limon MR, Edward L.
Queen Elizabeth Hospital, Kota Kinabalu, Sabah.
Problem
The problem of delayed and prolonged waiting time for plain x-rays’ results was an urgent priority to
be tackled following numerous verbal complaints from patients.
Approximately 18.54% of 1181 patients had been waiting for more than 30 minutes as compared to
the standard set by our Client’s Charter and the MS ISO 9000 of less than 10% per month.
Results showed that most of the patients waiting for more than 30 minutes were between 08:00
am to 11:30 am. Through brainstorming, duty roster had been modified including delegating and
sharing of tasks during certain peak hours.
Effect on Change
After remedial action, there was a great reduction in the patient waiting time for plain X-Rays of
more than 30 minutes from 18.54% to 4.8%.
Lessons Learnt
The study has demonstrated that reduction of patients waiting time could be achieved through
improved cooperation and enhanced delegation of tasks among staff regardless of their positions
which subsequently led to higher quality of plain x-rays taken and less mistakes made especially
during peak hours.
chapter 7
Radiology Department of Queen Elizabeth Hospital has a daily average of 129 patients undergoing
plain x-rays, which are carried out by one radiographer in each of the three operating rooms.
Radiology
Design
A continuous quality improvement methodology (CQI) was applied by the Radiology Department
Hospital Specific Approach Committee. Collection of the time recorded in the X-Ray Request forms
was undertaken from June-July 2002 (baseline data) and August-September 2002 (re-evaluation
study).
142
OP/2007
Towards Better Control of Bronchial Asthma Patients in Hospital
Tengku Ampuan Jemaah, Sabak Bernam
Jameela BAH, Harifah MN, Chandrakumar N, Borhan M, Jamilah M,
Norliza H.
Hospital Tengku Ampuan Jemaah, Sabak Bernam.
Poorly controlled asthma leads to increased morbidity and mortality. In Tengku Ampuan Jemaah Hospital
(HTAJ), 15% of casualty attendance is due to poorly controlled asthma and in total there were 9 asthmatic
deaths since 1995. This quality assurance project aims to identify the contributing factors, formulate and
implement remedial measures to achieve better control of asthma.
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Respiratory
To increase the percentage of patients with good control of their asthmatic condition to more than 50%,
and to reduce the percentage of severe persistent asthmatics to less than 5% .
This is a prospective cross-sectional study which was conducted in HTAJ casualty in April 2006. The reasons
for poor control of asthmatic condition were analysed and corrective actions were taken. Interventional
package was introduced from June to December 2006 to patients and staff. Post intervention data were
collected in January, March and June 2007.
The main reasons for poor control identified were inadequate knowledge of patients on asthma and
inadequate knowledge of healthcare providers in the severity assessment and management of asthma.
Strategy for Change
The intervention package consisted of a new work flow according to the model of good care, setting up
Asthma Committee and Clinic, introduction to Asthma clerking sheet, Disease Severity Chart, Step Care
Treatment Chart, Asthma Management Plan Booklet and regular patient education along with training of
health care providers.
Effects of Change
There was a significant improvement of asthma control where the percentage of patients with good
control increased from 31 % (before intervention) to 60.7% (1st cycle), 71.4% (2nd cycle) and 79.5% (3rd
cycle). There was no case of severe persistent asthma in all of the repeat studies. The patients’ knowledge
improved where 93.8% of patients obtained marks more than 70% and there was no failure. The doctors’
knowledge also improved where all of them obtained marks more than 85%.
Next Step
Asthma control is achievable with good quality management and a continuous education directed to
patients and healthcare providers. Incorporation of remedial measures into routine practice contributes to
further improvement. Asthma clinic services will be offered to all asthmatics with poor control. Home visits
are planned to monitor progress of disease for patients having difficulties in controlling their asthmatic
condition.
143
PP/2011
Menurunkan Peratusan Penolakan Kes Pembedahan
Dewan Bedah
Nurul Atikah H, Mohd Zahidi H, Kartini M, Sahaimi M, Nik Abdul Aziz RS.
Hospital Pasir Mas, Kelantan.
Kajian ke atas rekod sebab kes pembedahan dibatalkan dibuat pada 16 Disember hingga 31 Disember
2010, kaji selidik tahap pemahaman anggota wad mengenai pemantauan pesakit dibuat pada 22
Disember 2009 hingga 18 Januari 2010 dan kajian tahap pengetahuan pesakit telah dilakukan pada
29 hingga 31 Disember 2009 dengan menggunakan kaedah borang soal selidik.
Analisis terhadap 48 kes pembedahan yang ditolak menunjukkan 54% merokok, 10% tidak
berpuasa, 21% masalah teknikal dan 15% kegagalan kakitangan memenuhi kehendak senarai
semak pembedahan. Tahap pemahaman kakitangan mengenai senarai semak 68% dan didapati 88%
anggota memberi penekanan kepada pesakit mengenai kepentingan mengikut arahan premeditasi.
Hasil kajian pesakit pula mendapati 84% memahami dan 62% mempunyai maklumat persediaan
sebelum pembedahan.
Langkah penambahbaikan telah diambil dengan mengemaskini penggunaan senarai semak pra
pembedahan, mengadakan taklimat dan kursus kepada anggota, meletakkan papan tanda amaran
‘MEROKOK BOLEH MEMBATALKAN PEMBEDAHAN’ di setiap katil pesakit terlibat dan menyediakan
pamplet arahan serta nasihat yang perlu diikuti oleh pesakit sebelum menjalani pembedahan.
Peratusan penolakan kes pembedahan berjaya diturunkan daripada 13% pada tahun 2009 kepada
4.8% daripada Januari sehingga Ogos 2010. Selepas penambahbaikan berterusan dilakukan,
peratusan penolakan September 2010 sehingga Mac 2011 menunjukkan penurunan kepada 2.9%.
Langkah Seterusnya
Langkah proaktif serta komitmen anggota menggunakan langkah pemulihan merupakan faktor
utama kejayaan kajian. Penambahbaikan dan penyemakan semula akan dijalankan apabila kelemahan
dikesan bagi meningkatkan perkhidmatan di Dewan Bedah Hospital Pasir Mas.
chapter 7
Kajian ini bertujuan untuk menurunkan peratusan penolakan kes pembedahan yang dijadualkan
dilakukan di Dewan Bedah Hospital Pasir Mas. Standard yang ditetapkan adalah kurang daripada
5%.
Surgical
Peningkatan peratusan penolakan kes pembedahan yang dijadualkan didapati semakin meningkat
daripada 2.5% pada tahun 2007 kepada 13% pada tahun 2009. Walaupun mengikut Standard
National Indicator Approach (NIA) Kementerian Kesihatan, Malaysia jumlah penolakan kes
pembedahan tidak boleh melebihi 15%, terdapat peningkatan peratusan yang berlaku. Ini
membimbangkan pihak Dewan Bedah di samping mendatangkan implikasi kepada jabatan, anggota
dan pesakit.
144
OP/2011
Open Access Endoscopy Service Reduces Waiting Time and
Increases Gastrointestinal Cancer Detection
Mahadevan D, Dharmendran R, Azrina A, Vijaya S, Kandasami P, Ramesh G,
Jasiah Z.
Department of Surgery, Tuanku Ja’afar Hospital, Seremban, Negeri Sembilan.
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Surgical
In Malaysia, gastrointestinal cancer patients present late. There is no guideline to identify high risk
patients. Thus appointments are given without urgency, leaving some patients with late appointments
for specialist consultation. Failure to identify high risk patients in the health centre, followed by delay
in diagnostic endoscope procedure, is the reason for the delay in diagnosis, thus narrowing the
treatment options to palliation.
Time from presentation to health centre to endoscopic procedure is the direct indicator with the
standard of two weeks and cancer detection rate due to introduction of Open Access Endoscopy
(OAE) service compared to routine referral is the proxy indicator.
A three-pronged approach was undertaken. 1) Phase 1(2006): Development of the weighted scoring
system using cancer database and multivariate logistic regression model, 2) Phase 2(2007-2008):
Estimating positive predicting value, 3) Phase 3(2008-2010): Comparison of OAE to conventional
referral system. This is a prospective cross sectional study to determine diagnostic yield of both
systems.
From January 2004 till July 2006, a total of 59 stomach and 20 oesophageal cancers were studied,
with more than 90% of these being advanced disease. Mean time taken in the conventional referral
system, from the first appearance of cancer symptoms to the time of endoscopic procedure was 34
weeks. The delay in colonoscope appointment was 12-20 weeks.
Strategy for Change
We reduced the work process for referral and getting appointment for endoscope service by
introducing OAE. Medical officers in health centres could order endoscope appointment for high risk
patients directly without prior specialist consultation. OAE service in Negeri Sembilan is the first OPEN
ACCESS programme in Malaysia.
Effect of Change
After the implementation of strategies, all referral via OAE were done within 2 weeks, more stomach
cancers were diagnosed early and there was high yield of endoscope procedure. By identifying high
risk patients and reducing the endoscope appointment time, the cancer detection could be increased
and treatment hastened. Without this, high risk patients were not identified and consequently, their
cancers diagnosed late.
The Next Step
Consolidate and publish the findings, implement OAE nationwide.
145
PP/2007
Reducing Delay in Sending Patients to the Operating Theatre in
Department of Surgery Hospital Tawau, Sabah
Mohan Raj.R, Nawi W.
Surgical Department, Tawau Hospital Sabah.
A pre study was done from 1 September to 31 October 2005 in which out of 210 patients studied
59 patients took rnore than 10 minutes to be sent to the OT, giving the percentage of patients that
was delayed in being sent to OT 28.1%.
The contributory factors identified to cause the delay were inadequate pre-operative assessment
(32%), patient’s factors- Ryle’sTube or Continous Bladder Drainage (CBD) pulled out, uncooperative
patient, gone to toilet (14%), miscellaneous staff’s factors - staffs attending other cases, ignorant
staff, patient not prepared to OT, blood not taken (9%) and equipments - no trolley (4%).
Strategy for Change
Remedial measures taken included increasing awareness among staffs regarding the importance of
time management; doctors were required to double check pre-operative assessment on the night
prior to operation; morning duty staff were to go over the pre-operative check list again before
patients were called to OT; and all patients were asked to clean themselves before 7 o’clock in the
morning
Effects of Change
A post intervention data collection was carried out over 2 months from 1 January to 28 February
2006. A total of 264 patients were included, out of which 24 (9.1%) had delay of more than 10
minutes, showing an improvement compared to 28.1% before the remedial measures.
Reduction in delay of sending patient to OT will increase overall patient satisfaction. Good nursing
care and proper explanation and education to patients regarding the importance of minimising delay
in getting to the OT are vital in achieving this goal. Patients and medical personnel should realised
that getting the patient to the OT on time would reduce the chances of other cases being cancelled
for surgery due to inadequate OT time.
chapter 7
To reduce the incidence of sending surgical patients late to OT to less than 10%. Late to OT is defined
as the time taken into count when the patient is called to OT from the OT till the time patient arrives
in OT.
Surgical
Sending patient late to Operating Theatre (OT) causes frustrations and dissatisfaction to patients
and care providers. It prolongs the burden of OT staff by lengthening the OT time and reduces the
effective use OT facilities. A 2-week preliminary study showed that about one in two (57%) cases
due for surgery was delayed. This quality assurance project aimed to identify the contributing factors,
to formulate and implement remedial measures to reduce the incidence of delay in sending patients
to OT.
146
PP/2003
Pemonitoran Neurofisiologi semasa Pembedahan
Adnan T.
Unit Neurosains, Hospital Universiti Sains Malaysia, Kubang Kerian, Kelantan.
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Surgical
Pengenalan
Pengawasan Neurofisiologi semasa pembedahan telahpun digunakan untuk mengurangkan
kerosakan saraf semasa pembedahan. Tujuan pengawasan adalah untuk mengenal pasti perubahanperubahan fungsi pada otak saraf tunjang (spinal cord) dan saraf periferal (peripheral nerve) daripada
kerosakah yang kekal. Pengawasan semasa pembedahan juga berkesan di dalam mengenalpasti
struktur anatomi termasuklah saraf periferal dan sensori motor kortek. Pemonitoran ini dapat
membantu Pakar Bedah Saraf semasa pembedahan.
Perbincangan
Di HUSM, pernonitoran neurofisiologi semasa pembedahan masih di perinqkat awal dan jumlah
pembedahan yang dimonitor juga terhad. Jenis-jenis pemonitoran yang dilakukan di sini adalah seperti
Brainstem Auditory evoked potential (BAER), motor evoked potential (MEP), somatosensory evoked
potential (SSEP) and electromyography (EMG). Ini adalah untuk mengawasi pembedahan Barah Otak
dan pembedahan saraf tunjang seperti Acoustic Neuroma, C.P Angle tumour, Laminectomy dan
sebagainya.
Pemonitoran lain yang boleh dilakukan semasa pembedahan saraf ialah electroencephalography
(EEG) dan electrocorticography (ECoG). Rakarnan EEG secara terus daripada permukaan pial atau
ECoG berg una untuk membantu menentukan kawasan pembedahan yang lebih tepat semasa
pembedahan sawan (epilepsy surgery) dan mengawasi sawan semasa stimulasi electrik otak ketika
mapping cortical, function.
Keputusan
Dengan adanya pemonitoran neorofisiologikal semasa pembedahan ini, pembedahan saraf dapat
dilakukan dengan sempurna. Ini kerana, struktur anatomi dapat dikenalpasti dan komplikasi
kerosakan saraf dacat dielakkan atau dikurangkan.
Chapter 8
Pharmacy Related Projects
148
OP/2011
Reducing E-Prescription Error in a Hospital In-patient Pharmacy
Wan Najbah NN, Ngan YS, Muhd Nor Hazli N, Ng KY, Ching MW, Tan HF.
Pharmacy Department, Putrajaya Hospital, Wilayah Persekutuan Putrajaya.
The Computer-based Physician Order Entry (CPOE) system has been shown to reduce the number
of prescription errors. However, it may also lead to new kinds of prescription errors. A study in
2009 in Putrajaya Hospital demonstrated that the percentage of prescription errors in in-patient
pharmacy was 5.32%. This project aimed to reduce the percentage of prescription errors in in-patient
pharmacy, Putrajaya Hospital (HPJ).
The proposed standard for percentage of prescription errors in Putrajaya Hospital (HPJ) was 0%.
All in-patient prescriptions were sampled from 18 till 24 October 2010. During this phase, doctors
were asked the reasons for occurrence of errors. The contributing factors for errors were determined
by distributing self-administered questionnaires to all doctors in wards. Following remedial measures,
two more phases of data collection were carried out to evaluate its effectiveness.
chapter 8
First phase data collection detected 69 prescription errors out of 962 prescriptions (7.17%). Most
(88%) prescription errors involved houseman doctors and generally involved antibiotics (31.8%).
Surveys revealed that the most common problem faced by doctors was unsure of dosage regime
(42.4%).
Strategies for Improvement
Remedial actions carried out included promotion of Drug Information Services, distribution of dosage
mini cards to wards, presentation of project findings to the Head of Departments and also the
distribution of pocket size reference dosage cards to houseman doctors.
Effects of Change
Following remedial actions, the percentage of prescription error dropped from 7.17% to 2.25% and
later slightly increased to 2.94%.
The Next Step
“Medication ordering training” needs to be incorporated during IT orientation for new doctors.
Also, “default dosing for commonly prescribed drugs” was proposed. Although CPOE reduced
the number of prescription errors, more human effort and IT intelligence will be needed to prevent
prescription errors.
149
OP/2011
Re-Engineering the Process of Obtaining Special Formulary Drugs
by Oncology Patients
Tan PL, Azhari Wasi NA, Dhillon HK, Buang A, Sulaiman CZ, Mohd Zakaria IE,
Tan WC, Poopaladurai D.
Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala
Lumpur.
Oncology patients and/or their caregivers were subject to the inconvenient process of obtaining
special formulary cytotoxic drugs due to the different locations of cytotoxic drugs in University
Malaya Medical Centre (UMMC). The process also caused delays in reconstitution of drugs and thus,
administration time. Therefore, the aim of this project was to re-engineer the current process to
increase patients’ satisfaction.
• Reduction in time spent by patients to obtain cytotoxic drugs (<10 minutes)
• Reduction in time delay in reconstitution of cytotoxic drugs (<5 minutes)
• Decrease in patient’s inconvenience (≥80%)
The time spent per patient and the delay in reconstitution was 18.5 minutes per patient (N=216),
giving a difference of 8.5 and 13.5 minutes respectively from the standards set. A total of 143
feedbacks were received, with 48.9% positive feedback (patients felt easy to obtain the drugs),
hence a 31% gap from standard.
Strategy for Change
Centralised storage of special formulary cytotoxic drugs in a sterile complex and the change in
patients’ flow were initiated. Fax was used as a means of communication to initiate reconstitution.
Effects of Change
Time spent on obtaining cytotoxic drugs per patient was reduced to zero, whereas delay in
reconstitution was reduced to 3.7 minutes per patient (a reduction of 14.8 minutes). A total of 140
feedbacks were received with 84.3% being positive(an increase of 35.4%).
The Next Step
Implementation of the new process had successfully decreased patients’ inconvenience. One stop
payment in Pharmacy and online protocols will further simplify the process of care.
chapter 8
Time spent and delay as well as patients’ feedback were collected from 25 January to 26 February
2010 (5 weeks). The effectiveness of the new process was evaluated by monitoring the time and
patient satisfaction from 1 March to 2 April 2010 (5 weeks) measured using a simple questionnaire
with a scale from 1-5 (1=very easy, 5=very difficult).
150
OP/2011
Improving Adherence to Blood Sampling Time for Therapeutic
Drug Monitoring in a Government Hospital
Rosdi MZ, Dang CC, Ku SC, Norshazareen AM, Lim CW, Tan BL.
Pharmacy Department, Melaka Hospital, Melaka.
Non-adherence to blood sampling time may lead to inaccurate recommendation of drug dosage or
frequency given by the pharmacist and this may then lead to drug toxicity or inadequate therapeutic
response.
Adherence to blood sampling time was defined as blood samples that are taken according to the
Therapeutic Drug Monitoring (TDM) Guidelines on Blood Sampling Time. The Standard of Good Care
was set with the target of adherence to blood sampling time being more than 90%.
A data collection sheet was prepared and TDM forms were screened. TDM forms received from all
the wards of Melaka Hospital were included except from Psychiatric Wards, Outpatient Clinics and
other hospitals or polyclinics. Data needed were transferred from TDM forms to data collection sheet.
The same process was done for TDM forms received in August 2009, February 2010 and August
2010.
chapter 8
Percentage of adherence to blood sampling time was 45.9% before the remedial measures.
Strategy for Change
A series of talks were given to pharmacists, nurses and doctors. A ‘reminder sticker’ was introduced
to the current setting. Besides, TDM Guidelines on Blood Sampling Time was distributed to all the
wards in Melaka Hospital.
Effects of Change
The adherence had increased to 61.8% after the first remedial measure and had further improved to
88.6% after the second remedial measure.
The Next Step
All remedial measures taken were shown to improve the adherence to blood sampling time for TDM
in Melaka Hospital. However, the target set in Standard of Good Care has not been achieved yet.
More studies will be conducted to further improve the current system.
151
OP/2011
Mengurangkan Kekerapan Pesanan Luar Jangka dari Unit
Pemesan bagi Item Bukan Ubat di Unit Perolehan dan
Pembekalan
Noor Mariati O, Siti Masyitah MT, Noorulhuda S, Lee LG, Azizah M,
Khairul Anuar M, Norsiah MN.
Hospital Sultan Haji Ahmad Shah, Temerloh, Pahang.
Item bukan ubat perlu dipesan sebulan sekali. Peratusan pesanan luar jangka yang tinggi disebabkan
oleh kelewatan penerimaan barang daripada pembekal, stok dalam stor tidak mencukupi untuk
dibekalkan, tiada senarai alat dan senarai piawai alat dari unit pemesan, tiada sistem pemantauan
stok yang sistematik, ruang penyimpanan yang terhad dan penyusunan barang yang tidak sistematik
serta pesanan bulanan tidak mengikut jadual. Objektif kajian ialah mengurangkan kekerapan
pesanan luar jangka dengan mengenalpasti kekerapan pemesanan luar jangka, faktor penyumbang
dan menentukan langkah penambahbaikan serta menentukan keberkesanan langkah yang diambil.
Indikator kajian ialah peratus pesanan luar jangka yang diterima dengan standard kurang dari 20%.
Data pesanan luar jangka diperolehi dari buku daftar pesanan. Maklumat lain diperolehi melalui soal
selidik dan pemerhatian menggunakan borang pengumpulan data.
Empat strategi telah dilaksanakan iaitu mengadakan taklimat pengurusan stor kepada pegawai yang
menjaga unit/wad terlibat, penguatkuasaan jadual pesanan bulanan, mewujudkan senarai minima
dan maksima item bukan ubat dan pemantauan stor secara berkala.
Hasil langkah penambahbaikan yang telah diambil adalahpenurunan pesanan luar jangka dari 60.7%
ke 33.3%. Ini masih tidak mencapai standard yang ditetapkan iaitu 20%.
Langkah Seterusnya
Kajian lanjutan akan diteruskan untuk mengenalpasti faktor lain yang boleh menyebabkan
peratusan pesanan luar jangka yang tinggi serta langkah penambahbaikan yang perlu diambil untuk
mengatasinya.
chapter 8
Peratus pesanan luar jangka sebelum penambahbaikan dilakukan ialah 60.7%. Faktor penyumbang
utama kekerapan pesanan luar jangka ialah senarai piawai minima dan maksima item bukan ubat
dari unit pemesan iaitu 90% dan pesanan tidak mengikut jadual sebanyak 100%.
152
OP/2011
Role of the Pharmacist in Improving Targeted International
Normalised Ratio Value of Patients on Warfarin Theraphy
Shakirin SR, Izrul Azwa ML, Tan SY, Cheah SY, Wong MK, Chiew CW.
Department of Pharmacy, Labuan Hospital, Wilayah Persekutuan Labuan.
Inappropriate Warfarin dose was associated with higher bleeding events. Only 38.7% individual
International Normalised Ratio (INR) values of Warfarin patient are within targeted INR range.
Collaboration between physicians and pharmacists, who managed Warfarin Medication Therapy
Adherence Clinic (MTAC), was introduced to closely monitor INR and counsel regarding drug-drug
interactions, dietary intakes and lifestyle. This study aimed to improve targeted INR value of Warfarin
patients with increased involvement of pharmacists.
Warfarin MTAC pharmacists in Labuan Hospital decided to set standard percentage of individual INR
reading within the targeted therapeutic range of at least 50%.
chapter 8
23 patients were involved in this study. Their INR readings from June to November 2009 were obtained
from their Bed Head Ticket (BHT). Pre intervention investigation found that lack of pharmacist
involvement contributed to the non achievement of targeted INR value of Warfarin patients.
Of the 191 individual INR values from the 23 patients, only 38.7% were categorised as ”good”.”Good”
is defined as values within the target. Prior to Warfarin MTAC, the following flaws were observed
where there was no record of Warfarin counseling, proper documentation of INR reading in the BHT
nor was there any standard Warfarin booklet given to patients. Supply of warfarin was obtained from
the ‘Farmasi Klinik Pakar’.
Strategy for Change
We have implemented a one-stop service centre of Warfarin MTAC. The patients’ blood samples
were taken by the pharmacist using Point-of-care (POC) instrument and Warfarin was supplied during
the Warfarin MTAC session. Patients also received standard Warfarin booklets where INR values
and Warfarin doses were recorded. Warfarin patients also received continuous individual counseling
sessions.
Effects of Change
After implementation, the number of individual INR readings within target range increased from
38.7% to 55.9%.
The Next Step
The Warfarin MTAC pharmacists now aims to achieve improved patients’ INR reading targeted above
70% in the pharmacy practice with regular assessments.
153
OP/2011
Achieving International Normalised Ratio Targets and
Satisfaction of Warfarinised Patients
Subramaniam T1, Fudziah A1, Jeyaindran S2, Suliyana Y1, Lim SC1, Chong MF1,
Cheng PL1, Teng SC1.
Department of Pharmacy, Kuala Lumpur Hospital, 2Department of General Medicine, Kuala Lumpur
Hospital, Wilayah Persekutuan Kuala Lumpur.
1
Non-achievement of International Normalised Ratio (INR) among warfarinised patients results in poor
clinical outcomes and increased healthcare cost.
The key measures for improvement were percentage of INR readings within target range (2-3),
patients’ warfarin therapy knowledge and clinic waiting time.
The selected measures were assessed both in the pre and post-remedial actions phase. Five INR
levels of 331 patients were collected. A survey was conducted to assess the clinic waiting time and a
questionnaire was administered to assess patients’ knowledge of warfarin therapy.
Strategy for Change
The implementation of the remedial action is an on-going process and the remedial actions were
implemented in three phases based on process, knowledge and attitude. The process in terms of
blood taking method and clinic appointment was improved. Education sessions for both patients
and healthcare personnel were provided to improve their knowledge on warfarin therapy. A drug
consumption calendar was given to every patient to encourage positive attitude towards warfarin
therapy. Improved dosing method was used in Phase 2 whereas patients’ reminders were used in
Phase 3.
Effects of Change
The percentage of INR levels within target range increased by 16% upon the implementation
of the remedial actions. The average clinic waiting time was reduced by 51.5% to 98 minutes.
Average warfarin therapy knowledge questions answered correctly improved by 40%. In terms of
the satisfaction, 90% of the patients were satisfied with the time, information provision and overall
clinic management. In Phase 2, the percentage of INR reading within range for the selected patients
improved from 60% to 72%. Phase 3 is in progress.
The Next Step
Quality improvement in managing warfarinised patients is a continuous, multi-disciplinary, patient
oriented approach. These clinic-based remedial actions will be expanded to Fridays. We will explore
the possibility of conducting a pharmacoeconomic study.
chapter 8
Almost 50% (827 readings) of the INR levels did not meet the INR target. The average clinic waiting
time per patient among 100 patients was 202 minutes and these patients were only able to answer
on average 10 out of 18 questions correctly.
154
PP/2011
Reducing the Number of Medication Administration
Errors in a General Paediatric Ward
Hiew CY, Lee ML.
Department of Pharmacy and Department of Paediatrics, Tuanku Ja’afar Hospital, Seremban, Negeri
Sembilan.
Medication administration errors are common occurrences in any hospital setting especially in a
paediatric ward. This is because of the different doses required by the paediatric patients due to the
differences in their weight and age. This study aimed to identify the common medication errors that
occur in a general paediatric ward and measures that can be implemented to reduce these errors.
The Pharmacy Department had targeted to reduce any type of medication errors to 0%.
An audit was done in the general paediatric ward of Tuanku Ja’afar Hospital, Seremban from
November 2008 to November 2009. The audit was done using a pre-prepared checklist produced by
the Pharmacy Department. A pharmacist observed nurses when they prepared and administered
medications. There were 3 cycles in this audit. 100 medications consisting of 50 oral and 50
intravenous, were conveniently chosen for each cycle. Interventions were done after cycle 1.
chapter 8
The percentage of errors for intravenous drug administration was 34% while for oral drug
administration was 38%.
Strategy for Change
Periodical briefings about medication administration were given to new staff nurses and a pharmacist
would randomly countercheck medication administration by selected nurses.
Effect of Change
Both of the intravenous arm and oral arm of the study showed a remarkable reduction in the number
of ‘near misses’. The percentage of errors for intravenous drug administration was reduced from
34% to 16% while for the oral drug administration was reduced from 38% to 12%.
The Next Step
This system has been shown to be effective in reducing the number of medication administration
errors in the general paediatric ward. It should be applied in the normal practice during medication
administration in conjunction with other measures as well.
155
PP/2011
Optimisation of PharmCare Service in a Tertiary Hospital
Giam WL, Azhari Wasi NA, Buang A, Dhillon HK, Mohd Zakaria IE, Lee CE,
Jinan Taib JT, Ismail NS, Syed Othman SR, Abdul Wahab AR.
Pharmacy Department, University Malaya Medical Centre, Kuala Lumpur, Wilayah Persekutuan Kuala
Lumpur.
Pharmacy UMMC has PharmCARE services for patients with long term prescriptions where advance
preparation of medicines can be requested. Despite the availability of this service, a large number of
patients still come to the main outpatient pharmacy (OP) for supplies, resulting in under-utilisation of
PharmCARE. With the available resources, PharmCARE should be able to serve 400 patients per day.
Reduction in achievable benefit not achieved (ABNA) of PharmCARE patients per day to more than
30% after improvement, without compromising waiting time and patients’ satisfaction.
From the study, PharmCARE was only able to serve 90 patients/day compared to 400 patients/day.
Thus the ABNA is 77.5%. A total of 250 questionnaires were returned, with the main reason for
under-utilisation as lack of PharmCARE awareness (65.6%). Most patients (66%) were interested in
courier service for medicine collection.
Strategy for Change
Promotion to create awareness was initiated and a new service called BY-POST was introduced in May
2010 to further attract patients to use PharmCARE services.
Effects of Change
PharmCARE promotion and implementation of the BY-POST service had succeeded in increasing
the average number of patients from 90 to 162 patients/day by September without compromising
the waiting time and patients’ satisfaction. It had resulted in 18% ABNA reduction from 77.5% to
59.5%. Failure to achieve the targeted standard was due to unexpected workload for BY-POST service
and increase in medication counseling sessions that limited the process of patients’ recruitment.
The Next Step
Ensuring the continuity and expansion of PharmCARE for all patients with repeat prescriptions will
continue to improve the OP pharmacy service.
chapter 8
Retrospective analysis of the average number of patients was collected from January to December
2009 as verification. The reasons for under-utilisation of PharmCARE were identified using a
questionnaire from 11-22 January 2010 in OP pharmacy.
156
PP/2011
Minimising the Filling Errors in a Specialist Clinic Pharmacy
Siow CC, Menaga K, Noor Shafizah J, Muhd Redhuan N.
Specialist Clinic Pharmacy, Melaka Hospital, Melaka.
Filling errors will lead to dispensing errors and cause harm to patients. This study was carried out in
the Specialist Clinic Pharmacy, Hospital Melaka in order to minimise the filling errors and keep up the
standard of 0% filling error set by the Ministry of Health (MOH).
This study analysed the factors which led to filling errors during office hours on five working days.
The standard set was 0% filling error.
A prospective study was conducted from 1 June to 31 August 2010, to detect the filling errors and
to analyse the contributing factors from 1 June until 31 August 2010. A data collection form was
distributed to the person involved in the error upon error detection by the pharmacist in charge. Data
collected was keyed in and analysed using Microsoft Excel.
chapter 8
By using the data collection forms, the contributing factors were analysed. Human factors which
included carelessness, stress and inexperience contributed most (25%) to the filling errors. The study
showed that trainees contributed to the most errors (89%) compared to pharmacists’ assistants (9%)
and pharmacists (2%). 78% of errors were detected during peak hours.
Strategy for Change
The remedial measures included 5S implementation, increased number of staff (during office hour,
peak hour and lunch calls) and supervision of new staff. Next, three persons per week were assigned
to manage the telephone calls (disturbances at work place).
Effect of Change
Filling errors were reduced from 0.93% to 0.58%. Human factor was chosen to be the main
contributing factor.
The Next Step
The study and the remedial measures proved to be effective, thus the effort will be continued until
0% medication error had been achieved.
157
PP/2011
Clinical and Economic Impact of Pharmacist-Run Medication
Therapy Adherence Clinic Service on Patients With Type 2
Diabetes
Navin Kumar L, Chin ST, Rachel T, Lim KY, Fudziah A.
Pharmacy Department, Kuala Lumpur Hospital, Kuala Lumpur.
Poor glycaemic control of patients with Type 2 Diabetes which leads to diabetes related complications
and escalating healthcare cost could be contributed by low medication adherence.
Morisky Score (measure of medication adherence) and HbA1c (measure of glycemic control) were
selected. Standard of Good Care was defined as Morisky Score of more than 6 and HbA1c reduction
of more than 1%. Process of Gathering Information
Patients with Type 2 Diabetes who attended the Physician Clinic were divided into the Interventional
and Control Group (known as Standard Care group). HbA1c data and Morisky scores of the two
groups were recorded.
Strategy for Change
Change of process was applied by introducing a new service called Medication Therapy Adherence
Clinic (MTAC Diabetes) for the Interventional group while the other group continued receiving the
existing service. Patients who attended MTAC Diabetes clinic were seen by a pharmacist on a monthly
basis and received blood glucose and weight monitoring, medication adherence assessment, drug
related problem solutions, medication dispensing, individualised medication counselling and diabetes
education besides their doctor’s follow-up. Both groups were followed up prospectively for a period
of 9 months.
Effects of Change
During the post-remedial phase, medication adherence levels of patients in Interventional group
improved significantly from a mean Morisky score of 4.23 to 7.84 while their mean HbA1c level
showed a significant reduction of 1.7% from 10.6% to 8.9%. The Standard Care group only showed
a minimal increase in Morisky Score from 4.00 to 6.14 and HbA1c reduction of 0.6% from 10.7%
to 10.1%, although findings were both not significant (p>0.05). A Cost Effectiveness Analysis (CEA)
found MTAC Diabetes (Interventional) to be more cost effective (RM 446.01 per 1% HbA1c reduction)
compared to Standard Care (RM 1347.73 per 1% HbA1c reduction).
The Next Step
Continuous medication counselling and monitoring of patients with Type 2 Diabetes by the pharmacist
had shown positive clinical and economic outcomes. Therefore, this service will be extended to
patients with Type 2 Diabetes at the Out-Patient Department.
chapter 8
Both groups showed low medication adherence [mean Morisky Score of 4.23 (Interventional) and
4.00 (Standard Care)] and poor glycemic control [mean HbA1c of 10.6% (Interventional) and 10.7%
(Standard Care)].
158
PP/2011
Meningkatkan Pengetahuan Pesakit Tentang Perubahan Rupa
Ubat di Farmasi Pesakit Luar
Norhasmani M, Abby Ang SY, Rashidah AR, Omar O, Norfajariah I,
Arzarizah A.
Farmasi Pesakit Luar Hospital Raub, Pahang.
Pertukaran rupa ubat sering terjadi di agensi kesihatan Kementerian Kesihatan Malaysia dan ia
sesuatu yang tidak dapat dielakkan. Jika masalah ini tidak ditangani, ianya boleh membawa kepada
kesilapan dalam pengambilan ubat-ubatan dan seterusnya mengakibatkan komplikasi penyakit. Oleh
yang demikian, adalah penting unit farmasi mengambil inisiatif dalam meningkatkan pengetahuan
pesakit tentang perubahan rupa ubat.
Objektif kajian ini ialah untuk meningkatkan pengetahuan pesakit tentang perubahan rupa ubat di
Farmasi Pesakit Luar Hospital Raub. Projek QA ini diharap dapat menangani masalah kekeliruan ubat
ini dengan berkesan.
chapter 8
Kajian dengan menggunakan borang soal selidik telah dijalankan di Farmasi Pesakit Luar bagi
mengukur peratusan pesakit yang tahu tentang pertukaran rupa ubat dan bagi mengenalpasti faktor
penyumbang. Bagi kajian pra-intervensi, data telah diambil bermula Disember 2009 sehingga Januari
2010 manakala kajian selepas intervensi di jalankan bermula Mei sehingga Jun 2010.
Hasil kajian mendapati hanya 42% pesakit tahu tentang perubahan rupa ubat yang diambil.
Faktor penyumbang utama kurang pengetahuan adalah kurang penyebaran informasi, kekerapan
pertukaran ubat dan masalah bahasa serta jumlah ubat yang diambil.
Kumpulan QA kami telah menjalankan penambahbaikan untuk meningkatkan pengetahuan pesakit
tentang perubahan rupa ubat di Farmasi Pesakit Luar. Langkah penambahbaikan yang telah diambil
adalah seperti membuat inovasi dengan menghasilkan SMART BOARD yang dipamerkan di setiap
kaunter pembekalan ubat, penyediaan fail rujukan untuk menyimpan semua ubat yang bertukar
rupa serta membuat perubahan dalam cartalir proses kerja pembekalan ubat.
Setelah penambahbaikan dijalankan selama 2 bulan, didapati pengetahuan pesakit telah meningkat
daripada 42% kepada 74%. Langkah Seterusnya
Penambaikan tersebut diharap akan dapat meningkatkan pengetahuan pesakit tentang perubahan
rupa ubat supaya pesakit mendapat rawatan yang lebih selamat dan berkualiti daripada ubat yang
diambil, sejajar dengan Dasar Ubat Nasional. Limitasi kajian ini adalah ia hanya melibatkan pesakit
di jabatan pesakit luar dan adalah diharapkan kajian ini dapat diteruskan dan digunapakai di semua
unit farmasi.
159
PP/2009
Improving Complete Drug Prescription Yield in the Obstetrics &
Gynaecology Department
Mairin D, Zainab A, Nooraini H, Chris SYC, Ros Suliana Y, Sharmini Diana P.
Seberang Jaya Hospital, Penang.
Retrospective analyses done in 2006 in the O&G department revealed that less than 30% of the
prescriptions were completed. A drug prescription is considered to be complete when all the data
required in the prescription sheet were adequately filled in. Incomplete prescription can lead to delay
in appropriate drug dispensation and risk of medication error to patients.
This study intends to improve the number of complete drug prescription in the department. A
standard of more than 95% complete drug prescription yield was set.
A study on drug prescriptions from the department was carried out in January 2007 with reevaluations in July 2007, January 2008 and June 2008. The staff were assessed on their knowledge
and prescription-writing practices by using questionnaires and observational survey.
Strategy for Change
Retraining of staff by the pharmacist and the innovation of a mini Drug Formulary booklet was made
available to the whole department in March 2007. A further innovation of Common Drugs booklet
was made available in February 2008 to aid in prescriptions writing.
Effects of Change
The percentage of complete drug prescription was 49.6% in July 2007 but increased to 56.6%
and 70.6% in January and June 2008 respectively. There was also an overall improvement on staff
knowledge. ABNA was reduced from 68.6% to 24.4%.
The Next Step
We will continue this intervention by making it compulsory for all house officers to carry this mini
drug formulary and use it prior to writing a prescription.
chapter 8
In January 2007, only 26.4% of the prescriptions were completed. Discrepancy in staff’s knowledge
and their actual prescription-writing practice, lack in drugs knowledge, nurses inability to act on
detected incomplete prescription, and the scarcity of resources were identified as factors leading to
low rate of complete drug prescription.
160
OP/2009
Improving the Percentage of Compliance towards Sampling Time
Guidelines of Therapeutic Drugs Monitoring Blood Samples
in a Government Hospital
Rose Aniza R1, Haarathi C1, Syamhanin A2, Juhainun T3.
Hospital Tengku Ampuan Rahimah, Klang, 2Hospital Sungai Buloh, 3Hospital Kuala Kubu Baru,
Selangor.
1
Proper timing of samples collected for Therapeutic Drug Monitoring (TDM) is essential for meaningful
interpretation of drug concentrations. In 2005, only 29.17% of TDM blood samples received in
Hospital Tengku Ampuan Rahimah, Klang (HTAR) complied with the sampling guidelines. This quality
assurance project aimed at improving the percentage of compliance, identifying the contributing
factors and implementing remedial actions.
To increase the knowledge of medical staffs on TDM sampling time and to increase their adherence
towards the guidelines in taking blood samples.
chapter 8
A verification study was done to identify the extent of compliance from January to December 2005.
The contributing factors were determined by evaluating the knowledge and awareness of medical
staffs on TDM sampling time. Remedial actions were implemented from September 2006 to March
2007. Evaluation of the effectiveness of remedial actions took place from March to December 2007.
Antibiotics (aminoglycoside and vancomycin) were identified as the drugs with highest number of poor
sampling time cases and the wards involved were ICU, Medical and Pediatric wards. Poor knowledge
and lack of awareness among medical staffs were the major contributors in non-compliance to the
sampling time guidelines.
Strategy for Change
The remedial actions involved were sessions of Continuous Medical / Nursing Education for medical
staffs and implementation of new format of TDM request form.
Effects of Change
After remedial action, it was found that the percentage of compliance towards sampling guidelines
has improved tremendously from 29.17% to 72.4%.
The Next Step
Involvement of pharmacist in the wards to guide the medical staffs on TDM sampling time and
implementation of Standard Operating Procedure specifically for TDM blood sampling are expected
to give a positive outcome.
161
OP/2009
Dispensing Repeat Medications on Appointment Basis (S.M.A.R.T)
as an Alternative Dispensing Method to Reduce Patient Waiting
Time at the Pharmacy Department
Loganadan NK, Ariffin F, Mohd Nur N, Lim SY, Mohd Latiff IZ, Albert
Gunaratnam C, Kon EW, Saidi F, Muhammad Z, Nair A, Hamzah M, Man J.
Pharmacy Department, Kuala Lumpur Hospital, Kuala Lumpur.
Long waiting time at the pharmacy for patients to collect their repeat medications would lead to
customer dissatisfaction of the services provided by the pharmacy.
Patient waiting time was defined as the time prescription slip received until the drugs were dispensed.
The Standard of Good Care was set with the target waiting time for patients with repeat prescriptions
being less than 30 minutes.
The average waiting time for repeat prescriptions during the pre-remedial phase was 36 minutes.
Strategy for Change
A new dispensing system called Sistem Mendispens Secara Temujanji (S.M.A.R.T) was introduced
in which patients were given a S.M.A.R.T card each stating their appointment dates for the next
collection. Medications were prepacked one day earlier and dispensed on the appointment dates
given.
Effects of Change
During the post-remedial phase, the average waiting time was significantly reduced by only 4 minutes
(p<0.05). A total of 424 patients (88.9%) with the S.M.A.R.T card waited only for less than 5 minutes
to collect their medications.
The Next Step
Modification done to the routine work process for dispensing has enabled patients’ medications
ready to be dispensed on the collection date. This new dispensing method (S.M.A.R.T) will be offered
to all patients with repeat prescriptions to collect their medications.
chapter 8
In the pre-remedial phase, waiting time for 530 patients using the conventional dispensing method
was obtained. Patient waiting time data was collected from the Queue Management System
(QMS) software (that records waiting time for each patient) at Counter 1 and 2 of the Outpatient
Pharmacy which received majority of the repeat prescriptions. During the post-remedial phase (after
implementation of Sistem Mendispens Secara Temujanji (S.M.A.R.T) as a remedial measures), waiting
time for 477 patients who received the S.M.A.R.T service was collected from the QMS software.
Average patient waiting time for pre and post remedial phases were compared and analysed
statistically.
162
OP/2009
Reducing the Incidence of Medication Error in a Paediatric
Medical Ward
Wong PF, Amelia A, Hong JSS, Anim A, Azean W, Sabrina, Teoh SL, Anusha,
Zahanah A.
Pediatrics Department, Melaka Hospital, Melaka.
The puediatrics population is at an increased risk of medication errors because of the necessity of
weightbased dosage individualisation. The incidence of medication error is still unknown. This study
aims to determine the incidence of medication errors, identify the underlying causes and subsequently
implement the necessary remedial actions.
The standard is 0% medication error. For the purpose of this study, we have categorised it into
documentation error and drug administration error.
chapter 8
A cross-sectional study was done in May 2008 looking at documentation error (patient’s particulars,
prescription particulars, legibility of handwriting, presence of verbal order, transcription error, dosage
calculation error and uncorrected weight for age), knowledge (doctors and nurses) and the nursing
drug administration process. Data was collected from Bed Head Ticket (BHT) and drug charts,
questionnaires and observational checklists. Intervention to all these factors took place from June to
December 2008. The effectiveness of remedial measures was evaluated in January 2009.
86% of documentation errors detected were contributed by junior medical officers. No error was
detected in the observation of drug administration by the nurses. There was 100% acceptable
knowledge amongst the medical officers and nurses but only 61% amongst the junior medical
officers.
Strategy for Change
Measures to increase awareness include implementation of detailed bed tags (with patient’s age and
weight stated), introduction of a standard maximum dose-for-age reference chart in the ward and
introduction of a ward pharmacist. Strategies to improve knowledge include regular formal teaching
sessions to nurses and doctors.
Effects of Change
There is a reduction in documentation error from 14% to 4.5%.
The Next Step
This study managed to reduce the incidence of medication errors and the remedial measures proven
effective in reducing documentation errors as well as drug dosage errors.
163
OP/2009
Re-engineering the Unit of Use Drug Distribution System
of Ward Supply to Cater for Weekend Needs
Sin SF, Sin WL, Tan XY, Leong WC, Sharifah Nor Sazlin SZ,
Aida Roziana R, Tan CH.
Tengku Ampuan Afzan Hospital Kuantan, Pahang.
Current Unit of Use (UOU) documentation system prolonged turn-around-time causing failure to
complete the supply on time during weekend.
To improve timeliness in supplying medication to the wards and to cater for weekend needs.
The study was carried out from January to April 2008. Time taken for each process in medication
supply cycle was collected using a data collection form. Efficiency of the drug distribution system
before and after intervention was evaluated by measuring the time taken for the screening process.
Strategy for Change
The current UOU Drug Distribution System provides supply of medications for a duration of 3
days, causing top-ups to be done on weekends. This system was re-engineered by creating a more
systematic approach to supply medications to the wards. A new schedule for top-up and filling of
new prescription was drawn up for all the wards. With this intervention top-ups during weekends
was abolished or minimized.
Effects of Change
The implementation of the intervention succeeded in catering the ward’s weekend’s needs. With
decreased workload, the efficiency of ward supply staffs was increased.
The Next Step
Development of a new Hospital Specific Approach (HSA) indicator to periodically monitor number of
top-up slips received during weekend.
chapter 8
The average number of top-up slips received during weekends after intervention showed a
reduction of 79.3%. Timeliness in supplying medication to the wards in the weekends also showed
improvement after intervention. The average time taken for screening process in the weekend was
observed to be 198.7 minutes as compared to 288.9 minutes previously. A difference of 69.4% in the
screening time between weekdays and weekends was observed as compared to difference of 24.3%
recorded before the implementation. The workload was reduced and hence timeliness in supplying
medications to the wards were improved.
164
OP/2009
PHARMCARE: A Quality Improvement in Supplying Long-Term
Medications from the Outpatient Pharmacy in a Medical Centre
Nur Azrida AW1, Mohamed Noor R1, Alias A1, Amrahi B1, Pauline L1.2,
1
2
Pharmacy Unit, University Malaya Medical Centre, Kuala Lumpur
Department of Pharmacy, University of Malaya, Kuala Lumpur.
Patients collecting medications at the Outpatient (OP) Pharmacy in the University Malaya Medical
Centre (UMMC) usually have to wait longer than 30 minutes, resulting in many complaints. The aim
was to identify the contributing factors and implement a new service to reduce waiting time thus
increasing patient satisfaction.
Reduction in patients’ waiting time by serving at least 75% of its patients within 30 minutes and to
improve patients’ satisfaction. Ishikawa model was used to identify the problem.
chapter 8
Patients’ waiting time and feedback in OP pharmacy was collected retrospectively from the queue
management service and feedback forms from January to December 2006. PharmCARE was initiated
in January 2007. PharmCARE waiting time was recorded manually whilst patient satisfaction was
assessed using a patient satisfaction questionnaire from August to December 2007. The same
parameters for OP pharmacy was also collected as described earlier.
The mean waiting time per patient prior to intervention was 42.3 minutes. A total of 198 complaints
were received. The mean post intervention waiting time was 5.8 and 45.0 minutes for PharmCARE
and OP Pharmacy respectively. PharmCARE patients rated a mean satisfaction score of 66.7%. A total
of 101(94.4%) compliments were received.
Strategy for Change
A new service called PharmCARE was initiated. Patients with repeated prescription made an
appointment in advance via a visit or using the short messaging service. These medications were
then prepared in advance for collection.
Effects of Change
PharmCARE service has succeeded in achieving the OP pharmacy quality objective. Patients were also
more satisfied thus improving the image of the pharmacy unit.
The Next Step
Ensuring the continuity and expansion of PharmCARE for all patients with repeat prescriptions in
order to improve the OP pharmacy service.
165
OP/2009
Improving Waiting Time in the Outpatient Pharmacy Unit at a
Government Hospital during Medical Clinic Days
Lou JY, Martina H, Harry C, Wong JI, Nancy K, Lo KM.
Pharmacy Department, Sibu Hospital, Sarawak.
The main problem faced by patients in Outpatient Department (OPD) Sibu Hospital is long waiting
time while collecting medications, especially during medical clinic days. From a client satisfaction
survey conducted in 2008, most of the feedbacks were directed towards reducing waiting time.
Waiting time is defined as the time when a prescription is received to the time it is ready for dispensing.
Our objectives are to fulfill the Ministry of Health’s client charter of more than 90% of patients
receiving medications within 30 minutes, to investigate the problem contributing to the long waiting
time, to determine factors affecting the long waiting time and to implement remedial measures. The
mean waiting time before remedial measures was 58 minutes.
Results showed that the longest delay was the time needed for prescriptions waiting to be filled,
especially during peak hours between 11am-1pm. The main contributing factor was shortage of
manpower.
Strategy for Change
Deployment and rescue teams (comprising staff from other pharmacy units) were the remedial
actions taken in June 2008. In 2009, staggered lunch hours were implemented and new officers
were appointed.
Effects of Change
Results of re-evaluation showed that majority of the waiting time exceeded 30 minutes. In May 2009,
the waiting time of less than 30 minutes improved from 35.66% to 61.07%.
The Next Step
In conclusion, our main objective was not achieved but improvement was shown. Continuous
monitoring and fostering the spirit of teamwork are vital to improve the quality of service.
chapter 8
By using a time motion survey and systematic random sampling method, pre-remedial data collection
was carried out in April 2008 for ten days. Two re-evaluation were conducted in July 2008 and May
2009. The total waiting time was further divided into time for the prescription waiting to be filled,
time spent for filling and the time the medication waiting to be dispensed.
166
OP/2007
Counseling and Home Medication Review: Do They Improve
Compliance among Patients Taking Oral Hypoglycaemic Agents?
Saidatulraihan I, Nuratikah V, Lee ML, Chan BL, Nurulazam H.
Pharmaceutical Services Division, Melaka Health Department.
The rate of microvascular and macrovsacular complications in diabetes mellitus (DM) patients can be
reduced by good blood glucose control with hypoglycemic agents. Thus, compliance to medications
to achieve treatment goals is vital. This study aimed to determine and improve the compliance rate
to oral hypoglycaemic agents (OHA) in type 2 DM (T2DM) patients.
To improve the current compliance rate to at least 75% and to identify the major predictors associated
with poor compliance to OHA regimen.
A descriptive, prospective cross sectional study was carried out on T2DM patients taking OHA for at
least 6 months in September 2006. Compliance was assessed using pill-counting and the adapted
Medication Adherence Scale during home medication review (HMR).
chapter 8
Statistical analysis was calculated using EPI INFO 2002. Preliminary findings showed that only
48.6% of T2DM patients complied to their OHA regimen. The compliance rate was unaffected by
sociodemographic factors such as age, sex, race, education and income. The three major predictors
of poor compliance (p value d” 0.05) identified were poor OHA identification, OHA overstocking and
absence of pharmacist counseling.
Strategy for Change
We improved the quality of pharmacist counseling and introduced new HMR services. We increased
the counseling frequency and expanded the counseling scope. We assessed patients’ complete
medication regimen at their home settings during HMR.
Effects of Change
The compliance rate had increased to 70.1%, overstocking reduced to 20.9% and patient’s
identification of OHA improved to 79.1%, 3 months after the interventions. We also discovered that
the total number of to come again (TCA) medications is inversely proportional to compliance rate and
patients who forgot to take their OHA are likely to be poor compliant.
Next Step
To ensure that our remedial actions are sustainable, we implemented and monitored the outcomes
in other health centers. We concluded that the quality improvement of pharmacist counseling and
HMR services have resulted in the increased compliance rates.
167
OP/2007
Expedite Dispensing of Returned Prescriptions from Medical
Specialist Clinic
Murni R, Seow MV, Tham VV, Aminah S, Siti Hajirah T, Mariama T,
Kamariah T.
Outpatient Pharmacy Unit, Pharmacy Department, Tawau Hospital, Sabah.
Outpatient Pharmacy Unit received approximately 1,000 prescriptions daily, of which approximately
25-30% of them are returned prescriptions that is prescriptions given back to patient to collect
subsequent medication supplies. Others are new prescriptions from all Specialist Clinics and
Outpatient Departments.
High frequency of unscheduled returned prescriptions has caused delay in prescription processing,
resulting in increased patients’ waiting time. This study was designed with the objectives to identify
factors contributing to the delay in returned prescription processing and to develop a strategy to
expedite the dispensing of returned prescriptions for Medical Specialist Clinic in the hospital.
The processing time for returned prescriptions was monitored. Reducing the processing time for
returned prescriptions is expected to reduce patients’ waiting time and complaints due to long
waiting time.
One in ten (9.6%) of the total prescriptions received at the Outpatient Pharmacy needed longer than
30 minutes to be dispensed. Out of this, 83.9% were prescriptions from the Medical Specialist Clinic.
The proportions of the Medical Specialist Clinic’s prescriptions being processed more than 30 minutes
were 37.8% for returned prescriptions and 15.6% for new prescriptions.
Strategy for Change
Modification was made to the process of care model for dispensing returned prescriptions.
Introduction of “Kad Pakar A” and modification of the process of care had reduced 83% of time
taken to process returned prescriptions. The attached tag for returned prescription was also modified
to a simpler format.
Effects of Change
The results of this study showed improvement in the processing time of prescriptions from the Medical
Specialist Clinic. The processing time exceeding 30 minutes had reduced from 37.8% to 2.7% for
returned prescriptions; and from 15.6% to 5.4% for new prescriptions. The percentage of Medical
Specialist’s prescriptions being processed exceeding 5 minutes also had reduced, from 63.9% to
2.7% for returned prescriptions and from 31.6% to 12.4% for new prescriptions.
“Kad Pakar A” was implemented in the processing of all returned prescriptions for Medical Specialist
Clinic.
chapter 8
This is a prospective study conducted for 10 days in September 2006. A total of 1,961 prescriptions
were collected using the patients’ waiting time form.
168
OP/2005
The Lumut Armed Forces Hospital Project on Enhancing the
Quality of Oral Form Drug Management in Wards
M. Adlan A, Razni Shauna, Nurul Aizam, M. Ashadi, Raja Khursiah,
Aini Mastura, Wahid T, Jasmi D, Ismail S, M. Razi H.
Lumut Armed Forces Hospital, Pangkalan TLDM, 32100 Lumut Perak.
Problem
Current management of the oral form of drugs in the wards does not ensure quality, safety and efficacy
of supplied drugs to the inpatients.
Aim
To ensure the quality, safety and efficacy of the treatment given by controlling drug wastage, avoiding
rapid deterioration of the drugs, reducing the risk of dispensing error and preserving the freshness of the
drugs kept in the wards.
Design
A multi-disciplinary team led by the Pharmacist was established within the practice for knowledge transfer
purpose and to tackle the problem comprehensively. The team used continuous quality improvement (CQI)
methodology including the Plan-Do-Check-Act cycle.
Reducing quantity and the cost of expired and spoiled drugs in the wards. Improving efficiency by reducing
the frequency of disposing expired and spoiled drugs by ward staffs. Increasing the satisfaction level
among ward staffs towards pharmacy services.
The team used Fish Bone Analysis to identify the root cause of the problem and all relevant data was
collected using questionnaires and surveillance method.
chapter 8
Strategy for Change
Using a Plan-Do-Check-Act cycle for quidance, the team decided to (a) replace the bottle; (b) standardize
the drug label; (c) enrich information on the label; (d) set standard drug list and its quantity; and (e) create
a refill procedure.
Effects of Change
These were good achievement, as never before had data and results of such a study been statistically and
scientifically quantified and presented to the hospital.
Parameters
Percentage of expired drugs
Percentage of spoiled drugs
Value of Expired drugs wastage
Value of Spoiled drugs wastage
Disposing expired drugs experienced by ward staffs
Disposing spoiled drugs experienced by ward staffs
Satisfaction level among ward staffs
Before Interventions
Before Interventions
21%
16.5%
RM 1,660.45/ month
RM 158.30/ month
90% respondents
90% respondents
3%
6.5%
RM 48.96/ month
RM 10.31/ month
53% respondents (p<0.05)
37% respondents (p<0.05)
70% admit overall pharmacy
services less efficient
0% admit overall pharmacy
services less efficient (p<0.05)
The Next Step
The implemented solutions will continue to be monitored to enhance improvements and be used to
control the wastage for the benefit of hospital administration in ensuring the quality, safety and efficacy of
drugs supplied to our patients. In fact, the principles can be applied immediately to all the warships which
have sick bay facilities.
169
OP/2003
Peningkatan Mutu Sistem Pembekalan Ubat ke Jabatan
Kecemasan
Rokiah I, Samidah R, Wong AK, Muhammad M, Balkis O, Shaarani MH.
Hospital Seri Manjung, Perak.
Permasalahan
Keperluan untuk meningkatkan mutu sistem pembekalan ubat ke Jabatan Kecemasan agar
pengawasan ke atas bekalan ubat lebih mudah dan pembaziran ubat di Jabatan Kecemasan dapat
dikurangkan.
Rekabentuk
Kumpulan Kualiti Jabatan Farmasi telah ditubuhkan untuk menangani masalah ini. Kumpulan telah
bermesyuarat beberapa kali mengenalpasti langkah-Iangkah untuk memperbaiki sistem sedia ada,
memantau tindakan penambahbaikan yang diambil dan membuat pengesyoran kepada pihak
pengurusan.
Langkah untuk Penambahbaikan
Kumpulan bersetuju tindakan perubahan yang diambil pada sistem pembekalan ubat ke Jabatan
Kecemasan perlulah menjuruskan kepada satu sistem yang sistematik dan berkesan di mana
pengawalan ke atas pembekalan ubat menjadi lebih mudah, mengurangkan berlaku pesanan
berulang, mengurangkan bilangan ubat lupus atau rosak dan menjimatkan masa, kos dan guna
tenaga.
Strategi perubahan
Kumpulan telah mencadangkan langkah-Iangkah penambahbaikan kepada pihak pengurusan hospital
dan persetujuan telah diperolehi untuk menukarkan sistem pembekalan ubat dari menggunakan
borang format tradisional kepada borang format stok imprest, mengurangkan kekerapan pesanan
dari setiap hari ke 2 kali seminggu dan mengubah tempat letak ubat ke tempat simpanan yang lebih
selamat.
Kesan perubahan
Perubahan yang dilaksanakan telah mengurangkan pesanan berulang, menjimatkan masa memproses
pesanan sebanyak 8 jam sebulan, mengurangkan pembaziran ubat, menjimatkan kos ubat yang
luput atau rosak sehingga 95% dan menjimatkan kos kertas sebanyak 31%.
Pengajaran
Hasil dari projek ini, kumpulan dapati kerja berpasukan adalah kunci utama kejayaan sesebuah
kumpulan untuk menyelesaikan rnasalah. Sementara kreativiti dalam penentuan kaedah
pengumpulan data dan tindakan pembetulan merupakan faktor utama untuk pembaikan sesuatu
sistem kerja. Sokongan dari pihak pengurusan juga penting bagi memastikan pelaksanaan langkahIangkah penambahbaikan.
chapter 8
Latarbelakang
Aduan telah diterima dari anggota Farmasi bahawa berlaku peningkatan bekalan ubat, berlaku
pesanan berulang dan pembaziran ubat di Jabatan Kecemasan. Aduan juga diterima dari Pegawai
Perubatan Y/M Jabatan Kecemasan bahawa terdapat ubat berlebihan dan berlaku kehilangan ubat
di Jabatan kecernasan.
170
OP/2003
Long Waiting Time at the Specialist Clinic Pharmacy of Hospital
Kangar
Atia H, Paezaiton A, Zainab MY, et al.
Kangar Hospital, Perlis.
Outline of Problem
As the last point of stop for most patients after waiting at the Specialist Clinics, the waiting at the Pharmacy
makes it intolerable. An earlier study done at the Pharmacy in April-May 2002 had shown that the average
waiting time was 45 minutes; then, a consensus was made that 75% of prescriptions handled should be
processed within 45 minutes. The standards have to be evaluated and tested; hence a systematic step has
to be adopted to address the issue of long waiting time.
Key Measures For Improvement
Improvement to the long waiting time can be made by addressing issues such as congestion of prescriptions
to be processed at certain point of processing, prompt preparation of extemporaneous syrups, wasted
time reaching for stocks and etc.
A prospective study starting January 2003 was conducted on the waiting time at the Specialist Clinic
Pharmacy. The pharmacy counters were grouped into Group A and B Counters, according to their services.
Data generated by the QMS (Queue Management System) were analysed monthly; specifically the number
of prescriptions processed within various time frames i.e. within 45 minutes, more than 45 minutes, more
than 1 hour 30 minutes and more than 1 hour 39 minutes. The numbers of prescriptions were expressed
as percentage. Three months (January-March 2003) data were appraised.
chapter 8
For the Group A Counters; the average percentages of prescriptions processed within 45 minutes was 74.1
%, more than 45 minutes was 25.9%, more than 1 hour 30 minutes was 10.8% and more than 1 hour 39
minutes was 9.4%. For the Group B Counter; the average percentages of prescriptions processed within
45 minutes was 89.3%, more than 45 minutes was 10.7%, more than 1 hour 30 minutes was 3.6% and
more than 1 hour 39 minute was 3.5%.
Stage for Change
In April 2003 a change of work flow and reorganisation of the pharmacy counters were done. The
same data were analysed for the following three months (May-July 2003); and a comparison was made
to see the impact of the changes done.
Effects of Change
After the change, for the Group A Counters; the average percentages of prescriptions processed within 45
minute was 95.1 % (21 % improvement vs. before change); more than 45 minutes was 4.9% (21%
improvement vs. before change); more than 1 hour 30 minutes was 2.28% (8.52% improvement vs.
before change); and more than 1 hour 30 minutes 1.6 % (7.8% improvement vs. before change). For
the Group B Counters; the average percentages of prescriptions processed within 45 minute was 91.9%
(2.6% improvement vs. before change); more than 45 minute was 8.1% (2.6% improvement vs.
before change); more than 1 hour 30 minutes was 4.3% (0.7% reduction vs. before change); more
than 1 hour 30 minutes was 4.1% (0.6% reduction vs. before change).
The Next Step
Change work flow and reorganisation of the pharmacy counters had improved the waiting time. Other
factors that contribute to the waiting time have to be further addressed. Other studies that can look into
possibility of reducing the average waiting time less than 45 minutes will be planned; so as continuous
improvement can be taken.
171
PP/2003
Reducing Waiting Time in an Outpatient Pharmacy
Melinda P, Chen CU, Ronald L, Paula S, Andy T, Lee CP, Jacqueline L, Linda Y.
Penang Adventist Hospital, Pulau Pinang, Malaysia.
Outline of the Problem
The Outpatient Pharmacy Service is responsible for filling outpatient prescriptions for medication
and disposable medical supplies to outpatients as well as in-patients who are being discharged from
the hospital. The average waiting time for the filling out of prescriptions was often prolonged and
resulted in numerous complaints.
The key performance measure was the waiting time at the Outpatient Pharmacy Service, which was
targeted to below 15 minutes.
Waiting times were measured using the time recorded on the queue tickets and recording the time
when patients were called to collect their medications.
Strategy for Change
To improve the workflow, each person in the process was given a specific function, which he or she
was required to perform exclusively. Staffing issues were addressed. Peak periods were identified,
during which personnel from the Front Reception were deployed to assist in the normal operations
of the Outpatient Pharmacy Service.
Effects of Change
The Outpatient Pharmacy Service has cut the typical waiting time to 9 minutes. This reduction in
average waiting time has been accompanied by a significant improvement in customer satisfaction.
The Next Step
Continuous monitoring of the waiting time at the Outpatient Pharmacy will contribute to sustained
results.
chapter 8
Waiting times before and after intervention were analysed. The average waiting time for the filling
out of prescriptions was 35 minutes per patient. Root cause analysis identified several inefficiencies
in the workflow as well as staffing issues, particularly during peak times.
chapter 8
Chapter 9
Public Health Related Projects
174
OP/2011
Menurunkan Kejadian Anemia di kalangan Ibu Hamil pada Usia
Kandungan 36 Minggu
Norasikin M, Zaitun I, Roslenda M, Mazliza M, Rubiah L, Masriah M.
Pejabat Kesihatan Pontian, Johor.
Anemia semasa hamil boleh menyebabkan morbiditi dan mortaliti kepada ibu hamil dan anak yang
dikandung. Prevalens anemia di kalangan ibu hamil Daerah Pontian masih tinggi iaitu di antara 25%
hingga 33% dari tahun 2001 hingga tahun 2003.
Menurunkan prevalens anemia di kalangan ibu hamil pada usia kandungan 36 minggu. Standard yang
ditetapkan adalah kurang dari 10%.
Kajian irisan lintang telah dijalankan pada bulan Januari hingga Disember 2004. Seramai 671 ibu hamil
telah dipilih secara rawak di kalangan yang bersalin pada tahun 2003. Borang soal selidik dan kad ibu
hamil digunakan untuk mengetahui faktor yang mempengaruhi anemia di kalangan ibu hamil.
Hasil kajian menunjukkan daripada 671 responden, seramai 224 (33.4%) mengalami anemia bagi tempoh
satu tahun. Hanya faktor klinik kesihatan, status pekerjaan, cara kelahiran dan cara pengambilan bersama
hematinik mempengaruhi status anemia di kalangan ibu hamil (p<0.05).
chapter 9
Penambahbaikan dibuat bermula tahun 2005. Hasil kajian kad menunjukkan faktor suri rumahtangga
sepenuh masa dan kelahiran forsep mempengaruhi anemia. Oleh itu, ibu hamil yang ada faktor tersebut
ditanda biru supaya lebih diberi perhatian. Mereka diberi keutamaan dari segi pendidikan kesihatan
berkaitan pengambilan hematinik dan sentiasa dibuat pemantauan status Hemoglobin secara berkala.
Penekanan dari segi kaedah pengambilan hematinik diberi kepada ibu hamil. Risalah dan poster anemia
disediakan dan diedarkan ke semua 8 buah klinik kesihatan dan 33 buah klinik desa. Sesi pendidikan
kesihatan diberikan kepada anggota kejururawatan. Inovasi cakera anemia telah dihasilkan bagi
memudahkan anggota kesihatan terutama anggota baru mengendalikankes anemia supaya kes tersebut
dapat dipulihkan. Cakera anemia adalah cakera kertas mengandungi panduan pengurusan anemia ibu
hamil.
Kesan perubahan dinilai melalui laporan HMIS tahun 2007 bagi Daerah Pontian. Didapati prevalens
anemia hanya dapat dikurangkan daripada 33.4% pada tahun 2004 kepada 15.5% pada tahun 2007.
Kitaran QA keduapada tahun 2008 mendapati anggota kejururawatan kerap berpindah keluar dan
kurang pendedahan mengenai pengurusan anemia berlaku di kalangan anggota kejururawatan. Strategi
penambahbaikan difokuskan kepada pendidikan kesihatan, penggunaan cakera anemia, audit dan
penyeliaan anggota secara berterusan serta pelan tindakan spesifik diwujudkan. Penilaian semula melalui
laporan HMIS pada tahun 2010,mendapati prevalens anemia di kalangan ibu hamil pada usia kandungan
36 minggu menurun kepada 7.8%. Kajian menunjukkan sebanyak 70.8% anggota kejururawatan
mempunyai pengetahuan sangat memuaskan dan 29.2% memuaskan. Langkah Seterusnya
Memperkenalkan cakera anemia kepada anggota kejururawatan di lain daerah dan mewujudkan kit
hematinik semasa kursus perkahwinan.
175
OP/2011
Improving the Percentage of Asthmatics Receiving Optimal
Assessment During Follow Up in Health Clinics
Nor Azila MI, Shuaita MN, Uthayalaxmi N, Ahmad Nazifi S, Toh LS, Mohd
Azrul Z, Nor Izzah AS.
Kuala Langat District Health Office, Selangor.
The management of asthma in health clinics under Kuala Langat District Health Office was found to
be inadequate based on the findings from the National Indicator Approach (Appropriate Management
of Bronchial Asthma). Further evaluations disclosed that the assessment of patients during follow up
was suboptimal. This project aimed to focus and improve the assessment of asthmatics in Kuala
Langat health clinics.
Assessment of patients during follow up, adequacy of assessment tools in the clinic and sufficient
knowledge amongst the health care providers were the key measures for improvement in this QA
study. The target for the DSA QA indicator is more than 80% of patients should be optimally assessed
during follow up.
The study was conducted from September 2009 to May 2011 comprising pre-intervention period and
four cycles post-intervention. The records of all asthmatics attending clinic during the identified study
periods were selected. Audit was done using a special checklist to check availability of assessment
tools in the clinics and clinical assessment of asthmatics. A self-administered questionnaire was used
to evaluate the knowledge of all healthcare providers in the clinics.
Strategy for Change
The establishment of Asthma Record Book, local implementation protocol, the innovation of
the “ASTHMA KIT”, the provision of asthma diary to all asthmatic patients and workshops on
“Assessment & Management of Asthmatic Patients” for all health care providers had been identified
as the remedial measures. Following each cycle, reinforcements were done in the form of individual
coaching or group discussion.
Effect of Change
Post-intervention study revealed noticeable improvement of the DSA indicator from 2% to 49% in
the 1st Cycle, 68% in 2nd Cycle, 69% in the 3rd Cycle and went up to 79% in the 4th Cycle.
The Next Step
Regular audits are vital to sustain the results obtained. Further interventions in other components of
asthma management need to be implemented with the ultimate goal of improving patients’ asthma
control.
chapter 9
Initial evaluation showed only 2% of patients was optimally assessed during follow up in the health
clinics.
176
OP/2011
Meningkatkan Pengurusan yang Efektif bagi Ibu Hamil dengan
Anemia di Klinik Kesihatan
Suzaini MD, Junaidah I, Norhayati S, Nur Hazwani R, Rosnani R.
PKD Kangar, Perlis.
Di Perlis, peratus ibu hamil dengan anemia pada 36 minggu melebihi standard Kementerian Kesihatan
Malaysia. Pengurusan kes yang kurang sistematik dan tidak mengikut Clinical Pactice Guideline dikenalpasti
sebagai penyumbang kepada masalah.
Meningkatkan pengurusan yang efektif (mengikuti kesemua 4 elemen dalam strategi penambahbaikan)
dan mengurangkan peratus ibu hamil dengan anemia pada 36 minggu kepada kurang dari 26%
(mengikut KPI Kesihatan Keluarga).
Tiga kajian verifikasi dijalankan pada 2009 menggunakan kad KIK/1(B)/96 melibatkan 151 ibu hamil.
Hasil kajian mendapati pengurusan yang efektif hanya kepada 51 (33.8%) kes. Pemberian zat besi (iron)
profilaksis secara oral adalah 9.4% dan terapeutik 24.4% sahaja. Penyiasatan Iron Deficiency Anaemia
(IDA) dilakukan untuk 47 (31%) kes. Hanya 11 (7.3%) ibu menerima rawatan parenteral. Kajian KAP
mendapati 60% anggota kejururawatan kurang arif mengenai pengurusan kes anemia.
Empat penambahbaikan dilaksanakan bermula April 2010: (i) Mewajibkan pengesahan IDA atas kes
anemia (ii) Pemberian profilaksis zat besi secara oral (Ferrous Fumarate 200 mg b.d) kepada ibu dengan
Hb normal semasa ‘booking’. (iii) Memulakan rawatan terapeutik (Ferrous Fumarate 400 mg b.d) sertamerta apabila Hb<11 gm/dL.(iv) Rawatan zat besi secara parenteral iaitu Intravenous Drip Infusion (IDI)
untuk semua kes yang gagal rawatan oral selepas 2-4 minggu, sah kes IDA dan tiada kontraindikasi.
chapter 9
Kajian semula ke atas 320 ibu hamil pada 36 minggu dilakukan selepas 6 bulan strategi penambahbaikan
di implementasikan. Didapati, pengesanan kes anemia meningkat 17.1% di trimester ke-2 dan menurun
14.6% di trimester ke-3.Ujian pengesahan IDA mencapai 76%. Semua ibu hamil menerima zat besi secara
oral dengan 210 (65%) kes pada dos profilaksis dan selebihnya dimulakan dos terapeutik. Sebanyak
103(32.2%) gagal rawatan oral dan menerima parenteral iron. Hanya 82 kes penerima rawatan parenteral
boleh dianalisis disebabkan kekurangan data. Didapati 72(87.8%) kes menunjukkan peningkatan
Haemoglobin (Hb) selepas 1-2 minggu infusi iron. Kajian menunjukkan penurunan 9.0% kes anemia dan
peningkatan 8.8% kes tanpa anemia berbanding sebelumnya.
Pengurusan anemia yang efektif meningkat sebanyak 66% untuk strategi (i) dan (ii). Ujian pengesahan IDA
meningkat 45%. Peratus ibu hamil anemia tahun 2010 menurun dan mencapai standard yang ditetapkan
iaitu 26% dan ini merupakan penurunan ABNA sebanyak 4.0%.
Langkah Seterusnya
Meneruskan kesemua strategi penambahbaikan dengan penekanan kepada rawatan parenteral secara IDI
untuk kes yang layak.
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OP/2011
Meningkatkan Peratus Asma Bronkial Terkawal
Jayashree M, Shahrul Bariyah A, Norsiah MN, Ruzita S.
Klinik Kesihatan Pendang, Kedah.
Asma bronkial ialah masalah kronik melibatkan 4% penduduk Malaysia dan hanya 5% daripadanya
terkawal. Faktor penyumbang utama ialah pengendalian, pemantauan dan teknik metered-dose inhaler
(MDI) yang lemah. Dari tahun 2007 - 2009, peratus asma bronkial terkawal di Daerah Pendang merosot
daripada 49% kepada 39%. Penyumbang kepada fenomena ini ialah garispanduan sedia ada dari
kementerian yang agak lama dan mengelirukan.
Meningkatkan peratus asma bronkial terkawal di daerah Pendang. Piawaian yang ditetapkan ialah 80%.
Kajian verifikasi dibuat ke atas 57 pesakit pada Mac 2009 melalui audit kad pesakit luar, soal-selidik serta
temubual pesakit. Kajian tahap pengetahuan dilakukan ke atas anggota kesihatan yang mengendalikan
kes asma bronkial melalui borang soalselidik. Kajian penambahbaikan pula dilakukan ke atas 62 pesakit
pada Mac 2010 dan 42 anggota kesihatan yang terlibat.
Analisa sebelum penambahbaikan menunjukkan hanya 48% pesakit asma bronkial mempunyai bacaan
peak expiratory flow rate (PEFR). 82% pesakit menggunakan MDI dan hanya 41% boleh menunjukkan
teknik MDI yang betul. Hanya 31% anggota kesihatan mempunyai pengetahuan yang mencukupi.
Kesemua faktor ini menyumbang kepada pengawalan yang rendah iaitu 39% pada 2009.
Kesan penambahbaikan
Jumlah pesakit mempunyai bacaan PEFR meningkat ke 87% dan 71% pesakit boleh menunjukkan
teknik MDI yang betul. Pengetahuan anggota kesihatan meningkat kepada 86%. Kesemua faktor ini
meningkatan tahap pengawalan asma bronkial kepada 61% pada 2010.
Langkah Seterusnya
Kajian perlu diperluaskan kepada golongan kanak-kanak serta kesinambungan pengendalian berasaskan
Global Initiative For Asthma (GINA) diperkenalkan di KK Pendang. Projek ini telah mengorak langkah bagi
Daerah Pendang menuju ke arah pengawalan asma bronkial yang optima.
chapter 9
Strategi penambahbaikan
i) Buku pengurusan asma bronkial diwujudkan sebagai pendekatan sistematik.
ii) Penglibatan Pegawai/Pembantu Perubatan, Pegawai Farmasi dan Asthma Educator.
iii) Sesi pendidikan berterusan bagi anggota kesihatan.
iv) Pendidikan pesakit.
178
OP/2011
Reducing Incidence of Severe Neonatal Jaundice
Gadung A, Christina BL, Adeline WSF, Juliana H, Hilda B, Iya R.
Kuching Divisional Health Office, Sarawak.
The incidence of Severe Neonatal Jaundice (SNNJ) in Kuching District increased from 119.3 per
10,000 live births in 2005 to 123.3 per 10,000 live births in 2008, which was above the standard of
the National QAP Indicator of 100 per 10,000 live births.
The objective of this study was to reduce the incidence of SNNJ in Kuching District from 121.34/10,000
Expected Live Birth (ELB) to below 100/10,000 Expected Live Birth (ELB).
This study used a cross sectional design covering a period of six months. The sample comprised
113 nurses of all categories working in urban and rural maternal and child health clinics in Kuching
District. Tools used in the study were self-administered questionnaires in English and Bahasa Malaysia.
The pre-intervention survey on nurses showed that only 56.6% were able to identify the risk factors
for jaundice; 94.6% were able to define jaundice; 41.5% were able to detect jaundice while 70.8%
knew sign of kernicterus. As for normal post natal nursing schedule (Day 1, 2,3,4,6,8,10 and day
20 post natal), only 40.7% were able to practice the schedule while only 69.0% were able to give
advice on management of jaundice.
chapter 9
Strategy for Change
The interventions were Continuing Nursing Education sessions which included new nursing formats
and new reporting procedures. Vehicles were also provided for home nursing.
Effects of Change
Post intervention; 63.2% of nurses were able to identify the risk factors causing jaundice; 97.2%
were able to define jaundice while 97.2% were able to detect jaundice and 88.6% know sign of
kernicterus. In term of practising recommended post natal nursing schedule, it had increased to
49.9 % while 92.0% were able to give advice to mother on management of jaundice. Second day
postnatal nursing increased from 16.7% to 65%. The incidence of SNNJ dropped to 78 per 10,000
live births in 2010.
The Next Step
The interventions helped to improve the knowledge and practice of recommended measures to detect
neonatal jaundice early. Stronger emphasis will be placed on using the new reporting procedures and
new nursing sheets. Continuous monitoring through regular nursing audits is also essential to reduce
the incidence of SNNJ. Provision of vehicles for all busy maternal and child health clinics for home
nursing care is to be continued.
The interventions undertaken is effective and to be included for National Indicator Approach (NIA).
179
PP/2011
Improving Proper Usage of Fetal Movement Chart among
Pregnant Women
M. Nazari J, Maskinah A, Haizuna MY, Saruah B, Aishah B, Ismail A,
Adinegara.
Jasin District Health Office, Malacca State Health Department, Malacca Manipal Medical College,
Melaka.
Proper usage of Fetal Movement Chart (FMC) among pregnant women above 28 weeks of gestation
is important to monitor fetal well-being. The District Perinatal Mortality Review had notified that
improper usage of FMC had contributed to high stillbirth rate. The main objectives of the study were
to measure the magnitude of proper usage of FMC, identify the contributing factors, implement the
remedial measures and evaluate the effectiveness of remedial measures.
The indicator of the study was percentage of proper usage of FMC and the standard set was 90%.
A cross sectional study was conducted on both pregnant women and healthcare staff. Data were
collected using interview questionnaire and observational method.
A total of 120 pregnant women and 29 healthcare staffs were randomly selected. Only 74% of
pregnant women had properly used the FMC. The contributing factors were FMC not being reviewed
by healthcare staffs (p=0.02), unclear explanation (p=0.03), unsatisfactory and inappropriate examples
(p=0.01) as well as no reassessment of respondents’ understanding (p=0.01). Other factors noted
were FMC not being self-explanatory (p=0.03) and 7 out of the 29 healthcare staffs were unaware
of the existence of the FMC checklist.
Effect of Change
After three months increased of remedial actions, the proper usage of FMC increased to 98.3%, the
percentage of FMC reviewed by staff to 95.0%, explanation understood to 95.0 % and appropriate
example given to 93.3%. Reassessment of pregnant women’s understanding of FMC increased to
89.2%.
The Next Step
Continual staff re-training on how to explain and review the FMC by pregnant women at every visit
are important to ensure the proper usage of FMC.
chapter 9
Strategy for Change
Staff were re-trained on how to advise mothers on proper use of FMC. The FMC check-list was remodified. A “Must-see Sticker” was introduced to ensure that staff review the FMC at every visit.
180
PP/2011
Increasing the Success Rate of Quit Smoking Clinic among
Adolescents
Arbaiah O, Marina MS, Zaleha J, Zainal AR, Hariyaton R.
Batu Pahat Health Clinic, Johor.
Adolescents, target of tobacco industries, had smoking prevalence of 14.7%. Young smokers are
future statistics of strokes, heart diseases and cancers. Factors contributing to the poor performance
of Quit Smoking Clinic (QSC) among adolescents need to be identified.
To increase percentage of quit smoking among adolescents attending QSC in Batu Pahat to 80%.
Four cross-sectional studies were done between January and March 2009. Secondary data of clinicbased QSC performance were collected and followed by interviews of adolescents identified as
failed to quit for year 2008. Providers’ factors contributing to the quitting were obtained through
self administered questionnaires on 26 Medical Assistants (MA) who run the clinic- based QSC.
Adolescents from nine selected schools answered the questionnaires distributed.
chapter 9
Data from 2008 showed that only 2(16.7%) of 12 adolescents quit smoking. Of 10 adolescents
who failed to quit, 7(70%) had high Fagerstrom score, 9(90%) did not have time and transport
convenience to attend clinic-based QSC and 7(70%) revealed no intention of quitting. 61.5%
of MAs responded that heavy outpatient workload, uninterested clients (65.4%) and insufficient
training in running QSC (53.8%) were factors contributing to low performance of QSC. There were
204(16.5%) smokers from a total of 1231 students who answered the questionnaire. Transport and
time inconvenience of the adolescents combined with high workload of MAs prompted the team to
look for alternatives for QSC.
Strategy for Change
Smokers enrolled were introduced to the newly developed school-based module, conducted by
trained teachers and monitored by trained staff nurses. It was a 1-2 hour session per week for 8
consecutive weeks within the school hours. Factors contributing to smoking and quitting were
compared pre and post intervention.
Effects of Change
125(61.3%) of 204 students successfully quit smoking compared to 16.7% quit rate in 2008. Quit
smoking activities within school compound and hours resulted in higher success rate.
The Next Step
School-based quit smoking clinics were extended to 21 schools. Continuous improvement of the
module and approach is planned with the education department.
181
PP/2011
Meningkatkan Pengesanan Komplikasi Pesakit Diabetes yang
Lengkap di Klinik Kesihatan
Norhana Y, Fatimah M, Mazlinah M, Kamilah M, Che Azizah A.
Klinik Kesihatan Negeri Terengganu.
Pemilihan Peluang untuk Penambaikan
Pengesanan komplikasi Diabetes Mellitus (DM) yang lengkap di klinik kesihatan perlu dilakukan di peringkat
awal bagi mengurangkan kadar morbiditi dan mortaliti. Hasil kajian verifikasi menunjukkan pengesanan
komplikasi diabetes yang lengkap sangat rendah iaitu 2.8%.
Unit Kawalan Penyakit Tidak Berjangkit Jabatan Kesihatan Negeri Terengganu telah menjalankan kajian
dengan objektif untuk meningkatkan peratus pengesanan komplikasi diabetes yang lengkap dimana
indikator adalah peratus kes menjalani pengesanan komplikasi Diabetes yang lengkap dan standard yang
ditetapkan adalah 60%. Pemeriksaan Lengkap bermaksud setiap pesakit menjalani kesemua pemeriksaan
seperti kaki, neurologi, sistem vaskular periferi, pemeriksaan mata termasuk fundus serta electrocardiogram
dan ujian makmal seperti urine microalbumin/albumin, blood urea serum electrolyte dan creatinine.
Kajian telah dijalankan di dua buah klinik yang terpilih di setiap daerah Negeri Terengganu untuk
mengenalpasti faktor penyumbang kepada masalah tersebut. Kajian pengetahuan pengesanan komplikasi
diabetes telah dijalankan pada 4 hingga 28 Februari 2007. Borang soalselidik telah digunakan dan
melibatkan pesakit dan anggota yang terpilih. Selain dari itu audit peralatan dibuat untuk memastikan
peralatan mencukupi. Audit sistem penyeliaan dilakukan untuk memastikan adanya sistem yang teratur
dalam pengesanan komplikasi diabetes. Kajian semula setelah intervensi dilakukan pada 15 hingga 25
Februari 2009 dan 12 hingga 22 Disember 2010 menggunakan format yang sama.
Peratus pengetahuan baik bagi pesakit adalah sebanyak 15% manakala bagi anggota adalah 7%. Audit
teknikal peralatan menunjukkkan 78.6% peralatan mencukupi. Pengesanan komplikasi diabetes yang
lengkap ialah 2.8%.
Kursus pengendalian Klinik Diabetes peringkat negeri termasuk demonstrasi pemeriksaan kaki, Kursus
Fundus Photo Grading untuk pegawai perubatan dan paramedik telah diadakan. Audit klinikal dan teknikal
berkala dilaksanakan untuk memastikan pengesanan komplikasi dibuat secara lengkap dan penyeliaan
dilakukan secara berkala.
Kajian semula menunjukkan pengetahuan yang baik bagi pesakit meningkat ke 25.9% manakala bagi
anggota meningkat ke 22.6%. Audit teknikal peralatan menunjukkkan 92.9% peralatan mencukupi.
Sistem penyeliaan pengurusan diabetes telah diwujudkan. Pengesanan komplikasi diabetes yang lengkap
telah meningkat dari 2.8% ke 22.9% pada Februari 2009 dan 27.8% pada Disember 2010.
Langkah Seterusnya
Memantapkan sistem penyeliaan dan memberi latihan dan kesedaran secara berterusan kepada anggota
kesihatan.
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182
PP/2011
Mengurangkan Peratus Anemia Sederhana di kalangan Ibu
Hamil pada Minggu 36
Norazlina MN, Aida Rahayu AG, Shaebah MJ, Noor Azhan, Asma I,
Nor Azhan A.
Pejabat Kesihatan Daerah Kubang Pasu, Kedah.
Anemia di kalangan ibu hamil boleh membawa kepada kejadian post-partum hemorrhage,
intrauterine death, dan small gestational age. Walau bagaimanapun, kejadian anemia sederhana
didapati semakin meningkat di Daerah Kubang Pasu pada tahun 2008. Kajian ini bertujuan untuk
mengurangkan peratus anemia sederhana di kalangan ibu hamil pada usia kandungan 36/52 minggu.
Standard yang ditetapkan adalah 18%.
Kajian verifikasi dilakukan dari Februari hingga Mac 2009 melalui semakan kad antenatal, kajian
tahap pengetahuan dan sikap ibu hamil serta anggota kesihatan dilakukan dari April hingga Mei
2009 dengan menggunakan borang soal selidik. Begitu juga dengan semakan pengendalian kes
di klinik juga telah dilakukan melalui semakan kad antenatal dan audit data dari Clinical Practise
Guideline (CPG) dan borang semakan.
chapter 9
Analisis Dan Interpretasi
Kejadian anemia sederhana di kalangan ibu hamil pada 36/52 minggu pada tahun 2007 dan
2008 adalah 15% dan 23%. Tahap pengetahuan dan sikap ibu mengenai anemia adalah 56%,
manakala tahap pengetahuan anggota kesihatan adalah 76%. Kesemua anggota kesihatan tidak
pernah menghadiri sebarang CME atau kursus mengenai anemia. Semakan kad antenatal mendapati
pengendalian kes yang kurang berkesan di mana ibu hamil lewat diberi rawatan hematinik dan
ketiadaan defaulter tracing bagi kes yang tidak hadir ke klinik.
Tindakan penambahbaikan dijalankan dengan mengadakan kaunseling dan ceramah berkumpulan
kepada ibu hamil bagi meningkatkan tahap pengetahuan dan komplian terhadap rawatan. Anggota
kesihatan diberi latihan dan kursus bagi meningkatkan pengetahuan dan pengendalian kes anaemia.
Promosi kesihatan di komuniti diadakan bagi meningkatkan kesedaran umum berkaitan anemia
seperti ceramah pemakanan di sekolah menengah, serta ceramah ringkas semasa kursus praperkahwinan.
Berlaku penurunan peratus anemia sederhana di kalangan ibu hamil iaitu 15.6% untuk tahun 2009
dan 12.5% untuk tahun 2010.
Langkah Seterusnya
Pengetahuan ibu dan pengendalian kes yang berkesan di kalangan anggota kesihatan amat penting
untuk mengurangkan kejadian anemia di kalangan ibu hamil.
183
PP/2011
Increasing Percentage of Asthma Control Monitoring
at District Health Clinics
Mohd Fozi K, Junaidah I, Azirah Y, Nurul Azlyn MY, Mahani K, Ali O, Mardiana
A, Hamiza H.
Kangar Health District Office, Perlis.
Management of asthma must be based on level of control therefore monitoring of asthma control is
very important in ensuring optimum treatment. Audit on Appropriate Management of Asthma 2009
showed that only 22.1% of asthma patients in Kangar District were monitored for level of control. A
standard tool to assess level of control is using Global Iniatiative for Asthma (GINA) Guideline 2009.
Indicator used is percentage of asthma patients monitored for level of control using GINA Guideline
at health clinics in Kangar District. Our objective was to increase percentage of asthma patients
monitored for level of control using GINA Guideline at Health Clinics in Kangar District from 22.1%
to 50%.
Magnitude of poor monitoring of asthma control was measured by auditing 270 patients cards in
9 Health Clinics selected by systematic random sampling. Auditing of Asthma Clinic Management
System using Audit Checklist and evaluation of knowledge among patients and staffs using
questionnaire were done to identify the possible causes of problem.
Strategy for Change
New strategies instituted to improve patients monitoring system at clinics were introducing GINA
classification checklist, improvisation of patients’ cards and setting standard appointment system.
Regular health education to patients and staffs were organised to improve their knowledge.
Effects of Change
Percentage of asthma patients monitored for level of control using GINA Guideline at health clinics in
Kangar District had increased from 17% to 58.7%. Adherence to MOGC, level of staff and patients
knowledge had also increased.
The Next Step
To maintain and further improve the standards that had been established and achieved.
chapter 9
Only 17% of patients were monitored for level of control using GINA Guideline at health clinics in
Kangar District. Monitoring process for level of control did not follow standard in MOGC. 79.5%
of health clinics staff had unsatisfactory and poor knowledge on asthma. Only 50% of asthmatic
patients had good knowledge on asthma. Possible contributing factors to the problem are untrained
personnel, lack of health education to patients and poor monitoring system at health clinics.
184
PP/2011
Improving Detection Rate of Diabetic Foot Problems among
Patients with Diabetes
Samurah AR, Ganespathy P, Ibrahim AF, Molina J.
Kampung Pandan Health Clinic, Wilayah Persekutuan Kuala Lumpur.
Identifying patients with diabetic foot problems is important to ensure they are targeted for
appropriate management to prevent further foot complications. Detection of diabetic foot problems
at Wilayah Persekutuan Kuala Lumpur State Health Department (JKWPKL) had been poor whereby
the Audit Diabetic Control Management (ADCM ) 2009 revealed that the detection rate was 3%.
Detection rate at Kampung Pandan Health Centre was only 6.5%. Based on literature review the
pick-up rate should be 70-80%. This study aimed to increase detection rate of diabetic foot problems
among patients with diabetic at Kampung Pandan Health Clinic.
We set a standard of 40% detection rate of diabetic foot problems among patients with diabetes.
Patients with diabetes were given appointment dates for foot care assessments.15 patients per session
were allocated on Monday and Friday mornings. 15 staff were involved in the study including six staff
nurses and nine community nurses. Continuous Medical Education (CME) on foot assessment was
done for all the nurses prior to the study.
chapter 9
A total of 484 patients with diabetes were assessed from October 2010 until April 2011.Of these, the
detection of diabetic foot problems increased only to 24%. Each staff was re-assessed by a Family
Medicine Specialist. Staff knowledge was average and their examination skills were still poor. Only
half of the staff were able to make correct diagnosis. Each card was audited and the documentation
was also noted to be poor.
Strategy for Change
All the staff were retrained through dedicated personalised skill training by a Family Medicine
Specialist on proper examination techniques, on how to make correct diagnosis, on their knowledge
and proper documentation.
Effect of Change
Post remedial action revealed marked improvement on technique of examination, ability to make
correct diagnosis and staff knowledge. A different group of 261 patients assessed between 20 May
to 18 August 2011 revealed a marked increase in detection rate of diabetic foot problems to 72%.
The Next Step
The foot care assessment protocol had been implemented as a routine annual foot care assessment
at Kampung Pandan Health Clinic. The format of the clinical monitoring protocol can also be applied
to improve detection of other diabetic complications. These strategies will be shared with other
clinics in JKWPKL in order to improve the rate of detection of diabetic foot problems.
185
PP/2011
Menurunkan Kejadian Anemia Sederhana di kalangan Ibu Hamil
M. Adam MA, Nini Shuhaida MH, Rohanita N, Badariah S, Badariah M,
Wan Hafizah WM.
Pejabat Kesihatan Daerah Kuala Terengganu, Terengganu.
Anemia semasa hamil adalah masalah perubatan yang perlu dielakkan untuk mengurangkan risiko
morbiditi dan mortaliti kepada ibu dan bayi. Kejadian anemia sederhana di daerah Kuala Terengganu
didapati melebihi 20% setiap tahun. Kajian ini dilakukan untuk mengenalpasti punca masalah dan
cara mengatasinya untuk menurunkan kejadian anemia sederhana di kalangan ibu hamil.
Pejabat Kesihatan Daerah Kuala Terengganu telah menetapkan untuk mengurangkan kejadian
anemia sederhana ibu hamil pada 36 minggu kehamilan kepada kurang 20%.
Semakan reten KIB 210A dijalankan untuk verifikasi data. Audit kad antenatal secara retrospektif
dijalankan bagi mengenalpasti faktor risiko anemia. Kajian hirisan lintang mengenai pengetahuan
berkaitan anemia dibuat menggunakan borang soal selidik untuk ibu dan jururawat.
Pelaksanaan kursus dan taklimat penggunaan garis panduan dan protokol kepada anggota
kesihatan, audit kejururawatan, mewujudkan personalised care, menggunakan flip-chart untuk
pendidikan kesihatan, membuat demo masakan menu kaya zat besi, pemantauan pengambilan
hematinik secara berkala dan memperkasakan amalan perancang keluarga.
Kejadian anemia sederhana didapati menurun sehingga 16.4%. Intervensi yang dilakukan memberi
impak positif. Jururawat lebih mahir mengendalikan kes anemia dan kesedaran ibu tentang anemia
meningkat. Pengetahuan mengenai anemia dan disiplin untuk mematuhi garis panduan adalah
sangat penting untuk memastikan kejadian anemia tidak meningkat melebihi sasaran.
Langkah Seterusnya
Intervensi ini berkesan untuk menurunkan kejadian anemia sederhana dan perlu diteruskan dalam
amalan harian dengan penilaian berkala.
chapter 9
Kejadian anemia sederhana adalah sehingga 29.7%. Faktor risiko yang dikenalpasti ialah
grandmultipara (58.6%), jarak kelahiran kurang dua tahun (58.6%), lewat kesan anemia (64%), lewat booking (57.5%), rawatan tidak mengikut protokol (64.7%), kurang penyeliaan (55.6%) dan
tidak mengambil makanan kaya zat besi (71.6%). Ibu hamil didapati tidak faham tentang bahaya
anemia kepadanya dan bayi (35%), kepentingan pengambilan hematinik (27%) dan masa sesuai
mengambil hematinik (60%). Terdapat jururawat tidak tahu definisi (30%), klasifikasi (51%),
bagaimana anemia berlaku (45%) dan tanda-tanda anemia (29%).
186
PP/2011
Meningkatkan Peratus “Premis Bersih” Kantin Sekolah
Menengah
Norazema AA, Samsir Asuwat S, Mohd Zulfadhli MS, Mohd Zahari Y, Md
Kamal Ariffin AG, Zainal Abidin I, Azmi A, Jamaliah J.
Pejabat Kesihatan Daerah Sabak Bernam dan Pejabat Kesihatan Daerah Kuala Selangor, Selangor.
Semua kantin sekolah menengah di kedua-dua daerah dikehendaki menjalani pemeriksaan
kebersihan. Walaubagaimanapun peratus premis bersih kantin sekolah menengah yang mendapat
markah rating kurang dari 70% di kedua-dua daerah masih rendah dimana pada tahun 2006 jumlah
peratus premis bersih adalah 20% dan tahun 2007 14%. Markah rating merupakan jumlah demerit
yang ditolak dari jumlah keseluruhan 100% sekiranya adanya kesalahan dilakukan.
Pejabat Kesihatan Daerah Sabak Bernam dan Pejabat Kesihatan Daerah Kuala Selangor telah
menetapkan standad 100% premis kantin sekolah menengah bersih di daerah Kuala Selangor dan
Sabak Bernam.
Kajian verifikasi dijalankan dari Mei hingga Ogos 2008, Kajian Pertama Pre-Intervensi dijalankan
dari September hingga November 2008 dan Kajian Kedua Pos-Intervensi dijalankan dari Januari
hingga Oktober 2009. Data diperolehi melalui borang senarai semak, soal selidik isi sendiri, borang
pemeriksaan KMM 3P2 dan rekod pemeriksaan kantin sekolah menengah.
chapter 9
Data dibahagikan kepada 4 bahagian iaitu Perancangan Pemeriksaan Premis, Pemeriksaan Premis,
Pemeriksaan Kesihatan dan Penilaian Tahap Pengetahuan Pengendali Makanan. Kajian verifikasi
menunjukkan peratus Pemeriksaan Premis sebanyak 94.2%, pemeriksaan kesihatan sebanyak 48%
dan tahap pengetahuan pengendali makanan sebanyak 26%. Faktor utama premis bersih kantin
tidak dapat dicapai adalah pengendali makanan.
Penambahbaikan yang dilaksanakan ialah mewujudkan jadual pemeriksaan kantin sekolah
menengah, perbincangan bersama pengendali dan pengusaha makanan, mengadakan program
pendidikan kesihatan, mewujudkan notis amaran bertulis dan penguatkuasaan Prosedur Penutupan
Premis di bawah Akta Makanan 1983.
Kajian Pos Intervensi menunjukkan peningkatan sebanyak 100% untuk pemeriksaan premis, 86%
untuk pemeriksan kesihatan dan 83% untuk tahap pengetahuan pengendali makanan.
Langkah Seterusnya
Langkah penambahbaikan menunjukkan keberkesanan dan dipraktikkan bersama program yang
telah rancangkan.
187
PP/2011
Meningkatkan Aktiviti Fizikal melalui Kempen 10,000
Langkah di kalangan Masyarakat
Norasikin M, Rubiah L, Masriah M, Zaitun I, Masliza M, Roslenda M.
Pejabat Kesihatan Pontian, Johor.
Kajian WHO menunjukkan kehidupan yang tidak aktif secara fizikal menyumbang kepada 1.9 juta
kematian di seluruh dunia. National Health Morbidity Survey (2006) menunjukkan 43.7% penduduk
Malaysia tidak aktif secara fizikal dan bilangan penduduk di negeri Johor tidak aktif secara fizikal
berjumlah 46.0%. Kajian di kalangan kakitangan awam Daerah Pontian mendapati hanya 19.4%
bersenam setiap hari dan 18.4% bersenam 3 kali seminggu.
Meningkatkan peratus responden yang mengamalkan aktiviti fizikal. Standard yang ditetapkan
adalah melebihi 70 peratus (>70%).
Satu kajian irisan lintang telah dijalankan pada bulan Jun 2008 ke atas 151 orang penduduk Kampung
Permatang Duku, Benut, Pontian berumur 10 tahun ke atas. Kajian menggunakan borang soalselidik
serta pemeriksaan fizikal dan makmal.
Memperkenalkan “Kempen Berjalan 10,000 Langkah” setiap hari kepada masyarakat Daerah
Pontian. Promosi ”Kempen Berjalan 10,000 Langkah” dengan mempamerkan banting kempen
10,000 langkah dan edaran risalah di kesemua 8 klinik kesihatan, 33 klinik desa dan jabatan kerajaan.
Ceramah, promosi melalui radio dan lawatan ke mukim dijalankan di peringkat Daerah Pontian.
Penubuhan Ahli Jawatankuasa peringkat daerah dan dijalankan aktiviti berjalan 10,000 langkah
secara berterusan di semua peringkat Daerah Pontian juga dijalankan.
Penilaian semula pada bulan Disember 2008 ke atas responden yang sama mendapati 76.3% dari
151 responden mengamalkan aktiviti fizikal selepas kempen 10,000 langkah dijalankan. Aktiviti
fizikal telah dapat ditingkatkan dari 52.3% kepada 76.3%. Pengetahuan, sikap positif dan kepatuhan
terhadap senaman juga telah dapat dipertingkatkan (melebihi 70%).
Langkah Seterusnya
Langkah seterusnya adalah mempromosikan ”Kempen Berjalan 10,000 Langkah” di semua peringkat
umur dan tempat dalam Daerah Pontian dan dalam Negeri Johor.
chapter 9
Kajian menunjukkan hanya 52.30% daripada responden mengamalkan aktiviti fizikal. Hasil kajian
mendapati pengetahuan yang rendah, sikap negatif, amalan yang negatif dan tidak komplain
terhadap senaman menyumbang secara signifikan (p<0.05)
188
PP/2011
Mengurangkan Pencemaran Longkang dan Saliran Awam
oleh Sisa Minyak Terpakai
Azraei R, Ganggaraj A, Abdul Hamid MD.
Jabatan Kesihatan & Alam Sekitar, Dewan Bandaraya Kuala Lumpur, Wilayah Persekutuan Kuala
Lumpur.
Pemilihan Peluang Untuk Penambahbaikan
Tinjauan yang telah dijalankan mendapati kebanyakan pengusaha premis makanan di Wilayah Persekutuan
Kuala Lumpur telah membuang sisa minyak masak terpakai ke dalam longkang dan saliran awam. Senario
ini akan mengundang banyak implikasi negatif terhadap kesihatan persekitaran.
Objektif program adalah mengurangkan pencemaran sisa minyak masak dan lemak di dalam longkang
dan saliran awam serta membantu pengusaha restoran dan kedai makan melupuskan sisa minyak masak
terpakai dengan sempurna. Indikator yang dikenalpasti adalah tiada lagi aduan awam yang berkaitan
dengan pencemaran longkang atau saliran dan peningkatan isipadu kutipan sisa minyak masak oleh
pengusaha kedai makan. Piawaian yang dikenalpasti adalah berdasarkan pemerhatian fizikal iaitu
kehadiran lapisan filem minyak dan lemak atas permukaan air dan di tepi dinding longkang.
Kajian verifikasi data dibuat dari bulan Januari hingga Jun 2011. Lokaliti data merangkumi kawasan di
sekitar Jalan Bukit Bintang, Jalan Alor, Kepong, Jalan Kelang Lama, Mont Kiara, dan Bangsar. Pengumpulan
data adalah melalui rekod dan laporan kutipan sisa minyak masak terpakai dari premis makanan oleh
kakitangan Dewan Bandaraya Kaula Lumpur dan panel swasta yang dilantik.
chapter 9
Pada tahun 2010 (Januari hingga Jun) 19, 212kg sisa minyak telah dikutip. Manakala pada tahun 2011
(Januari hingga Jun) 27, 446kg sisa minyak telah dikutip. Kadar peningkatan peratusan jumlah kutipan
(kg) adalah sebanyak 42%. Peningkatan sebanyak 42% ini menunjukkan tahap keberkesanan program
telah diyakini sepenuhnya.
Suatu inovasi telah dikenalpasti bagi mengatasi masalah ini berserta peluang penambahbaikan yang
berterusan. Bagi memastikan keberkesanan usaha ini, Dewan Bandaraya Kuala Lumpur (agensi kerajaan)
akan menjalinkan usahasama secara 3 hala dengan kontraktor kutipan (agensi swasta) dan pengusaha
kedai makan (komuniti). Selain itu, khidmat nasihat juga diberikan dari semasa ke semasa kepada para
pengusaha kedai makan yang belum lagi mempraktikkan kaedah ini.
Impak positif program ini adalah tiada lagi pembuangan sisa minyak ke dalam longkang dan saliran awam
oleh pengusaha kedai makan. Walaubagaimanapun, apa yang paling penting ialah program ini mampu
membantu para pengusaha kedai makan/pusat penjaja untuk melupuskan sisa minyak masak dengan
sempurna dan terurus.
Langkah Seterusnya
Pencemaran longkang dan saliran awam dapat diatasi dengan lebih baik dan mampu menjanjikan pulangan
yang ‘bersih’ terhadap persekitaran alam semulajadi khususnya. Di samping itu, suatu keseimbangan
ekologi antara manusia dan alam sekitar juga mampu diperolehi kerana sisa minyak masak yang terpakai
boleh dikitar semula untuk penghasilan biodiesel yang berguna untuk keperluan manusia amnya.
189
OP/2009
Improvement of Blood Pressure Management in Diabetic
Nephropathy Patients at Health Clinics
Wong PF, Gan EM, Azah AS, Adnan MD, Kwa LC, Asonah D.
Pantai Health Clinic, Kuala Lumpur.
Diabetic nephropathy is the leading cause of end stage renal disease worldwide and is associated with
increased cardiovascular risk. The rate of progression to end-stage renal disease and cardiovascular
disease can be delayed by aggressive management of blood pressure, glucose and lipids. Thus, tight
blood pressure control offers cardioprotective benefits as well as prevents the deterioration of renal
function in this group of patients.
Improvement can be instituted by reinforcing the adherence to Clinical Practice Guidelines (CPG)
among health care professionals. Process of Gathering Information A prospective study was
conducted in Pantai Health Clinic over 3 months to evaluate the blood pressure control in diabetic
nephropathy patients.
Only 32% of diabetic nephropathy patients have optimum blood pressure control. One of the main
contributing factor was poor adherence to the CPG by healthcare professionals.
Strategy for Change
The aim is to optimize the management of blood pressure in this group of patients. Improvement
can be brought about by reinforcing the adherence to CPG among health care professionals and
providing them with copies of CPG, audit cards and flash cards.
The Next Step
The result of this study was encouraging and we can conclude that adherence to CPG does bring
about improvement to the management of diabetic nephropathy patients.
chapter 9
Effects of Change
Optimal blood pressure control increased from 32% to 45% after intervention. The percentage of
patients with blood pressure of >145/95mmHg was reduced from 39% to 18%. There was a reversal
of urine albumin concentration. 16% of these patients reverted back to normoalbuminuria of
< 20mg/L.
190
PP/2009
Improving Compliance of Diabetic Care Assessment by the
Healthcare Providers Based on Clinical Practice Guidelines
at Health Clinics
Bariyah K, Azah AS, Murniati H, Thang HT, Kaharnisah MN.
Tanglin Health Centre, Kuala Lumpur.
Patients with diabetes should be managed according to clinical practice guidelines to avoid late
detection of diabetic complications. Lack of knowledge and awareness may also be a contributory
factor to the poor management.
By improving the system using a checklist for diabetes assessment and emphasising on the importance
of following the protocol will improve the care given to patients with diabetes. The standard proposed
was set at 100%.
An audit of the diabetic record book was conducted at the health clinic over 9 months to evaluate the
number of patients with diabetes who had received complete annual assessments and the percentage
of healthcare providers who adhere to protocols after appropriate intervention was taken.
Pre-study showed only 10% of 607 diabetic record books received complete annual assessments. 18
healthcare providers consisting of 33.3% medical officers, 27.7%staff nurses and 38.8% community
nurses were involved in the Diabetic Care Management. It was found that 44% of the healthcare
providers lacked training on how to use the diabetic record book. All the paramedics involved were
trained and only 82% of the 18 healthcare providers in all categories scored more than 80% in
knowledge assessment. As a result only 82% of the healthcare providers were considered competent.
chapter 9
Strategy for Change
The strategy for change was divided into three components: improving the knowledge of the
healthcare providers, improving the system of work process for diabetic patients and provide
supervision with the checklist of diabetes assessments.
Effects of Change
After six months post intervention there was improvement in the adherence to protocol from 55% to
73%. Percentage of diabetic patients that received complet annual assessment improved from 10%
to 96%. The competency of the staff also improved from 82% to 91% which was measured using
the knowledge assessment score after the intervention.
The Next Step
To increase awareness among the healthcare providers on the importance of adhering to diabetic
protocol with regular supervision to enable appropriate diabetic care.
191
PP/2009
Meningkatkan Peratus Hadir Temujanji Pesakit Diabetes di
Klinik Kesihatan
Zil Falillah MS, Iza Noor Ruaida D, Azwan KM, Fuziah A, Nurfariza H,
Rohaya H.
Klinik Kesihatan Kijal, Kemaman, Terengganu.
Sejumlah 197 pesakit diabetes aktif telah dikenalpasti melalui audit kad pesakit dan buku temujanji.
Kajian verifikasi mendapati bilangan yang gagal temujanji di Klinik Kesihatan Kijal pada tahun 2006
adalah 31.6%. Ini menyebabkan pesakit datang dengan komplikasi seperti neuropathy 28.4%,
nephropathy 6.5%, amputasi kaki 0.5%, diabetic foot 5%, retinopathy 16.2%. Objektif kajian ini
adalah untuk meningkatkan peratus kehadiran temujanji pesakit diabetes.
Untuk mengurangkan peratus gagal temujanji kurang daripada 15%.
Kajian dijalankan melalui audit kad pesakit, pemerhatian berdasarkan senarai semak yang sedia ada
dan Knowledge Attitude Practice (KAP) pesakit dilaksanakan menggunakan borang kaji selidik.
Tahap pengetahuan pesakit meningkat dari 60% kepada 85%, sikap dari 50% kepada 71.5% dan
amalan dari 60% kepada 92.5%. Faktor KAP pesakit dan sistem pengurusan klinik diabetes yang
kurang berkesan terutamanya sistem temujanji merupakan penyumbang utama.
Jurang ABNA dikurang dari 36% kepada 13% selepas penambahbaikan. Terdapat penambahbaikan
yang ketara di dalam pencapaian markah domain pengetahuan, sikap dan amalan pesakit
diabetes. Sistem pengesanan pesakit diabetes telah diwujudkan dan dilaksanakan dengan jayanya.
Kemudahcapaian sistem temujanji juga telah tercapai.
Langkah Seterusnya
Kajian ini telah dapat mengenalpasti faktor yang dapat meningkatkan peratus kehadiran temujanji.
Strategi penambahbaikan yang dibuat menunjukkan pencapaian positif. Beberapa perancangan bagi
internalisation masa hadapan juga dikenalpasti.
chapter 9
Mewujudkan carta alir yang jelas bagi sistem temujanji bagi memperbaiki kemudahcapaian sistem
pengesanan dan tindakan bagi kes gagal temujanji, Model of Good Care (MOGC), dan senarai tugas
bagi pengganti tugas pasukan Non-Communicable Disease (NCD). Pendidikan kesihatan secara
individu yang berfokus kepada topik kepentingan hadir mengikut temujanji dilaksanakan.
192
PP/2009
Kewajaran Pengurusan Hypertensive Disorder in Pregnancy oleh
Anggota Kejururawatan
Muhd Khairi MT, Norlian I, Nurly Zahureen M, Norazman A, Anis S,
Chuang SM.
Pejabat Kesihatan Rompin, Pahang.
Kewajaran Pengurusan Hypertensive Disorder In Pregnancy (HDP) Oleh Anggota Kejururawatan Daerah
Rompin, Pahang adalah sangat penting kerana ketidakwajaran pengurusan akan mengakibatkan
komplikasi seperti eklampsia, Intra Uterine Growth Retardation dan lain-lain seterusnya meningkatkan
morbiditi dan mortaliti.
Kewajaran pengurusan HDP yang sempurna boleh dicapai melalui peningkatan pengetahuan,
pengesanan kes, pengurusan kes dan pendaftaran awal kehamilan kurang dari 12 minggu.
Sasaran pencapaian kewajaran pengurusan kes HDP ditetapkan melebihi 80% di kalangan anggota
kejururawatan.
Kajian pengumpulan maklumat dilaksanakan pada 16 April hingga 1 Mei 2007 dengan menggunakan
dua kaedah iaitu melalui audit semua kad postnatal HDP dan pengedaran borang soal selidik kepada
semua anggota kejururawatan.
chapter 9
Hasil pengauditan kad postnatal menunjukkan kewajaran pengurusan HDP adalah 37.04% dan
tahap pengetahuan anggota kejururawatan dari soal selidik adalah 25.5%. Faktor-faktor kelemahan
pengurusan adalah kurang pengetahuan definisi HDP 62%, tanda-tanda serta gejala 38%, checklist
dan kod tidak tepat 56%, lemah menentukan HDP 27%, tidak cekap bertindak semasa ketiadaan
strip ujian urin 62% dan pendaftaran lewat kurang dari 12 minggu 60.4%
Strategi penambahbaikan kewajaran pengurusan HDP adalah Continuous Medical Education (CME)
kepada semua anggota, mempamerkan/mengedarkan poster/Carta aliran pengurusan HDP kepada
semua Klinik Kesihatan dan Klinik Desa di Daerah Rompin, memberi ceramah kepada klien klinik
tentang kepentingan datang awal pemeriksaan antenatal sebelum 12 minggu kehamilan dan
memperkukuhkan sistem pengurusan HDP.
Hasil penambahbaikan telah meningkatkan pencapaian pengurusan HDP dari 37.04% kepada 62.5%
(penilaian melalui audit kad postnatal) dan peningkatan tahap pengetahuan anggota kejururawatan
dari 25.5% ke 54.5% (penilaian melalui edaran borang selidik kepada semua anggota kejururawatan).
Langkah Seterusnya
Projek ini telah dijadikan State Spesific Approach bagi Negeri Pahang yang telah bermula pada
November 2008 sebagai pilot study dan telah diteruskan sehingga kini di mana pengumpulan data
adalah setahun sekali pada bulan September.
193
OP/2009
Quality of Diabetes Care at Ministry of Health Healthcare
Facilities: Glycaemic Control
Zainal Ariffin O, Fatanah I, Feisul Idzwan M, Zanariah H, Nor Izzah AS,
Nik Jasmin NM, Rotina AB, Mastura I.
Public Health Division, Ministry of Health, Putrajaya.
This NIA looks at the proportion of diabetes patients who are on follow-up at MOH health clinics
achieving glycaemic target of <6.5%. The optimum achievable standard was set at ≥30% from the
total of patients sampled.
Data was collected from the ‘Green card’ (diabetes record held in the clinic) of patients with type 2
diabetes who were on ‘active followup’, using a pre-determined format.
Several major contributing factors were identified, and only a few were categorised as feasibly
modifiable at the district level.
Strategy for Change
The main remedial measure taken was to strengthen the knowledge and skills of the various health
care personnel involved in the care and management of diabetes patients at the primary care level.
While the newly introduced “Diabetes Clinical Audit” provides information on the current status of
care, this new NIA provides a formalised system for remedial measures. It provides a standardised
mechanism for continuous monitoring on the quality of care of diabetes patients at the MOH health
clinics, and aids in clinical supervision of health care personnel involved with diabetes care. The results
are also comparable between all districts in Malaysia.
The Next Step
Any improvement in the system of managing diabetes patients may take several years to manifest
itself. Therefore, the remedial measures need to be more comprehensive and efforts to improve the
system require persistence.
chapter 9
Effects of Change
Data for the pilot implementation in Negeri Sembilan was only available for 2007 and 2008. The
proportion of diabetes patients achieving glycaemic target of <6.5% decreased slightly from 11.5%
in 2007 to 11.1% in 2008.
194
OP/2009
Meningkatkan Pengambilan Sampel Darah Kedua untuk Ujian
IgM Denggi
Norafidah AR, Abd. Rahman Y, Azirudin I, Ahmad Tarmizi AR,
Ahmad Syaifuddin R, Mat Rani A, Zairudin J.
Pejabat Kesihatan Daerah Hulu Terengganu, Terengganu.
Semua kes demam denggi perlu diambil sampel darah pertama untuk ujian IgM denggi dan sekiranya
negatif, sampel darah kedua diperlukan untuk tujuan pengesahan diagnosis demam denggi. Walau
bagaimanapun di daerah Hulu Terengganu, pengambilan sampel darah kedua untuk ujian IgM
denggi adalah rendah.
Kajian ini bertujuan untuk meningkatkan kadar pengambilan sampel darah kedua untuk ujian IgM
denggi. Standard yang ditetapkan adalah 90%.
Proses Pengumpulan Data
Kajian verifikasi data dibuat melalui buku rekod pendaftaran kes denggi. Kajian tahap pengetahuan
dan kajian Continous Medical Education (CME) dilakukan pada anggota hospital dan kesihatan
pada bulan Mei 2007. Kajian audit sistem dilakukan dengan menggunakan kaedah senarai semak
sementara kajian pesakit tidak datang dijalankan dengan menggunakan kaedah borang soal selidik.
chapter 9
Pada tahun 2005 dan 2006, sampel darah kedua yang berjaya diambil hanyalah 29% dan 40%. Tahap
pengetahuan anggota yang berpengetahuan baik hanyalah 41.3% (hospital) dan 28.5% (kesihatan).
Semua anggota tidak pernah menghadiri sebarang CME dan kajian audit sistem mendapati tiada
sistem yang sempurna dalam pengurusan pengambilan sampel darah kedua. Hasil kajian pesakit
tidak datang pula mendapati tiada surat arahan diberikan untuk datang mengambil sampel darah
kedua.
Langkah-langkah penambahbaikan yang telah diambil termasuklah mengeluarkan Prosedur dan
Arahan Kerja, menampal pelekat peringatan pada rekod rawatan pesakit dan papan kenyataan,
menggunakan borang seragam di Klinik Kesihatan dan di rumah. Meningkatkan pengetahuan
anggota kesihatan dengan melaksanakan kursus dan tunjuk ajar serta menyelia penggunaan borang
(Vektor-P 01/07).
Peratus pengambilan sampel darah kedua untuk ujian IgM denggi telah berjaya ditingkatkan
sebanyak 92.9% dalam tahun 2008 dan sebanyak 100% dalam tahun 2009.
Langkah Seterusnya
Pengurusan sampel darah yang sistematik merupakan kunci utama dalam meningkatkan kadar
pengambilan sampel darah kedua untuk ujian IgM denggi.
195
PP/2009
Using Mosquito Larvae Trapping Device as an Additional Tool
for Dengue Fever Control in Kuala Lumpur
Zainol Ariffin P, Ahmad Zaidi ZA, Norhayati S, Umi A, Osman H,
Awaluddin MA, Abdul Halid H, Omar H, Mohd Haslan M.
Vector Borne Disease Control Division, Health Department City Hall Kuala Lumpur, Kuala Lumpur.
Dengue Fever is a public health problem in Kuala Lumpur. The number of dengue notifications to
Health Department ranges from 7000 (2007) to 5001 (2008). The City Hall of Kuala Lumpur spends
about RM 14 million per year to control the vector. This quality assurance project aimed to reduce
Aedes mosquito population in the environment especially in residential areas by using Mosquito
Larvae Trapping Device (MLTD). The device provides a low maintenance, surveillance and control tool.
It is a tool for dengue alert system with community participation.
The MLTD index obtained from the placement of devices will be used as an indicator for carrying out
preventive fogging and Ultra Light Vehicle (ULV).
Reading of MLTD index will be done every three months except in certain circumstances. Prophylactic
fogging and ULV will be done based on MLTD Index. Numbers of dengue notifications were also
recorded.
Number of dengue cases, outbreaks, houses inspected and houses allowed fogging were recorded
during pre and post MLTD placement. Numbers of MLTD vandalised were also recorded.
Effects of Change
An increased in the public awareness on usage of MLTD for Dengue Fever control was noted. Cases
of dengue fever reduced and no new cases reported by using this tangible device.
The Next Step
This QA project successfully increase the awareness and collaboration between the public and City Hall
Kuala Lumpur. MLTD usage can be extended to other premises. Training programmes will be planned
to companies and students to read a MLTD Index. Studies on public awareness and participations can
be focused in future.
chapter 9
Strategy for Change
MLTD were placed in persistently outbreak locality, controlled outbreak, new outbreak and new
positive cases. The community was given ownership and commitment to take care of the MLTD on
voluntary basis.
196
PP/2007
Improving the Management of Pregnancy - Induced Hypertension
in Hulu Langat District Health Clinics
Nor Izzah AS, Nik Mazlina M, Noor Laila S, Salmiah B, Mahawa AM,
Norkiah H, Noraini K, Jameah MS, Zaharah MY, Rahimah MA, Ruhaini I.
Health Clinics in Hulu Langat District.
Eclampsia is one of the main causes of maternal morbidity and mortality in this country. Inappropriate
management of pregnancy induced hypertension (PIH) and late detection of pre-eclampsia (PE) may
increase the incidence of eclampsia. There was a sudden increase in the occurrence of eclampsia for the
year 2005 in Hulu Langat. This caused a concern to the District Health Officers as eclampsia is a preventable
condition and is regarded as a reflection of overall quality of antenatal care provided to antenatal mothers.
The incidence of eclampsia in Hulu Langat District was monitored with the target to have less than 3 cases
per 10,000 live births.
A retrospective study was carried out in June 2006 to determine the weaknesses in the management
of PIH patients. All antenatal mothers diagnosed with PIH in the year 2005 were included. Appropriate
remedial measures were taken and another prospective study was carried out in 2007 to determine the
effect of remedial measures.
chapter 9
We found the following weaknesses. Low percentage of early antenatal booking (18.7%); poor monitoring
of weight and urine for albumin in mothers with PIH (21.9% and 36.6%, respectively), low percentage of
early examination of PIH mothers by Medical Officer (38.2%), unsatisfactory fetal kick chart distribution and
review of fetal surveillance (50.4%), few mothers had biochemical investigations done to monitor progress
of disease (2.4%), poor defaulter tracing (50%) and poor patient stabilisation for all pre-eclampsia and
symptomatic PIH patients prior to transportation to the hospital (57.8%). In assessing the knowledge of
health care providers, our analysis showed that 38% scored more than 80% of the total marks allocated,
54% scored between 60-80%, while 8% scored below 60%.
Strategy for Change
Among the strategies taken was to conduct training for the health care providers, auditing of antenatal
cards and designing a checklist to assist health staff in their management of mothers with PIH. Other
strategies included improving clinical documentation as well as strengthening the defaulter tracing system
and health education.
Effects of Change
There was improvement in the management of patients with PIH and level of knowledge of the health
care providers in this area. The incidence rate of eclampsia has reduced from 2 cases/10,000 deliveries in
2005, to 1 case/10,000 deliveries in 2006 and no case of eclampsia has been reported so far for year 2007.
All health care providers in Hulu Langat District should strive to maintain and sustain the remedial measures
to ensure continuity of quality care. Reevaluation must be carried out from time to time, including reviewing
the standards of care.
197
PP/2007
Improving Tracing of Serological Results for Dengue among
Clinically Diagnosed Dengue Fever Cases Notified
to the Health Department, City Hall Kuala Lumpur
Zainol Ariffin P, Norhayati S, Horng LY, Suraini B, Nor Azizah MY,
Abdul Halid H, Mohd Rahim CD.
Vector Borne Disease Control Division, Health Department, City Hall K.L
Dengue Fever is a public health problem in Kuala Lumpur. The number of cases of dengue fever notified to
the Health Department ranges between 5000 - 7000 cases a year from 2003 to 2005. The city authority
of Kuala Lumpur spends about RM 14 million per year to control the disease. Dengue needs to be notified
within 24 hours of diagnosis. Many of the dengue fever cases were never confirmed through serological
investigation, and no serological results were accompanied upon notification of cases. This quality
assurance project aimed to identify the contributing factors for the low yield of serological investigations
and to improve tracing of serological results for these dengue cases.
To improve tracing of serological results for clinically diagnosed dengue fever from 20% to 80%, in
accordance to target set at national level.
Process for Gathering Information
Retrospective analysis of data from 2003 - 2005 was carried out. The contributing factors for the low yield
of serological results of dengue were identified. A prospective intervention study from January 2006 to
August 2007 evaluated the effectiveness of the remedial measures.
The main contributing factors for the poor yield in tracing serological results were the poor practice of
investigation of cases of dengue fever; the difficulty in getting the case notes of patients from hospital
wards; the laboratories were not releasing the results directly to the health personnel. Some other minor
factors included lack of personnel for case investigation, and no subsequent notification and reporting of
the serological status from the doctors treating the cases.
The tracing for serological results was changed from the notification agencies of Hospital Kuala Lumpur.
Pusat Perubatan University Malaya, Hospital Universiti Kebangsaan Malaysia and Hospital Selayang to
the laboratory units of those agencies that carried out the tests. A list of notified dengue cases to each
notifying agency was prepared and handed to their laboratory services to match with the serological
results.
Effects of Change
A significant increase in the percentage of serological result being traced was observed, from 25.9% in
2003, 24.5% in 2004 and 22.7% in 2005 to 51.7% in 2006, and 56.0% in 2007 (up to August).
Lessons Learnt and Next Step
This project successfully increased the awareness and collaboration among the laboratory services of the
hospitals and the controlling health agency of City Hall Kuala Lumpur. However, we noted that there
were a high number of notified cases with no request made for serological investigations and untraesd
serological results. We hope the laboratory services will introduce the Polymerase Chain Reaction (PCR)
tests for cases diagnosed before the fifth day from the date of onset of the illness, and using the ELISA
test for cases diagnosed after the fifth day. This will increase the number of dengue cases serologically
confirmed to complement the clinical diagnosis of dengue fever.
chapter 9
Strategy for Change
198
PP/2007
COMBI - Keberkesanan Melawan Denggi di Pangkalan TLDM
Lumut
Samiran S, Saadah R, Mohd Adlan A, Mat Daud MJ, Rosdan M, Mohd Akhir N
Hospital Angkatan Tentera, Pangkalan TLDM Lumut Perak
Pangkalan Tentera Laut Diraja Malaysia (TLDM) Lumut merupakan Pangkalan TLDM terbesar di
Malaysia dengan 3934 unit kediaman menampung lebih 25,000 penghuni. Kepadatan penduduk
dan pengetahuan kesihatan yang rendah mencetuskan persekitaran yang kondusif untuk pembiakan
nyamuk aedes. Pangkalan ini pernah disenaraihitamkan sebagai kawasan kritikal di dalam Program
Pembasmi Demam Denggi Daerah Manjung berdasarkan statistik kes demam denggi yang dilaporkan
sejak sepuluh tahun kebelakang.
Kes-kes demam denggi yang bermula di dalam Pangkalan TLDM Lumut mencapai tahap sitar setiap
bulan.
Kajian ke atas statistik kes demam denggi melibatkan anggota tentera dan keluarga serta kakitangan
awam yang bekerja di dalam pangkalan ini, yang dilaporkan dan yang rnendapat rawatan di Hospital
Angkatan Tentera Lumut (HATL) dan Hospital Seri Manjung. Selain itu, sesi soal selidik terhadap
penghuni dan pemerhatian terhadap persekitaran tempat tinggal dijalankan.
chapter 9
Beberapa punca dikesan penyebab demam denggi tinggi di pangkalan ini iaitu masalah struktur
bangunan dan penyelenggaraannya, kediaman ditinggalkan dalam jangkamasa yang lama, fogging
yang tidak sempurna, rumah berkunci (keluar belayar, balik kampung, enggan bekerjasama, sedang
bertugas) serta pergerakan keluar daerah/masuk ke pangkalan yang merupakan punca utama
pembawa masuk demam denggi.
Meningkatkan kesedaran penduduk melalui kempen dan hebahan, penguatkuasaan undangundang ketenteraan kepada anggota yang tidak memberikan kerjasama, menubuhkan dan melatih
pasukan pemantau (tim DeVIT) di setiap blok dengan memberikan kuasa membuat pemantauan di
blok masing-masing dan pemantauan berkala oleh HATL dan Pejabat Kesihatan Manjung. Program
COMBI dilancarkan secara menyeluruh melibatkan semua warga pangkalan ini mulai April 2005.
Kesan Perubahan
Dalam tempoh 30 bulan selepas pelaksanaan COMBI sehingga Sept 2007 bilangan kes sifar telah
berjaya dikekalkan sebanyak 17 bulan (57%). Selebihnya pangkalan ini berjaya mencapai paras iaitu
di bawah enam kes. Di samping itu, masalah kekurangan tenaga kerja untuk pemantauan dapat
diatasi dengan wuiudnya tim DeVIT.
Langkah Susulan
Pelaksanaan program COMBI dipertingkatkan dan diteruskan lagi.
199
OP/2007
Menurunkan Kadar Jaundis Teruk di Daerah Segamat Johor
Suriati H, Zaharah MS, Awa @ Awal O, Thavamale R, Rohaya V, Ruzanah M,
Salmiah S, Suhaidah Z, Zuraini R, Noriah G.
Klinik Kesihatan Segamat, Johor.
Kejadian Jaundis Neonatal Teruk semakin meningkat dari 96 kes pada tahun 2005 ke 108 kes pada
tahun 2006.
Objektif Penambahbaikan
Tujuan kajian adalah untuk menurunkan kadar jaundis teruk kurang daripada yang ditetapkan oleh
National Quality Assurance Program (iaitu 100 kes /10,000 kelahiran hidup).
Prosedur Kajian dan Kutipan Data
Kajian dilakukan secara retrospektif bagi semua kes-kes Neonatal Jaundis Teruk yang berlaku dari
Januari - Disember 2006. Perbandingan bagi 3 bulan yang pertama dibuat iaitu 18 kes untuk 2006
dan 8 kes bagi 2007.
Analisis dan Data Interpretasi
Terdapat 34.3% kes jaundis adalah bayi yang telah didiscaj dan dimasukkan semula sehari selepas
didiscaj daripada hospital. Kes-kes kelahiran yang dinotifikasi lewat iaitu sebanyak 17.5% dan 6.4%
dikesan awal tetapi tidak dirujuk.
Langkah Seterusnya
Kelemahan-kelemahan yang dikenalpasti diperbaiki dengan kerjasama di antara pihak hospital dan
kesihatan.
Ciri Tambah Nilai
Cop jaundis telah diperkenalkan untuk digunakan oleh anggota yang menjalankan lawatan ke rumah
supaya pengesanan awal jaundis dapat dibuat.
chapter 9
Tindakan dan Kesan Penambahbaikan
Langkah-Iangkah penambahbaikan telah diambil dengan meningkatkan kerjasama di antara pihak
kesihatan dan hospital. Oi antara langkah-Iangkah yang diambil adalah membuat lawatan ke rumah.
Ini diwajibkan untuk 6 hari pertama. Sehelah langkah-Iangkah penambahbaikan diambil, didapati
peratus kejadian Neonatal Jaundis Teruk bagi 3 bulan pertama 2007 telah menu run kepada 1.2%.
200
PP/2007
Mengurangkan Kadar Kejadian Neonatal Jaundis Teruk di Klinik
Kesihatan Ibu dan Anak, Kuala Kangsar
Leelavathy N, Rukumani V, Hayati L, Mazida AJ, Salia A, Zawiyah Y.
Klinik Kesihatan Ibu & Anak, Kuala Kangsar, Perak.
Peluang Untuk Penambahbaikan
Semenjak tahun 2003, Kadar kejadian Severe Neonatal Jaundice (SNNJ) di Daerah Kuala Kangsar
didapati melebihi standard kebangsaan di mana penyumbang utamanya adalah Klinik Kesihatan lbu
dan Anak, Kuala Kangsar.
Langkah Utama Ke arah Penambaikan
Kajian dijalankan untuk mengenalpasti faktor penyumbang dan seterusnva mengambil langkahIangkah penambahbaikan untuk mengurangkan Kadar Kejadian SNNJ.
Pengumpulan data secara retrospektif dibuat atas kes SNNJ tahun 2005 dengan menggunakan
Borang Kajian SNNJ (QA). Soal selidik atas anggota kesihatan dan ibu postnatal juga dilakukan. Ini
diikuti dengan kajian prospektif untuk mengetahui hasil perubahan selepas penambahbaikan.
Hasil kajian pra intervensi menunjukkan faktor penyumbang utama berkaitan kelewatan dalam
menerima notifikasi kelahiran, rnelakukan perawatan postnatal, dan merujuk kes.
Strategi perubahan berikut telah dilaksanakan. Mempertingkatkan lawatan rumah kepada ibu
hamil yang hampir tarikh bersalin dan yang berisiko tinggi; memperkukuh tugas atas panggilan;
berkomunikasi dengan pihak hospital untuk mendapat maklumat segera kes didiscaj serta
menqadakan kursus dalam perkhidmatan kepada anggota berkenaan.
chapter 9
Kesan Perubahan
Kadar Kejadian SNNJ dapat dikurangkan dari 338.3/10,000 (Julan-Dis 2005) ke 112.8/10,000 (JanJun 2006).
Pengajaran
Kajian ini telah meningkatkan kesedaran anggota kejururawatan dalam menangani jaundis di
kalangan bayi baru lahir serta komplikasinya.
Langkah Seterusnya
Langkah penambahbaikan bagi memperkukuhkan penjagaan pranatal dan postnatal ke arah
mengurangkan Kadar Kejadian SNNJ akan dipanjangkan ke semua klinik dengan penilaian secara
berterusan untuk mengurangkan kadar SNNJ.
Ciri Tambah Nilai
Beberapa orang anggota kejururawatan telah dilatih untuk memasukkan data-data menggunakan
program SPSS untuk memudahkan mereka membuat analisis data tersebut. Membuat penambahbaikan
keatas Borang Kajian SNNJ (QA) sedia ada. Audit ke atas perawatan postnatal di rumah dilakukan
denqan menggunakan Senarai Semak Audit Kejururawatan Perawatan Postnatal. Lawatan kerumah
setiap hari termasuk hari cuti turut dilakukan sebagai satu langkah penambahbaikan.
201
PP/2007
Improving the Appropriate Management of Asthma Patients in
Klinik Kesihatan Sungai Acheh, Seberang Perai Selatan
Rafidah MN, Tan HJ, Suhaimi V, Rohaizat Z, Anita S, Jastina MS,
Norazriza MS, Nur Rasidah H.
Klinik Kesihatan Sungai Acheh, Seberang Perai Selatan, Pulau Pinang
Since the inception of the National Indicator for Appropriate Management of Asthma in Primary
Health Care, the performance of Klinik Kesihatan Sungai Acheh was not satisfactory. The percentage
of Appropriate Management of Asthma was only 13.4% in 2005. This quality assurance study was
to identify the contributing factors and find remedial actions to improve management of asthmatic
patients.
To increase the percentage of appropriately managed asthma patients to at least 50% within a year
period.
A cross-sectional study, involving 70 adult asthmatic patients was carried out in April 2006. This
was followed by an intervention and reassessment, carried out in November 2006 and May 2007,
respectively.
Strategy for Change
To overcome the poor management of asthma patients, the use of Clinical Practice Guidelines
(CPG) for Management of Adult Asthma, produced by Ministry of Health, was enforced. An asthma
educator team named the “A-Team” was formed to conduct patient education. Reinforcement of
inhalers as the main treatment and correct technique were also stressed upon during the intervention
period.
Effects of Change
Post-intervention assessment showed that there were significant improvement in the management
of asthma during the following two cycles of data collection (33.3% in November 2006 and 43.3%
in May 2007).
Next Step
The study showed that enforcing the use of CPG by staff and educating patients were vital in improving
appropriate management of asthma. The two strategies must be carried out systematically to increase
patients’ compliance to treatment. Continuous assessment is needed to ensure sustainability of the
approach.
chapter 9
The significant findings noted were poor compliance, poor patient monitoring, incorrect use of
inhalers, and shortage of manpower, pointing to lack of patients’ education.
202
PP/2007
Quality Improvement in Asthma Management at Primary Care
Setting
Narayanan S, Nor MS, Lau TM, Wan CD, Wan S.
Klinik Kesihatan Mantin, Negeri Sembilan.
Poorly managed asthma can lead to increased morbidity and mortality, as well as loss of productivity
due to sickness absenteeism. A previous quality assurance (QA) study (2003) revealed suboptimal
management of asthma in Mantin Health Clinic. This QA project airns to formulate and implement
remedial measures so that patients with asthmatic conditions are appropriately managed.
Increase in the percentage of respondents who satisfy the six-point audit criteria proposed-in the
Appropriate Management of Asthma QA Protocol which includes the following: (1) use inhalers only,
(2) peak flow measurement during clinic visit, (3) able to identify severe asthma symptoms, (4) aware
of steps to take when asthma become severe, (5) daily use of prophylactic inhalers (if needed), (6)
able to demonstrate correct inhaler technique.
A sample of 30 patients with history of asthmatic condition since the last 3 consecutive years (2003
to 2005) was included in the study. A standard questionnaire was used which incorporated the 6
audit criteria.
Overall no asthmatics achieved all of the 6 criteria in 2003 and 2004. Three criteria (1, 2 and 5) were
not achieved by 80% of respondents in 2003 and 2004.
chapter 9
Strategy for Change
The number of medical officers at the clinic was increased so that more patients could be reviewed
by doctors. The Family Medical Specialist briefed and supervised the medical officers and medical
assistants in the appropriate management. An asthma register was initiated and maintained.
Effects of Change
More than half (55%) of patients achieved all of the 6 criteria in 2005. One criterion on the lise of
peak flow measurement during clinic visit achieved a low rate, where it was used to only 65% of
respondents).
Remedial measures have improved asthmatic care. Medical Assistants and Doctors should have regular
updates on asthma management. Health education to patients must be provided at every visit.
Educating the healthcare workers bring about better management of asthma. By involving healthcare
workers in the audit project, quality criteria of asthma care are more likely to be implemented.
203
PP/2007
Improving the Percentage of Exclusive Breast Feeding in Health
District of Marang
Siti Aminah AM, Tg Fatimatul TH, Mimah J, Halimaton H, Nur Syafini A.
Health District of Marang Terengganu.
The percentage of exclusive breast feeding was low in the District of Marang which was only 7.4 % in
March 2005. The National Health and Morbidity Survey (1996) showed that exclusive breast feeding
was practiced by 30% of the population nationwide.
To increase the percentage of exclusive breast feeding to more than 30% among babies aged 6
months.
Processs of Gathering Information
A cross sectional study was carried out using two sets of questionnaire, one for mothers and another
for nursing staff to assess their knowledge, attitude and practice about breast feeding. Two cycles of
data collection were carried out at the maternal and child health clinics in Health District of Marang,
Terengganu.
The study showed that the factors contributing to low exclusive breast feeding were early introduction
to weaning decreased in frequency of breast feeding, popular use of infant fornula and presence of
other barriers to breast feeding.
Effects of Change
The initial percentage of exclusive breast feeding was 7.1 % in March 2005. After the intervention,
the percentage improved to 17.1% in March 2006 and to 28.7% in March 2007 which approximated
to the agreed standard of ≥ 30% of exclusive breast feeding.
Lessons Learnt
Achieving higher percentage of exclusive breast feeding is possible by improving knowledge of
mothers and nursing staff with training and improving health education methods and materials.
chapter 9
Strategy for Change
Changes to practice were made based on results of the study. Early introduction to weaning
decreased breast feeding frequency, popular usage of infant formula and breast feeding barrier were
the causative factors for low practice of exclusive breast feeding. Appropriate changes were made.
204
OP/2007
Improving the Use of Contraception among Women
with History of High Risk Pregnancy
Siti Aisah H, Hassmah Y, Rahimah I, Eshah J, Harisseli H.
Klinik Kesihatan Ibu dan Anak, Machang, Kelantan.
More than half (57%) of pregnancies in Klinik Kesihatan Ibu dan Anak (KKIA) Machang were high
risk pregnancies. High risk pregnancies were associated with increased risk of maternal morbidity
and mortality. More than two-third (69%) of women with history of high risk pregnancy were not
on contraception. Family planning can prevent 20 - 35% of all maternal deaths. The objectives
of this study were to determine the percentage of contraceptive use among women with high
risk pregnancies, to identify contributing factors for low contraceptive use and to evaluate the
effectiveness of the remedial measures taken.
The contributing factors to low contraceptive use identified were poor knowledge about contraception
among staff, unavailability of a counseling guide, staff not able to identify potential clients, no support
group and women worry of side effects and safety of contraception.
A cross-sectional study was carried out in January 2006 for Phase 1 of the study to determine the
percentage of women with history of high risk pregnancy. A phase 2 study was carried out in February
2006 to identify factors that contributed to low percentage of contraceptive use among women with
history of high risk pregnancy.
chapter 9
Only 38% women with high risk pregnancy used contraception. Only half (53%) of the nursing
staff had attended the family planning course during the last five years and 41 % of them had poor
knowledge about contraception. None of the staff referred to the ‘WHO Medical Eligibility Criteria
for Starting Contraceptive Use’. More than half (52%) of women with history of high risk pregnancy
had poor knowledge about contraception.
Strategy for Change
A family planning course was conducted and the “WHO Criteria For Starting Contraceptive Use” was
simplified. A support group was established for nursing staff, identification system was introduced
in which mothers already on contraception had a written identification stamped on their home
based card and those who were not, will have the opportunity to be counselled on the benefits of
contraception, counseling sessions were enhanced and women with history of high risk pregnancy
and were not on contraception were referred to medical officers.
Effects of Change
The course improved staff’s knowledge and practice, whereby 60% of staff had started to use the
modified WHO criteria. The support group boosts staff’s commitment, motivation and team spirit.
The women’s knowledge on family planning also improved.
Next Step
Conduct of regular courses on family planning to update staff and to strengthen scheduled supervision
and monitoring.
205
PP/2005
Appropriate Management of Hypertension in Hypertension Clinic
in Bayan Baru Community Polyclinic
Hafizah H, Gan LL, Shanny K, Norazrin AR, Rosli A, Namisah K.
Bayan Baru Community Polyclinic, Pulau Pinang.
Outline of Problem
Hypertension is a major risk factor for stroke and cardiovascular disease. Although many studies had
shown that optimal control of high blood pressure can lead to a marked decline in hypertension
related complications, the management of hypertension is still far from optimal. One of the reasons
behind this is due to lack of knowledge among staff and patients about hypertension itself. This study
was done to determine the effectiveness of improving level of knowledge among staff and patients
to improve patients’ blood pressure control.
The study was conducted at Bayan Baru Community Polyclinic over a period of 9 months (from
March-December 2004). Random sampling of 50 hypertensive patients were selected and followed
up during those 9 months to detect any level of improvement in terms of knowledge, attitude
and level of blood pressure control. After the intervention, the study was repeated to detect any
improvement.
A prospective study was carried out using questionnaires as a tool to assess patients’ knowledge
especially in three components - complications, diet and exercise. Similar assessment was also carried
out among health care workers. Patients’ blood pressure levels were obtained from their cards.
The following remedial measures were carried out for health workers: refresher courses in subjects
of hypertension and its complication, management of hypertension - pharmacological and nonpharmacological, and proper technique of blood pressure measurement. Health education to the
patients was also done stressing on pharmacological and non-pharmacological measures.
Percentage of patients scoring 80% and above increased from 10% to 30%, having well-controlled
blood pressure increased from 20% to 62%, practicing right diet i.e. low fat and salt increased from
42% to 78% and exercising increased from 48% to 78%. All patients had their blood investigations
taken compared to 88% before interventions. Staff knowledge in managing hypertension improved
from 44.33% to 80%.
Strategy for Change
Structured and concise health education sessions were conducted to improve the level of knowledge
and to bring a change of attitude of patients and staff.
chapter 9
Key Measures of Improvement
To improve the level of knowledge and competency of staff in managing hypertension and to improve
the knowledge and compliance of the patients, which will further improve patients’ blood pressure
control.
206
PP/2005
Impact of Tailored Interventions in Managing Poorly Controlled
Blood Pressure in Patients with Diabetes Mellitus
Azah AS, Gan EM, R. Sukumar, Suzanne I, Nurul Afiza.
Tanglin Polyclinic, Kuala Lumpur.
Outline of Problem
Tight blood pressure control in patients with diabetes mellitus will reduce incidence of micro and
macro vascular complications. Many diabetic patients with uncontrolled blood pressure have not
been properly managed by primary care doctors. Lack of knowledge and awareness may contribute
to poor management.
Reinforcement of current recommendations will improve care given to diabetic patients.
An interventional study was conducted in Tanglin Polyclinic over four months to evaluate the number
of patients with diabetes with uncontrolled blood pressure (BP> 140/90mmHg); whether appropriate
action was taken and to determine the impact of tailored intervention on blood pressure management
by the medical officers.
169 adult patients with diabetes who have at least three follow-ups in the past one year were
included in the study. First audit showed 65.1% of these patients had uncontrolled blood pressure of
which 54.5% were managed accordingly.
chapter 9
Strategy for Change
The doctors were given tailored interventions that include audit review, discussion of clinical practice
guidelines and use of clinical monitoring protocols.
Effects of Change
Post intervention audit of 116 patients who came for follow-up showed 46.6% had uncontrolled
blood pressure of which 59.3% were managed accordingly. A subgroup of these patients (n=44)
who had uncontrolled blood pressure on both pre and post audit visits were analysed using chisquare test. Results showed a significant change in the management of their bIood pressure after
intervention (p=0.006).
The Next Step
Tailored interventions on doctors can improve the management of blood pressure control. These can
be applied to improve management of other parameters. Regular supervision and audit will ensure
that the quality improvement is sustained.
207
OP/2005
Towards Improving Appropriate Care of Gestational Diabetes
in Kulim District
Noorlia Y, Siti Aishah, Fatimah Hajar A, Norpishah R, Rohana M, G. Ratenamala.
Kulim Health District, Kedah.
Problem
Inappropriate management of gestational diabetes has resulted in harmful outcomes of pregnancy
such as perinatal morbidity and mortality, particularly if there is reduced access to effective obstetric
care. Longer term consequences of Gestational Diabetes Mellitus (GDM) include future development
of type 2 diabetes and development of obesity, impaired glucose tolerance and or type 2 diabetes in
the offspring.
The indicator chosen is the percentage of women with gestational diabetes receiving appropriate
care and the threshold set was not less than 80%.
A cross-sectional study was conducted at all antenatal clinics in Kulim District to identify factors
contributing to the problem. Data was collected using special formats. Staff and patients knowledge
were also assessed.
Results of the study showed tbat only 2.8% of staff had good knowledge on GDM leading to
incorrect colour coding, incomplete history taking and incorrect appointment. 24% of defaulters
were not traced and 84.2% of postnatal cases had no Modified Glucose Tolerance Test (MGTT) done.
Effects of Change
The percentage of appropriate management of gestational diabetes have increased from 14.2% to
75.5% after intervention.
Lessons Learnt
An in-depth knowledge of the disease is an important component in the management of gestational
diabetes. Screening based on risk factors will miss many diabetes cases.
chapter 9
Strategy for Change
Intervention activities include re-training of staff, screening of all antenatal mothers for GDM,
effective health education for patients, developing an effective recall system and close monitoring of
the indicator.
208
PP/2005
Pengawalan Wabak Demam Denggi di Daerah Seremban
Mariappan S, Omar M, Shaiffullah A, Rozi MK, Muthusamy S.
Pejabat Kesihatan Daerah Seremban, Negeri Sembilan.
Penyataan Masalah
Masalah pengawalan wabak demam denggi menjadi masalah utama di Daerah Seremban sehingga
Mac 2003. Cadangan projek ini adalah untuk mengawal wabak denggi dalam masa 14 hari dengan
memusnahkan tempat pembiakan larva dan menghapuskan nyamuk aedes dewasa melalui beberapa
kaedah bersepadu yang dirancang dengan teliti.
Pengurangan kawasan wabak dan kes denggi.
Proses pengumpulan data bermula pada bulan Januari hingga Jun 2003. Setelah projek ini dilaksanakan
mulai bulan Julai 2003 hingga Jun 2005, didapati bilangan kawasan wabak tldak terkawal menurun
dengan ketara.
Analisa semasa menunjukkan semburan asap/kabus dapat dilaksanakan dalam masa yang dltetapkan
walaupun tenaga kerja terhad dengan pelaksanaan semburan Modified Fogging. Semburan ulangan
untuk kes yang sukar dilaksanakan sebelum ini juga dapat dilaksanakan selepas 7 hari. Semua kes
baru walaupun banyak pada satu masa juga dapat dilaksanakan dengan cara baru ini.
chapter 9
Strategi Perubahan
Untuk mencapai objektif ini, strategi aktiviti bersepadu iaitu Modified Fogging, Aktiviti penguatkuasaan
perundangan, Program COMBI (Communication for Behavioural Impact) dan kaedah pemusnahaan
tempat pembiakan aedes dengan aktiviti Larvaciding dan Abating telah dilaksanakan.
Kesan Perubahan
Kesan daripada pelaksanaan strategi baru ini telah menunjukkan bahawa pencapaian pengawalan
wabak dapat dipertingkatkan dari 73.9% ke 93.5% bagi setengah tahun pertama 2005, berbanding
tahun 2003. Secara tidak langsung bilangan kawasan wabak (kes denggi) juga dapat dikurangkan dari
69 lokaliti (511 kes) ke 31 lokaliti (105 kes). Disamping itu, masalah kekurangan sumber tenaga kerja
telah diatasi dan pengurangan kos perbelanjaan aktiviti juga dicatatkan. Ia juga telah meningkatkan
kesedaran masyarakat tentang penyakit demam denggi.
209
OP/2005
Improving Dengue Outbreak Control in Kg Koh, Manjung District
Choo OM, Yeoh SF, Ling HM, N Hisyam H, Vijaya R, Zulkhairi MD, Rohana A,
Mazuriana MS.
Manjung District Health Office, Perak.
Outline of Problem
Dengue Outbreak Control Index (DOCI) was low in Kg Koh area. This will increase the risk of dengue
morbidity and mortality. Early notification, prompt case investigation, proper fogging, larviciding and
‘search & destroy’ (S&D) are essential in controlling dengue outbreak.
DOCI is used for assessing effectiveness in controlling dengue outbreak.
A retrospective study was carried out to identify the causes of low DOCI. Knowledge and skills of staff
regarding fogging was assessed using questionnaire.
Low DOCI was due to lack of larviciding and S&D.
Effects of Change
DOCI in Kg Koh area increased from 66.7% to 100% (standard = 80%). Re-evaluation showed Dom
of 100% for 2 cycles but Oct-Dec 2004 DOCI was 50%. Analysis revealed that larviciding and S&D
were not done regularly in Kg Koh area due to dengue outbreaks in different areas at that period.
With proper planning and deployment of staff to implement the strategies, there was no outbreak
from January-June 2005. Sustainable improvement was seen after implementing the strategies for
the district. DOCI of Manjung district increased from 75.5% to 86.7%.
The Next Step
A study on larviciding using slow release 500E is in progress.
chapter 9
Strategy of Change
Slow release Abate 500E was formulated for longer larvicidal effect in septic tanks. Prompt and
extensive S&D was done regularly. ‘List of dengue outbreak localities’ was sent weekly to all health
facilities to increase awareness for early notification and control measures.
210
PP/2005
Meningkatkan Pengesanan Awal Kes Neonatal Jaundis Teruk di
Daerah Kangar, Perlis
Suzaini MD, Mohd.Anuar AR, Azirah I, Zainab CA, Noriza S.
Pejabat Kesihatan Daerah Kangar, Perlis.
Penyataan Masalah
Pengesanan lambat kes neonatal jaundis (NNJ) di Klinik Kesihatan (KK) menyebabkan kadar kejadian
neonatal jaundis teruk (KKNJT) di Daerah Kangar mengalami shortfall in quality dalam Program
National Indicator Assurance (NIA). KKNJT sentiasa melebihi 250 bagi setiap 10,000 kelahiran hidup
semenjak tahun 2000.
Tujuan kajian ini dilakukan adalah untuk mengenal pasti faktor penyumbang kepada pengesanan
lambat kes NNJ di KK, mengambil langkah pembaikan dan seterusnya meningkatkan pengesanan
awal dan mengurangkan KKNJT.
Kajian retrospektif dilakukan dengan menyemak 167 kes NNJ teruk [Serum Blirubin Capillary
(SBC)>20 mg/dL] pada tahun 2002 dan 2003, melalui Borang Kaji Selidik NNJ Teruk. Untuk melihat
hasil kaedah pemulihan, kajian prospektif dijayakan dari 1/1/2004 sehingga 30/12/2004 di semua 9
Klinik Kesihatan (KK) dan wad postnatal Hospital Kangar.
Kegagalan mengenal pasti ibu-bayi berisiko tinggi untuk mendapat jaundis, kelewatan pemberitahuan
kelahiran oleh keluarga bayi dan pengesanan kes NNJ pada hari ke-2 dan 3 yang rendah adalah tiga
faktor penyumbang utama.
chapter 9
Strategi Perubahan
Meningkatkan pengesanan ibu-bayi berisiko tinggi semasa antenatal dan postnatal (berdasarkan
panduan dalam Malaysian Clinical Practice Guideline (CPG) dan memastikan semua bayi di bawa ke
KK berdekatan untuk pemeriksaan SBC dalam masa 24 jam selepas di discaj dari hospital.
Kesan Perubahan
Hasilnya, 77.8% kes NNJ berjaya dikesan awal iaitu hari ke-2 dan ke-3. Pemberitahuan awal kelahiran
oleh keluarga bayi kepada KK dalam masa 24 jam meningkat ke 48.9% berbanding 29.6% pada
tahun 2003. Jumlah kes NNJ teruk berkurang sebanyak 55.6% dan hasilnya, KKNJT tahun 2004 di
Daerah Kangar menurun sebanyak 51% berbanding tahun 2003 (128.6 /10,000 anggaran kelahiran
hidup).
Langkah Seterusnya
Pengesanan awal kes berisiko tinggi membolehkan bayi diberi pengawasan sewajarnya. Mekanisma
di mana semua bayi yang di discaj dari hospital mesti di bawa ke KK berhampiran dalam masa 24 jam
untuk ujian SBC membantu meningkatkan masa pemberitahuan kelahiran dan secara tidak langsung
meningkatkan pengesanan awal kes NNJ. Kaedah pemulihan ini masih berjalan dengan pemantauan
berterusan oleh Pakar Perubatan Keluarga dan Ketua Jururawat PKD Kangar. Penilaian kedua akan
dibuat pada 30/12/2005 dengan harapan berjaya menurunkan KKNJT kurang dari 100/10,000
anggaran kelahiran hidup.
211
OP/2005
To Increase Identified Tuberculosis Contacts Coming for Screening
in the Health District of Cameron Highlands
Stella Jane JR, Amirruddin S, Norazlinda R.
Cameron Highlands Health District, Pahang.
The inadequacy of Tuberculosis (TB) contact screening contributes to ineffective TB control and
elimination efforts in Cameron Highlands.
Increasing the rates of TB contact screening and case detection among contacts are part of the efforts
to contain and eliminate the disease in Cameron Highlands.
Pre-intervention data collection via retrospective analysis of year 2004 TB contacts was carried out to
identify factors that contributed to failure of screening. Post-intervention 3-monthly monitoring was
introduced by using a QA indicator obtained from TBIS contact registry.
Analysis of questionnaire using EPI Info for 30 respondents showed that the main factors contributing
to failure of screening were poverty (40%), transport problems (30%) and unavailability of local X-ray
facility (the nearest x-ray facility is at Hospital Ipoh or Hospital Tapah).
Effects of Change
Increased number of TB contacts screened and case detection rate. Initial post remedial 3-monthly
surveillance (June 2005) showed the rate of contacts screened was 97.3%.
The Next Step
Tuberculosis contact screening can be improved with commitment and teamwork of those involved.
Inter-agency collaboration is crucial and will be emphasised. The 3-monthly surveillance will continue
and the strategy proposed above will be strengthened.
chapter 9
Strategy for Change
The strategies included getting JHEOA’s commitment in arranging transport for Orang Asli and
payment for x-rays done at private clinics. X-rays read by JKN Pahang, training via courses and CME,
emphasis on persistent commitment and competency of staff, and re-organisation of the district TB
team which consisted of 1 Medical Officer, 2 Medical Assistants, 1 Health Inspector and 1 Public
Health Oversea.
212
OP/2003
Poor Control of Blood Pressure among Diabetic Hypertensive
Patients in the District of Kulim, Kedah Darut Aman
Noorlia Y, Faudzi A, Noraliza MGan SC, Azlina I, Muthusamy M.
Kulim District Health Office, Kedah.
Outline of Problem
Hypertension in patients with diabetes increases the risk of morbidity and mortality as it contributes
to coronary artery disease, stroke, peripheral vascular disease, end stage renal disease and diabetic
retinopathy. The percentage of poor control of blood pressure among these patients has not improved
very much. Treatment to achieve a goal blood pressure of less than 130/85mmHg is essential if
significant risk of complications is to be reduced.
Improve knowledge and competency of staff in managing patients, patients to have better
understanding of disease and improve compliance.
A retrospective study was conducted to identify factors leading to the problem. Patients were assessed
for their knowledge, attitude and practice of the disease. Assessment of knowledge and skills of staff
were also conducted. Analysis and Interpretation
Poor knowledge of staff (66.6%) was identified as the general factor affecting the management
leading to inappropriate medication (24%), incorrect appointment (29%) and 11.6% of defaulters
not traced.
Patients have positive attitude towards drug compliance (97%); follow up appointments (96%);
however, 26% defaulted treatment and 12% did not comply with medication.
chapter 9
Strategy for Change
Intervention activities include re-training of staff, scheduled education programme for patients and
close monitoring of identified indicators.
Effects of Change
The percentage of poorly controlled blood pressure has been reduced from 51.4% to 25%.
Knowledge of patients and staff has improved. Achievable benefits not achieved (ABNA) reduced
from 39.4 % to 5%.
The Next Step
The team experience suggests that management of diabetic patients with hypertension is an active
partnership between patients, their family and the health care team. By strengthening the intervention
activities we hope the standard set (20%) can be achieved.
213
PP/2003
Reduction of Born Before Arrival (BBA) and Unsafe Deliveries in
Puchong District
Mimi O, Noriah A, Nurul Azzah ZA, Looi PS, Rushidi R, Norsiah J,
and G. Thavamalar.
Klinik Kesihatan Puchong, Selangor.
Background
The number of BBA cases increased drastically from 10 cases in 1999 to 44 cases in the year 2000
and remained high in the year 2001. As a result, the rate of unsafe deliveries in Puchong increased
from 0.40 in 1999 to 1.73 in the year 2000 and further increased to 2.02 in the year 2001. The
main objective of this study is to reduce the number of BBA cases, hence reducing the rate of unsafe
deliveries in Puchong government clinics to 0.8 or less.
Method
The study was conducted in two phases at Puchong Government Health Clinics. Phase 1 was a
retrospective study to retrieve information on all cases of BBA that occurred from 1.1.2000 to
31.12.2001. The antenatal cards of all BBA cases in that period were collected and the information
was recorded in a BBA Registry. Information that was not available in the antenatal cards was
obtained during interviews. Demographic data and reasons for BBA were obtained and interventional
strategies formulated. Phase 2 was a prospective study whereby the interventional strategies were
carried out from 1.1.2002 to 31.12.2002. Conclusion
The majority of BBA cases were foreigners who did not have any antenatal visits. The interventional
strategies that were undertaken were successful in reducing the number of high-risk home deliveries.
Hence, the rate of unsafe deliveries reduced from 2.02 in the year 2001 to 0.61 the following year,
well below the target rate of 0.8.
chapter 9
Results
Phase 1: A total of 84 cases were recorded of which 65.5% were foreigners. The majority of BBA
cases were unbooked or had antenatal checkups at private clinics. 90% of unregistered cases were
foreigners. The midwife was called after delivery in 81 % of cases. Phase 2: Following intervention,
the number of BBA cases dropped to 13 cases.
214
PP/2003
Pengurangan Kadar Pembiakan Nyamuk Aedes di Kawasan
FELDA
Veerasingam K, Mohd. Yazid M.
Pejabat Kesihatan Tampin, Negeri SembiIan.
Pengenalan
Penyakit demam denggi merupakan satu penyakit bawaan virus yang utama dan paling serius di
Malaysia. Tren jangkitannya telah mula berubah dari kawasan Bandar ke kawasan separa bandar/
luar bandar. Di Daerah Tampin, kawasan Lembaga Kemajuan Tanah Persekutuan (Felda) merupakan
salah satu kawasan yang sering dilanda demam denggi dan kawasan Felda Jelai 3 (kawasan kajian)
diklasifikasikan sebagai kawasan keutamaan satu (priority one) di kawasan luar bandar.
Objektif Kajian
Objektif kajian ini adalah untuk mengenalpasti kepadatan nyamuk aedes, tempat-tempat pembiakan
nyamuk di samping memberikan maklumat/pengetahuan kepada masyarakat setempat tentang
penyakit demam denggi beserta langkah-langkah perlu bagi kawalan penyakit tersebut.
Latarbelakang Kawasan Kajian
Kawasan Felda Jelai 3 merupakan satu-satunya kawasan luar bandar yang diklasifikasikan sebagai
kawasan keutamaan satu (priority one) di mana hampir setiap tahun terdapat kes-kes demam
denggi. Kawasan ini mempunyai jumlah rumah (507 buah) dan penduduk (2797 orang) yang padat
disamping tahap kebersihan/kesihatan persekitaran yang kurang memuaskan dan membimbangkan.
chapter 9
Metodologi Kajian
Kajian dijalankan dalam 5 fasa iaitu: - Fasa I - pengumpulan maklumat/mengenalpasti masalah dan
penyediaan pelan tindakan. Fasa II - pra-kajian aedes dan ovitrap untuk penentuan indikator. Fasa III
- tindakan pemulihan - aktiviti gotong-royong/kempen kebersihan/ceramah kesihatan dan program
penyertaan masyarakat. Fasa IV - kajian semula aedes dan ovitrap - untuk menentukan penurunan
indikator, Fasa V - penyediaan laporan terakhir. Kajian aedes dijalankan ke atas 507 buah rumah yang
berada di Felda Jelai 3 manakala kajian ovitrap dijalankan keatas 100 buah rumah terpilih. Selepas
pra-kajian dijalankan (kajian aedes dan ovitrap) maka dapatlah ditentukan penetapan indikator bagi
kajian ini iaitu menurunkan 70.0% dari Index (aedes/Breteau) Asal.
Tindakan Pemulihan
Selepas ditetapkan indikator asal maka tindakan pemulihan dirancang/ditentukan seperti: ceramah
demam denggi kepada Pengurusan Felda/JKKTR diadakan; ceramah dan tayang gambar kepada
pelajar-pelajar sekolah (Rendah/Menengah) yang terdapat di Felda Jelai 3; ceramah dan tayangan
gambar kepada semua lapisan masyarakat, orang perseorangan, NGO’s dan sebagainnya; minggu
kebersihan dan gotong royong perdana di Felda Jelai 3; pameran kesihatan/pemeriksaan kesihatan
asas untuk warga Felda Jelai 3. Selepas semua aktiviti-aktiviti yang dirancangkan dapat dilaksanakan
maka kajian semula Aedes/Ovitrap (Post Kajian) dijalankan untuk menentukan sama ada penurunan
indikator dapat dilaksanakan. Hasil dari kajian ini didapati bahawa Index Aedes/Breteau dapat
diturunkan melebihi 70.0% dari Index Asal.
215
PP/2003
Quality Perinatal Bereavement Counselling - Is There A Need?
Zainah SH, Chan TL, Adiratna MR, Hamidah A, Aliah O, Kuan GL.
Department of Paediatrics, Hospital Melaka.
Outline of Problem
Optimal management of perinatal bereavement reduces the frequency of prolonged emotional disturbances
and abnormal grief reaction; and also minimise the dissatisfaction of parents towards medical care.
Observational study on 11 neonatal deaths occurring in the month of January and February 2002, where
bereaved couples was offered bereavement counselling service in clinic. 7 couples (64%) attended the
clinic but only 3 couples perceived that bereavement support offered at the time of death was adequate.
Therefore, it is important to improve the quality of care given to bereaved parents by initiating bereavement
counselling service and identifying contributory factors to sub-optimal bereavement management.
Perinatal bereavement counselling service was started since 1.3.2002. Basically, it was run by a bereavement
counselling team, which consisted of a paediatrician, senior medical officer and 3 staff nurses. Bereaved
parents were offered counselling at the time of death and given a 6-week follow-up.
Data Collection Process
A prospective questionnaire-based study on all neonatal deaths occuring from 1 March till 31 October
2002 was carried out. Information was obtained from medical records and by interviewing medical staff
in-charge and bereaved parents.
Strategy for Change
Creating awareness about the importance of good perinatal bereavement management among the staff
in nursery. At the same time encouraging on-duty ward staff to offer this service during the death of a
baby, instead of totally dependant on designated counselors.
Effects of Change
A re-evaluation study was carried out from 1 November 2002 till 28 February 2003. A higher proportion of
parents (75%) perceived that they had received adequate bereavement support at the time of death and
all of them (100%) thought that the bereavement clinic was useful.
The Next Step
This study suggested that existence of bereavement counselling service obviously improves the quality of
care given to our bereaved parents. It showed that there is a need for this service in our setting and we
should maintain or even expand it.
chapter 9
Data Analysis and Interpretation
A total of 44 neonatal deaths occurred during the study period. 84% of parents received optimal
bereavement management at the time of death. Another 16% of parents were unfortunate because at the
time of death, doctors were too busy attending other cases and the counselors were off duty. 15 couples
attended the bereavement clinic after 6 weeks and only one of them received sub-optimal bereavement
management at the time of death. Only 67% perceived that they received adequate bereavement support
at the time of death. 87% of parents perceived that the 6-weeks bereavement clinic was useful.
216
OP/2003
Reducing Waiting Time in a Health Screening Programme
Tan M, Ng D, Tan JK, Ooi G, Teh A, Fatimah M, Niqmathnesa, Tham SL,
Tong AI.
Penang Adventist Hospital, Pulau Pinang, Malaysia.
The Wellness (Health Screening) Program offered by Penang Adventist Hospital includes an abdominal
ultrasound, which is performed in the Radiology Department. Abdominal ultrasound scanning was
often delayed and therefore a source of patient dissatisfaction.
Key performance measures were waiting times and patient satisfaction ratings.
Patient satisfaction surveys were used to measure both waiting times and overall patient satisfaction.
Waiting times for abdominal ultrasound scans were often prolonged, lasting up to 2 hours. Only
41% of patients rated the Wellness Program as Good or Very Good in patient satisfaction surveys.
Root cause analysis identified inefficiencies in the process and inadequate communication between
Wellness Centre and Radiology staff.
chapter 9
Strategy for Change
To improve the workflow, the Radiology Department set aside an appropriate number of appointments
to accommodate patients who required an abdominal ultrasound as part of the Wellness Programme.
In addition, patients planning to undergo the Wellness Programme were given a preparation checklist
before the day of their appointment. Communication between Wellness Centre and Radiology staff
was also improved.
Effects of Change
Penang Adventist Hospital has cut the typical waiting time for abdominal ultrasound scans, which
are performed as part of the Wellness Programme, to 10 minutes or less. This reduction in waiting
times has been accompanied by a significant improvement in patient satisfaction ratings (77% of
respondents gave a rating of Good or Very Good).
The Next Step
Continuous monitoring of the key performance measures has contributed to sustained results. A
similar strategy may be adopted to improve the waiting times at other Outpatient Services.
Chapter 10
Training Related Projects
218
OP/2011
Meningkatkan Kompetensi Pelatih Program Diploma Pembantu
Perubatan melalui Intervensi Simulasi Klinikal
Elengovan V, Nazri A, Yong KK, Zafri Y, Liew CF.
Bahagian Pengurusan Latihan, Kementerian Kesihatan Malaysia, Wilayah Persekutuan Putrajaya.
Hasrat Institusi Latihan Kementerian Kesihatan Malaysia adalah untuk melahirkan anggota kesihatan
yang berilmu, kompeten dan pengamal selamat bagi merealisasikan dasar dan wawasan kesihatan
Negara. Walaubagaimanapun, kemampuan dan kualiti graduan yang dihasilkan sering dipersoalkan.
Isu kurang kompetens serta faktor seperti peluang pendedahan, suasana pembelajaran, penyeliaan,
kerelaan pesakit, isu keselamatan pesakit dan perundangan membawa kepada theory-practice gap
di unit klinikal.
Kajian ini bertumpu ke arah meningkatkan kompetensi pelatih ke paras piawai 85%. Model of
Skills Acquisition (Dreyfus & Dreyfus, 1980) digunakan sebagai indikator bagi mengukur kombinasi
kemahiran, pengetahuan, sikap, nilai dan keupayaan pada peringkat kompetens dalam pengendalian
kes klinikal.
Kajian ini dijalankan dari 4 hingga 30 Julai 2010 dan melibatkan sampel seramai 50 orang pelatih dari
Kolej Pembantu Perubatan Ulu Kinta, Alor Setar, Seremban dan Kuching. Ujian Objective Structured
Clinical Examination (OSCE) berasaskan senario klinikal digunakan untuk mengukur komponen
kompetensi sebelum dan selepas intervensi simulasi.
Hasil kajian sebelum intervensi menunjukkan bahawa pelajar hanya mampu memperolehi min skor
51.19% dengan sisihan piawai 10.89. Prestasi ini tidak memenuhi piawai latihan.
chapter 10
Sebagai langkah penambahbaikan, Kolej Pembantu Perubatan telah memperkenalkan pendekatan
‘Intervensi Simulasi Klinikal dalam Meningkatkan Kompetensi Pelatih’. Integrasi simulasi dalam
pedagogi latihan menggunakan senario kes klinikal sebagai stimulus pembelajaran dan dibantu oleh
pelakon, manikin, peralatan ICT serta pengajar sebagai fasilitator dalam pengendalian kes klinikal.
Kajian keberkesanan menunjukkan bahawa gabungan program simulasi dan penempatan klinikal
(Study Group) dapat menganjakkan prestasi dan kompetensi pelatih dari paras 51.2 % ke paras 77.3
% (Pre-test- x: 51.19; sd: 10.89; Post-test- x: 77.30, sd: 6.90) berbanding dengan pelajar yang hanya
mengikuti program penempatan klinikal di Hospital (Control Group Pre-test- x: 43.72; sd: 12.09;
Post-test- x: 55.09, sd: 14.72.). Walaupun piawai yang ditetapkan adalah 85.0 %, intervensi ini telah
memberi impak dan kejayaan dalam meningkatkan prestasi, kompetensi dan keyakinan pelatih.
Langkah Seterusnya
Aktiviti pengajaran dan pembelajaran yang menggunakan pendekatan simulasi klinikal dapat
membangunkan kompetensi klinikal disamping memudahcarakan pemindahan ilmu kepada situasi
klinikal sebenar. Impak dan kejayaan projek ini memberi ruang dan peluang bagi memperluaskan dan
mengintegrasikan konsep simulasi klinikal dalam kurikulum serta membangunkan konsep makmal
simulasi.
219
PP/2011
Improving the Passing Rate of Nursing Students in Anatomy and
Physiology Subjects
Tan SC, Chin SK, Khaw ES, Rogayah I, Lim JK.
College of Nursing Penang, Taiping, Kuantan and Kuching.
Anatomy and Physiology subjects are the foundations of knowledge and generic skills that will
influence students’ success throughout the three years course. Without Anatomy and Physiology,
nurses would not know what to watch for in patients with medications reactions, or how these
patients are responding to care. Therefore, if the nurse has a thorough understanding of how the
body works, she will be better prepared to give safe and quality patient care. The study aimed
to identify effective teaching and learning strategy to increase the passing rate of Anatomy and
Physiology among student nurses of Year I Semester II.
The four nursing colleges in the Training Division Ministry of Health had decided to set the standard
of increasing the passing rate from 70% to 90%.
Retrospective record review from January 2008 to June 2010 showed an increase in the failure rate.
Interventional study was conducted from 1 July to 31 December 2010. Remedial measures were
evaluated by monitoring the results of summative examinations.
A total of 350 students took part in this study. The result of Summative Examination in November 2010
showed there is an improvement in the passing rate for the subjects, Anatomy and Physiology. 51%
of the respondents were satisfied with this methodology because it encouraged group interaction
and 52% reported that their workload and difficulty in studying Anatomy and Physiology were
reduced.
Effects of Change
Retrospective summative examinations of 2 years (2008-2010) showed about 70% of the students
passed the subject on Anatomy and Physiology. The new teaching methodology was implemented
for a period of 2 months (July – August). After the implementation the passing rate had increased by
20%, that is from 70% to 90%.
The Next Step
The use of Cooperative Learning and Computer aided Learning is effective and will be used
continuously when teaching Anatomy and Physiology in all nursing colleges.
chapter 10
Strategy for Change
We introduced Cooperative Learning and the use of log book to enhance students learning and
retention power in studying Anatomy and Physiology.
220
PP/2005
Implementation and Evaluation of Communication Skills Training
Programme for Pre-Clinical Medical Students:
A Malaysian Context
Hera L, Zuhrah B, Galy M, and Reiko Y.
Behavioural Sciences Section, International Medical University, Kuala Lumpur.
A concern was raised on the quality of students’ communication skills at International Medital University
(IMU). The concern was on the students’ lack of competency in lnterpersonal communication with
patients. If this problem persists, IMU graduates will face significant difficulties when they become
doctors. To address this, a quality assurance project was employed to investigate IMU’s communication
skills training programme during the pre-clinical phase. It was found that the programme adopted
mainly a didactic and non-systematic approach, and it lacks standardisation and continuity.
A new programme was developed to address these limitations and to achieve the following quality
indicators: develop and/or enhance 1) students’ attitude towards the need for good doctor-patient
communication and their 2) competency in and 3) knowledge of interpersonal cornrnunlcation. A
longitudinal study was conducted to evaluate the efficacy of the new programme using the before
after design. Prior to and after receiving the new communication skills programme, 189 first year
medical students completed an inventory of measures on their attitude towards the need for good
doctor-patient interactions, their perceived competency in interpersonal communication and their
knowledge on how to communicate effectively with patients.
chapter 10
The results provided evidence that the new programme is effective and plays a significant role in
achieving the three quality indicators stated above. Following the exposure to the new programme,
students’ attitude were more positive towards the need for good doctor-patient interactions, they
perceived themselves to be more competent in interpersonal communication and they had a better
theoretical knowledge of doctor-patient communication. The findings also highlighted areas for
further improvement.
221
PP/2003
Peratusan Kelulusan Peperiksaan Semester 1 KKM, di Kolej
Kejururawatan Kubang Kerian Tidak Menepati Piawaian
Bahagian Pengurusan Latihan, Kementerian Kesihatan Malaysia
(85%)
Che Rasmaniah CM, Hamidah M, See TL, Natrah M.
Kolej Kejururawatan Kubang Kerian, Kelantan.
Penyataan Masalah
Semester 1 selama 6 bulan adalah asas kejayaan setiap pelajar untuk meneruskan kursus ke semester
seterusnya. Di KKKK didapati pelatih kumpulan 1/2001 rnencapai kelulusan 63.4%, pelatih 2/2001
mencapai kelulusan 71.2% dan pelatih 1/2002 mencapai kelulusan 51.1% berbanding standard
yang ditetapkan iaitu 85%. Pelatih yang gagal akan ditamatkan latihan. Ini akan mengakibatkan:
-
-
-
-
Pembaziran wang biasiswa selama 6 bulan
Kuantiti jururawat terlatih berdaftar yang diperlukan oleh kerajaan tidak mencapai target
Imej kolej terjejas
Pelajar mengalami stress kerana hilang sumber pendapatan
Oleh itu kajian QAP dibentuk setelah meneliti kajian retrospektif, tindakan pemulihan diperkenalkan
dan diimplementasikan kepada pelatih kumpulan 2/2002 di mana hasilnya telah menggalakkan
pelatih belajar dengan lebih aktif. Tindakan Pemulihan
Kepada pelatih:
- Prep class di bawah pengawasan pengajar
- Latih-tubi menjawab soalan-soalan
- Pelatih belajar secara berkumpulan
- Ujian mingguan dan bulanan
- Pemberian insentif untuk meningkatkan persaingan dil kalangan pelatih
- Melibatkan pelatih secara aktif dalam aktiviti ko-kurikulurn
- Menjalankan kaunseling kepada pelatih secara individu dan kelompok
- Semua pelatih menyediakan jadual waktu aktiviti harian
- Mengadakan English day pada setiap hari Ahad
- Mengadakan morning talk setiap pagi dalam Bahasa Inggeris selama 15 minit
Kepada pengajar:
- Memperbagaikan kaedah pengajaran.
chapter 10
Metodologi
Kajian retrsopektif terhadap semua kumpulan pelatih 1/2001, 2/2001 dan 1/2002 yang gagal dengan
menggunakan borang soalselidik. Kajian secara soal selidik juga dilakukan kepada semua pelajar
tersebut.
chapter 10
Chapter 11
Collaborative Projects
224
OP/2009
Reducing Medication Administration Delays:
A Collaborative Approach
Koay WY1, Claire R1, Razwan A R1, Yi FK2.
Pharmacy Department & 2Nursing Department, National Heart Institute, Kuala Lumpur.
1
A medication administration (MA) error audit was first conducted in Institut Jantung Negara (IJN)
in October 2008. Medication administration delays was the most frequently observed MA error
(30.38%). This may adversely affect patient’s quality of care. This study aimed to identify the
contributing factors and implement remedial measures.
‘Delay in medication administration’ was defined as a medication that was administered more than
one hour after the scheduled time. The target is less than 15% of all scheduled doses.
Three pharmacists observed 30 medication administration rounds in October 2008 and May 2009.
Details of administered medications, scheduled and actual serving times of drugs were recorded on
an audit form.
Medication administration delays were due to the unavailability of drugs at medication serving time
and inadequate number of nurses serving medications.
Strategy for Change
Following the results of the first audit, the Nursing Division changed the management of patient-care
in the wards from functional to cubicle-nursing. The Pharmacy Department changed their medication
management system in the wards from the floor-stock to unit-of-use system and started a 24-hour
service of medication supply to wards.
chapter 10
Effects of Change
In May 2009, medication administration delays were significantly reduced to 12.3%. The
implementation of cubicle-nursing and the provision of a 24-hour pharmacy service enabled
medication to be administered to patients in a timely manner.
The Next Step
The May 2009 audit indicates room for improvement. Future plans of implementing the Computerised
Physician Order Entry (CPOE), automated-dispensing system, and Bar-Code Point-of-Care Technology
(BPOC) will help reduce delays at the prescribing, preparation and administering points of medications
in IJN.
225
PP/2007
Reducing Missing Laboratory Investigation Results
Sent From O&G Department Hospital Melaka
Lee MY, Herda Rohayu B, Mohd Shafie DA, Nor Idayu K,
Nong YK, Shujatha MPR, Asmah A, Noriha M.
Department of Pathology and Department of Obstetrics and Gynecology, Hospital Melaka.
Missing laboratory investigation results is a serious problem faced by the Obstetric and Gynecology
(O&G) outpatient clinics in Hospital Melaka, causing delay in instituting specific clinical management
for patients, thus reducing patients’ satisfaction. One in ten (10.9%) of laboratory investigation
results was found missing in July 2006. This quality assurance project aimed to identify the causes,
formulate and implement remedial measures to reduce missing results.
To reduce the rate of missing laboratory investigation results to less than 5%.
Prospective cross sectional analysis in July 2006 identified the causes. Interventional study and its
analysis took place from October to November 2006. Evaluation of the effectiveness of remedial
measures took place from April to June 2007.
The main cause determined was the wrong filing due to poor filing system and untrained staff. Other
causes include results being wrongly dispatched, wrong patients’ identification and others.
Strategy for Change
Remedial measures included early tracing of results; training of staff involved in filing; reallocation
of staffs for filing; stamping “O&G clinic” in the investigation forms; and patient’s full name written
in capital letters with complete identity card number.
Next Step
This study successfully identified the causes and able to reduce the rate of missing laboratory
investigation results through implementation of specific remedial measures. Laboratory results should
be dealt with more systematically. All remedial measures taken must be reinforced from time to time
since there is a high turnover rate of staff in the hospital.
chapter 10
Effects of Change
A significant reduction in the rate of missing laboratory results from 10.9% to 7.1% and further
reduction to 3.5% after second remedial measures.
226
OP/2005
High Incidence of Follow-up Patients Coming
without Appointment
Raja Norliza, Kasthuri N, Azlina S, Koh LN, Koh WL, Chi SL, Linda Y.
Skin, Eye, ENT, Dental Clinics, Melaka Hospital.
High incidence of follow-up patients coming without appointment to specialist clinics causes
unnecessary increase in workload for staff, increase in number of patients to be seen for that day
and difficulty in tracing their cards. Thus, it will lead to prolonged waiting times for patients with
appointment and hence cause dissatisfaction.
The visits without appointment may be contributed by situations when a patient has acute relapse of
sickness, has finished medication, received urgent referral from other units, patients who were told
to return when necessary and those who missed their appointments due to various reasons.
Cross-sectional studies were carried out in the EYE, ENT, Dental and Skin specialist clinics for a month
by using data collection sheets and forms. The objectives were to determine the number of follow-up
patients coming without appointment, to identify their reasons for returning without appointments
and to recommend remedial measures.
In this study, the indicator was calculated by the number of follow-up patients coming without
appointment divided by the total number of follow-up patients, multiplied by 100.
The standard set was at 3%. The pre-remedial study showed that 3.5% of the follow-up patients
came without appointment. The reasons were identified and appropriate remedial measures were
implemented. Post-remedial studies were carried out on two occasions, showing a reduction of
follow-up patients came without appointment of 1.5% and 1.4%, respectively.
chapter 10
This showed the remedial measures applied were successful in reducing the number of follow-up
patients coming without appointment. Hence, it could be implemented to all clinics to help them run
smoothly and efficiently.
Chapter 12
Others
228
OP/2011
The BRAINwaves System: Development of a Mind Stimulating
System to Improve Neurocognitive Health by Increasing
Alertness in the Workplace
Zalina I, Wan Asim WA, Idris L, Aida Fadriah M, Wan Raihana WA,Yang SA,
Kumar J, AlHindi R, Gisely V.
BRAINetwork Centre for Neurocognitive Science, School of Health Sciences, Universiti Sains Malaysia,
Kubang Kerian, Kelantan.
There was a daily loss of about 0.9 hours of productivity due to decreased mental alertness. Many
nurses utilised social networking sites, tea breaks or personal discussions to refresh their minds and
find it difficult to get back to their job. An opportunity existed for creating a cheap and an effective
way of improving alertness without sacrificing money, time or productivity.
The BRAINwaves System was expected to improve alertness, productivity, focus and wellness by 50%.
The Blue Ocean Strategy and Prashnig’s Working styles analysis were used to identify neurocognitive
health issues of 70 administrators and nurses in the Intensive Care Unit and Operating Theatres of
Universiti Sains Malaysia (USM) between January and June 2011.
Fifty percent of respondents indicated that decreased alertness was a major neurocognitive problem
while lack of socialisation, lack of reward and recognition and unsatisfactory facilities scored 20%.
Strategy for Change
The BRAINwaves System was developed and an interventional study was carried out. Respondents
were randomly selected for confirmatory electroencephalography tests. Neurocognitive changes
were also assessed by the Cambridge Neuropsychological Test Automated Battery (CANTAB).
Effects of Change
BRAINwaves improved alertness, productivity, focus and wellness by 85%, lowered costs by 96%,
with projected savings of RM122 000/ year. Focus group studies indicated that BRAINwaves met
current market needs and created value innovation by improving mental alertness across five different
domains. It is highly specific yet diverse enough to cut across communities, age groups and cultures.
chapter 12
The Next Step
The BRAINwaves System is highly effective and will be applied to all administrators and nurses in USM
as part of a management effort to improve productivity in the workplace by improving neurocognitive
health.
229
PP/2009
Does Hand Hygiene Campaign Works? – IJN Experience
Tuminah J, Rusmawati K.
National Heart Institute, Kuala Lumpur.
Proper hand hygiene is the single most effective method to reduce health care-associated infections.
The purpose of the campaign is to evaluate the compliance of hand hygiene among the health care
workers and to determine the type of hand hygiene preferences.
Increasing the compliance rate of hand hygiene following the activities at the campaign.
Two Infection Control nurses, Infection Control Link nurses and one cardiovascular technician carried
out a hand hygiene audit for 2 weeks pre campaign (April 2008) and for 2 weeks post campaign (July
2008) to observe the compliance of hand hygiene.
Hand hygiene requirement for this audit was patient contact and environmental contact. Either
alcohol based hand rub or hand washing were used. During pre-campaign audit, hand hygiene
compliance rate was 42.3%.
Strategy for Change
Due to poor compliance to hand hygiene, various activities were carried out during hand hygiene
campaign week including lectures, distribution of hand hygiene posters, walkabout to various
departments and inter departmental hand hygiene competition.
Effects of Change
There was an increased in the percentage of compliance to hand hygiene between pre and post
campaign, from 42.3% to 55%. Health care workers prefer to do hand washing especially in critical
care unit.
chapter 12
The Next Step
With the improved compliance after the campaign, it was noted that there was a reduction in health
care-associated infections rate in the subsequent month. Sustainability over time can be a challenge.
Ongoing promotion campaigns, communications and informations should be used to increase
awareness of all staff to the need for good hand hygiene. Regular audit will be useful.
230
PP/2009
Improving Hand Hygiene Compliance among Health Care
Workers in a Government Hospital
Wan Noraini WY, Rohani S, Abidah M, Maria M.
Kajang Hospital, Selangor.
Hand hygiene compliance amongst health care workers in Hospital Kajang is very poor (16.9%).
It is the lowest among all Ministry of Health’s Hospital in Selangor. At the same time, our Hospital
Acquired Infection (HAI) rate is the third highest in Selangor.
This study was conducted to identify problems and contributing factors to improve hand hygiene
compliance amongst health care workers (HCW). Hand hygiene compliance standard is 80%.
Data were collected by using questionnaires and observation forms adopted from World Health
Organization (WHO). This study was done in 4 cycles from August 2008 to Jun 2009.
Few factors were identified as possible contributing factors for low hand hygiene compliance
amongst HCW, i.e. availability of hand soap or rub (15%), lack of awareness (13%) and knowledge
on importance of hand hygiene (5.3%).
Strategy for Change
Few remedial measures were identified; increase awareness and knowledge on hand hygiene practice,
improve availability of hand rub at strategic locations, pledge commitment from head of unit and
link nurse in ward.
Effects of Change
During study period, hand hygiene compliance was increased from 16.9% to 63.6%; clean hand
every time before touching a patient (5.7% to 53.6%), clean hands immediately before any aseptic
task (11% to 100%), clean hands immediately after an exposure risk to body fluid (35.3% to 100%),
clean hands after touching a patient (27% to 66.3%) and clean hands after touching any object or
furniture in the patient’s immediate surrounding (18% to 59%). Two units; Hemodialisis (HDU) and
Special Care Nursery (SCN) showed highest hand hygiene compliance of ≥ 80% (above standard).
chapter 12
The Next Step
Continual remedial measures, emphasising on health attendants, medical assistants and senior staffs
due to lack of hand hygiene knowledge and compliance. Audit on hand hygiene compliance for
student nurse as they might play in HAI.
231
OP/2005
Prospective Studies of Patient’s Satisfaction level
in Armed Forces Hospital Terendak from 2003 - 2005
Izzuniddin MY.
Terendak Armed Forces Hospital, Melaka.
Patient satisfaction is inevitably one of the common indicators used to evaluate quality of health
care services. Since 2003, the Armed Forces Hospital (AFH) Terendak has used the level of patient
satisfaction to identify specific areas in its services that need improvement. Patient satisfaction is also
a critical component in the monitoring and evaluation of MS ISO 9001:2000.
A series of three studies had been conducted using SERQUAL. The aims of these studies were to
determine the level of patient satisfaction and the socio-demographic characteristics associated with
satisfaction, and to identify areas that need improvement. Each of the three studies was a crosssectional quantitative descriptive study, conducted twice yearly for the period of one and a half
month.
The studies include all in-patient and out-patient departments, except the Casualty and Paediatric
wards. Self-administered questionnaire based on SERQUAL dimensions was used. The more negative
the result, the less satisfied the patient. A total of 1061 respondents were included in the three
studies.
The overall levels of patient satisfaction were registered in the mildly dissatisfied category (-0.3300
to -0.2000) and an improvement pattern was observed over the three studies. The greatest
dissatisfaction was report in the dimension related to “tangibles”. The level of satisfaction for all
dimensions improved in the third study. There were significant associations between the respondents’
satisfaction and status of education (p=0.027), gender (p=0.034) and marital status (p=0.049).
chapter 12
Overall improvement in facilities and hospital environment, customer service quality and presence of
committed work force had contributed to improved level of patient satisfaction. Monitoring the level
of patient satisfaction is a useful tool for continuous quality improvement.
232
OP/2003
Sistem Pengurusan Aset
Lokman A.
Pusat Pengajian Sains Perubatan, Universiti Sains Malaysia (USM) Kubang Kerian.
Masalah
Kaedah pengurusan maklumat berkaitan sesuatu alat/aset yang tidak efektif memerlukan perubahan
dalam cara merekod, menyimpan dan memperolehi semula maklumat bagi tujuan pemantauan,
penyelenggaraan dan perolehan baru.
Rekabentuk
Satu pasukan kualiti (QA) telah ditubuhkan di peringkat Jabatan. Ahli-ahli pasukan ini terdiri
daripada beberapa kategori staf. Projek dilaksanakan dalam beberapa peringkat dan melibatkan
sesi perjumpaan dan perbincangan yang diadakan sekali sebulan. Format pelaksanaan projek adalah
berdasarkan kepada kaedah Kumpulan Meningkat Mutu Kerja (KMK) dengan sokongan fasilitator
dalaman Hospital Universiti Sains Malaysia.
Latarbelakang
Kajian projek pengurusan aset melibatkan 15 jabatan dan unit berasaskan makmal/klinikal.
Pengurusan aset menggunakan software FileMaker Pro.
Tanda Aras Penambahbaikan
Mengurangkan masa kos dan tenaga manusia, mengurangkan ralat dan keperluan ruang bagi
pengurusan aset.
Strategi
Dengan kaedah Rancang-Buat-Kaji-Tindak (RBKT) sebagai panduan kumpulan ini telah memutuskan
untuk:
a. mendapatkan maklumat daripada pejabat pengurusan aset dan semua unit terlibat
b. merekabentuk satu sistem aplikasi asas pengurusan aset
c. memasukkan maklumat aset ke sistem d. Menilai keberkesanan sistem
Kesan Perubahan
Masa perolehan maklumat aset telah berjaya dikurangkan dari 1 hari bekerja kepada 1 jam
(pengurangan sebanyak 90%) keperluan tenaga kerja telah dikurangkan daripada 10 kepada 1
orang beberapa pihak telah menunjukkan minat untuk menggunakan sistem ini.
chapter 12
Pelajaran Diperolehi
Penggunaan IT telah terbukti berjaya menjimatkan masa, kos dan tenaga manusia serta mengurangkan
ralat dan keperluan ruang bagi pengurusan aset.
233
PP/2003
Quality Assurance Programme in Hospital Support Services Managing Hospital Excellence
Wang HB, Zamane AR, Nik Musalmah M.
Engineering Services Division, Ministry of Health Malaysia.
Problem
Information on equipment and facilities were only available at hospital level and net integrated at state and national level. In some
hospitals, the level of maintenancre service was very much to be desired leading to high downtime and reduced facilities and
equipment lifespan. This problem was chosen due to the high costs involved in repairing the equipment and facilities due to lack of
regular maintenance as well as unavailability of equipment and facilities which has detrimental effect on the healthcare service to
patients. Therefore, there is an urgent need to institute a better care program for the facilities and biomedical equipment and improve
the availability of those equipment to enable healthcare personnel perform their duties effectively. No concerted efforts for continuous
improvement program and as the maintenance program was very much up to the local site management.
Measurements
Improvement in the program constitutes less downtime, higher availability of equipment and proper maintenance program. The
following indicators have been set to measure the improvement achieved:
Indicator No.
Indicator Name
1
Percent of PPM schedule completed 100
as scheduled per month.
(PPM completed for the month) x 100
(PPM scheduled as per HSIP)
2
Percent of asset meeting uptime
100
target per month.
(No. of asset meeting uptime target) x 100
(Total No. of asset)
5
Percent of PPM scheduled completed
100
as scheduled per month.
(PPM conducted for the month) x 100
(PPM scheduled as per HSIP)
6
Percent of asset meeting uptime
100
target per month.
(No. of asset meeting uptime target) x 100
(Total No. of asset)
A core team comprising personnel from Ministry of Health
(MOH), 3 concession companies and “Sistem Hospital Awasan
Taraf (SIHAT)” had developed procedures for monitoring 4
indicators to address the above problem. The QAP process
was developed using PDCA (Plan, Do, Check, Act) approach:
-
-
-
-
-
-
-
Collection, verify and audit data
Calculate and analyze data
Identify root cause
Investigate and identify root causes
Prioritize problems
Implement corrective & preventive action
Monitor and review performance
Formula
protocol to inform the user of the coming PPM activities to
trigger better communications between the parties and preplan the work.
Effects of Change
The QAP has enabled the service providers to measure the
availability of facilities and equipment, which was not available
then. Any shortfall in quality is investigated and solution is
implemented to improve the performance level.
Lessons Learnt
First implementation commenced in July 2002 for 5 equipments
in 143 hospitals (ambulance, air conditioning system (except
split unit and window unit), haemodialysis, radiology and
ventilator) and runs on a 6-month cycle, Common QC Tools
are used to analyse the QAP data.
Better communications between the maintenance party and
users help make the maintenance program successful. The
MOH personnel are now able to monitor the performance of
the Concession Companies more effectively with the integrated
on-line information on the equipment at various levels. (Level
1-5) and hence to make strategic decision-making. Benefits of
QAP are extended to the remaining equipment and facilities in
the hospitals in the 4th cycle.
Next Step
The results for the first and second cycle are presented
in Appendix B. The current and historical QAP results are
available on-line at www.cmis.com.my at asset, hospital, state,
consortia and national levels.
Strategy for Change
Various changes were made at different levels. For example,
an Inspection Checklists for Ambulances were developed and
implemented to enable the Drivers and Concession Companies
representative to carry-out joint daily inspection prior to using
the vehicle. Schedules for Planned Preventive Maintenance
(PPM) were reviewed and amended to ensure higher PPM
achievement. The Concession Conwany also established a
To further develop the program in the following aspects:
To further develop corrective actions and hence monitor them
To plan the finding and shortcomings in terms of the Shortfall
in Quality,
To include more assets and equipment into the program
To develop the remaining indicators for CWMS, CLS, and LLS,
Factors to improve quality:
- Proper planning
- Proper definition of the objectives, scope and vision of the
program
- Instigated teamwork between personnel at all levels among
the concession companies.
chapter 12
Standard
chapter 12
Notes

Muat Turun - Portal Rasmi Kementerian Kesihatan Malaysia

Transcription

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