MSQH SURVEY 4th Edition RECOMMENDATION / FINDINGS
Date & Time Survey
Standard & Department
Department & HOD & Surveyor
22nd August 2016 9.00am
Standard no 9 & 13A
O&G, L&D Services
Dr Mah SL
Dr Thiyagar Nadarajan
23rd August 2016 9.00am
Standard no 9
Paediatric Services
Dato Dr Michael Khor
Dr Thiyagar Nadarajan
22nd August 2016 10.30am
Standard no12
i-Endoscopy
Dato Dr Chong KF
Dr Fatahul Laham Mohamed
23rd August 2016 10.30am
Standard no 12
i-Urology
Dr Sazali Satari
Dr Sritharan Subramaniam
23rd August 2016 2.30pm
Chronic Haemodialysis
Nephrology & Haemodialysis
Dr Goh HK
Dr Fatahul Laham Mohamed
Commendable
Orientation checklist
C&P competency assessment
2 OBGYN on call for Obstetric emergency
Pain management 24 hour service
KPI in breast feeding from 70% to 85%
SCN spacious
Patient fully aware of breast feeding support
SBAR good way of communication
Well documented meeting minutes
Orientation checklist
C&P competency assessment
Orientation checklist
C&P competency assessment
Recommendation
Orga chart with clinicians involvement
To go for baby friendly status
Policy on removal of baby tagging home base
Security issue via lift 3&4 during transportation for LSCS
NRP recertification for Midwives & Nursery
Orga chart with clinicians involvement
Paediatric clinic to stand by ambu bag
Security in Paediatric ward & clinic play area
Specialized allowance for Paediatric trained
Vaccines in Pharmacy with cold chain on transfer
The availability of reading material
Preferably gastroenterologist to head the department
Stainless steel cupboard for scope storage
Removal of door stopper toward washing areas
E-trolley with safety control
Handling of fluoroscopy by Urologist
Checklist for medication drawer for expiry
Quality indicator made known to clinician & review
trending & RCA
Orga chart with clinicians involvement
Quality tracking for Seroconversion & Intradialytic Death
Electrical safety for plug points
 MSQH SURVEY 4th Edition RECOMMENDATION / FINDINGS

Date & Time Survey Recommendation

Standard & Department
Department & HOD & Surveyor

22nd August 2016 Reading material for dual language

Patient & Family Right - PFR PFR reading material to extend to clinic areas
Dr Goh KY Lack of reading material in clinic area
Dr Harif Fadzilah

Engineering F&M & BME Corridor 3 plug point socket to cover to ensure child safety
IR Mr Tan JK Equipment lapse in calibration
Mr David No service updated label on equipment

23rd August 2016 To have matric risk for types / nature of disaster
Environment Service Standard no2 Collaboration to test run external disaster with other companys support ie factory base
Disaster Plan
Dr Goh KY
IR Mr Tan JK