BENGKEL MSQH PPP SGH 2023.pptx

ACCREDITATION OF HEALTH
CARE FACILITIES AND SERVICES
MSQH (6TH EDITION) TRAINING PROGRAMME
FOR ASSISTANT MEDICAL OFFICER
STANDARDS 25 :
MEDICAL ASSISTANTS SERVICES
UNIT PERKHIDMATAN PPP, HOSPITAL UMUM
SARAWAK
PREPARED BY :
PPP U32 RIGEN GEORGE
PPP U32 MOHD SAIFULLAH AFFENDI NGO

TABLE OF CONTENT :
1. OVERVIEW & INTRODUCTION OF HOSPITAL
ACCREDITATION (MSQH 6th EDITION)
2. LIST OF MSQH SERVICE STANDARDS
3. MSQH FOCUS/KEY ELEMENS AREA
4. MSQH SERVICE STANDARDS 25 : MEDICAL ASSISTANTS
SERVICES
5. MSQH STANDARDS 25 : CORE / KEY ELEMENS 1-6
6. MSQH STANDARDS 25 : PERFORMANCE INDICATORS
7. MSQH SERVICE STANDARD 25 : FRAMEWORKS
8. MSQH STANDARD 25 : RATING SCALE SYSTEM

OVERVIEW & INTRODUCTION
OF HOSPITAL ACCREDITATION
• THE HOSPITAL ACCREDITATION PROGRAMME (HAP) IS A
VOLUNTARY, INDEPENDENT PROGRAMME SUPPORTED AND
ADMINISTERED BY HEALTHCARE PROFESSIONALS :
ORGANISED UNDER THE AUSPICES OF THE MALAYSIAN
SOCIETY FOR QUALITY IN HEALTH (MSQH)
• THE HAP OR MSQH PROVIDES AN AFFECTIVE MEANS
WHEREBY HEALTHCARE FACILITIES CAN ASSESS THEIR
LEVEL OF PERFORMANCE AGAINTS APPLICABLE NATIONAL

• THE MSQH ACCREDITATIONS PROVIDE A BENCHMARK
AGAINTS WHICH HEALTHCARE ORGANISATIONS CAN
REGULARLY ASSESS THEIR ORGANIZATIONAL/FACILITY’S
PERFORMANCE AND CONTINUOUSLY IMPROVE IN AN
ONGOING & REITERATIVE BASIS.
• THE SURVEYOR VISIT ORGANISED BY MSQH PROVIDES
OPPORTUNITIES FOR EXTERNAL PEER REVIEW, MUTUAL
LEARNING & EDUCATION, VALIDATION OF CURRENT
PERFORMANCE ASSESSMENT AND SHARING OF BEST

• THE EMPHASIS AND FOCUS OF THE HOSPITAL
ACCREDITATION PROGRAMME (MSQH) IS A CONTINUOUS
IMPROVEMENT, PROMOTION AND PROPAGATION OF
PATIENTS SAFETY, QUALITY CULTURE IN THE
HEALTHCARE FACILITY OR ORGANIZATION.

• Non-profit
• Non-governmental
• Formed 1997 (ROS)
• Accredited over 142
hospitals
Enhancing
Patient Safety
and Quality of
Care
Nationally
• National
Accreditation Body
for healthcare
facilities and services
• Recognised by
Standards Malaysia
• Internationally
certified by ISQua
• Formed through
smart partnership
between public,
private and
professional bodies
• Initiated by MoH

MSQH (MALAYSIAN SOCIETY
FOR QUALITY IN HEALTH) – 6TH
EDITION
(TEMPOH IDEAL PELAKSANAAN : 1 TAHUN)

• IMPROVEMENT GRADIENTS ARE EMBENDED INTO THE HEALTHCARE
ACCREDITATION PROCESS
• ACCREDITING AGENCY/BODIES REVICE THEIR STANDARDS OVER TIME SO THEY ARE
BASED ON UP-TO DATE RESERCH AND CCEPTED BEST PRACTICES (between 3 to 5
years)
MSQH (MALAYSIAN SOCIETY
FOR QUALITY IN HEALTH) – 6TH
EDITION
Improvements
CQI
1st Ed 2ND Ed 3RD Ed 4TH Ed 5TH Ed 6TH Ed
4 YEARS :
1996 – 2000 (1ST EDITION )
2001 – 2005 (2ND EDITION)
2006 – 2010 (3RD EDITION)
2011 – 2015 (4TH EDITION)
2016 – 2020 (5TH EDITION)
2021 – 2024 (6TH EDITION)
1ST Ed 2ND Ed

COUNTRIES WITH ACCREDITATION
PROGRAMME :
Countrieswith National Accreditation Services

MALAYSIA HOSPITAL WITH
MSQH ACCREDITATION : KEMASKINI
30.05.2023
BIL NEGERI HOSPITAL KERAJAAN HOSPITAL SWASTA
1 JOHOR 1. HOSPITAL SULTANAH NORA ISMAIL
2. HOSPITAL TEMENGGONG SERI MAHARAJA
TUN IBRAHIM
1. COLUMBIA ASIA HOSPITAL
2. KPJ JOHOR SPECIALIST
3. KPJ PASIR GUDANG
4. KPJ BANDAR MAHARANI
5. PANTAI HOSPITAL BATU PAHAT
6. GLENEAGLES MEDINI
7. REGENCY SPECIALIST HOSPITAL
2 KEDAH 1. HOSPITAL JITRA 1. PANTAI HOSPITAL, SUNGAI PETANI
2. KEDAH MEDICAL CENTRE
3 KELANTAN 1. HOSPITAL TENGKU ANIS
2. HOSPITAL TUMPAT
1. KPJ PERDANA SPECIALIST HOSPITAL
4 MELAKA 1. MAHKOTA MEDICAL CENTRE
2. ORIENTAL MELAKA STRAITS MEDICAL CENTRE
3. PANTAI HOSPITAL AYER KEROH
5 NEGERI
SEMBILAN
1. HOSPITAL TUANKU AMPUAN NAJIHAH 1. KPJ SEREMBAN SPECIALIST HOSPITAL
2. AURELIS HOSPITAL NILAI
6 PERLIS 1. KPJ PERLIS SPECIALIST HOSPITAL

7 PAHANG 1. HOSPITAL SULTAN HJ AHMAD SHAH
2. HOSPITAL RAUB
3. HOSPITAL KUALA LIPIS
4. HOSPITAL JERANTUT
5. HOSPITAL BENTONG
1. KMI KUANTAN MEDICAL CENTRE
2. KPJ PAHANG SPECIALIST HOSPITAL
8 PULAU PINANG 1. HOSPITAL KEPALA BATAS 1. PANTAI HOSPITAL PENANG
2. PENANG ADVENTIST HOSPITAL
3. BAGAN SPECIALIST HOSPITAL
4. LOH GUAN LYE SPECIALIST CENTRE
5. ISLAND HOSPITAL
6. KPJ PENANG SPECIALIST HOSPITAL
7. LAM WAH EE HOSPITAL
9 PERAK 1. HOSPITAL SLIM RIVER
2. HOSPITAL SUNGAI SIPUT
3. HOSPITAL PARIT BUNTAR
4. HOSPITAL TELUK INTAN
5. HOSPITAL CHANGKAT MELINTANG
6. HOSPITAL BATU GAJAH
7. HOSPITAL GERIK
1. COLUMBIA ASIA TAIPING
2. KPJ IPOH SPECIALIST
3. PANTAI HOSPITAL IPOH
4. PANTAI HOSPITAL MANJUNG
5. HOSPITAL FATIMAH
10 TERENGGANU - -
MSQH ACCREDITATION :

BIL NEGERI HOSPITAL
KERAJAAN
HOSPITAL SWASTA
11 PERLIS 1. KPJ PERLIS SPECIALIST HOSPITAL
12 SELANGOR 1. HOSPITAL KUALA KUBU
BAHRU
2. HOSPITAL SELAYANG
3. INSTITUT KANSER NEGARA
1. ARA DAMANSARA MEDICAL CENTRE 11. KPJ AMPANG PUTERI
2. COLUMBIA ASIA BUKIT RIMAU 12. KPJ KAJANG
3. KPJ RAWANG SPECIALIST CLINIC 13. KPJ SELANGOR
4. KPJ SELANGOR SPECIALIST CLINIC 14. MSU MEDICAL
CENTRE
5. BUKIT TINGGI MEDICAL CENTRE 15. KPJ DAMANSARA
6. PANTAI HOSPITAL KLANG 16. PANTAI HOSPITAL
AMPANG
7. SUBANG JAYA MEDICAL CENTRE 17. KPJ KLANG
8. SUNWAY MEDICAL CENTRE 18. SRI KOTA SPECIALIST
M.C
9. AVISENA SPECIALIST CLINIC 19. COLUMBIA ASIA
KLANG
10.COLUMBIA ASIA HOSPITAL CHERAS
13 WILAYAH
PERSEKUTUAN
1. HOSPITAL REHABILITASI
CHERAS
2. HOSPITAL CANSELOR
TUANKU MUHRIZ, UKM
1. GLENEAGLES HOSPITAL KL 8. PANTAI HOSPITAL KL
2. KPJ TAWAKKAL 9. COLUMBIA ASIA SETAPAK
3. KPJ SENTOSA 10. HOSPITAL PUSRAWI
4. PARK CITY M.C 11. TUNG SHIN HOSPITAL
5. PRINCE COURT M.C 12. INSTITUT JANTUNG
NEGARA
6. PANTAI HOSPITAL CHERAS 13. KPJ SENTOSA KL

14 SABAH 1. HOSPITAL BEAUFORT
2. HOSPITAL KENINGAU
3. HOSPITAL KOTA MARUDU
4. HOSPITAL KUALA PENYU
5. HOSPITAL KUNAK
6. HOSPITAL MESRA BUKIT PADANG
7. HOSPITAL SIPITANG
8. HOSPITAL QUEEN ELIZABETH
9. HOSPITAL WANITA & KANAK2 LIKAS
1. GLEANEGLES HOSPITAL KOTA KINABALU
2. KPJ SABAH SPEACILIST HOSPITAL
3. JESSELTON MEDICAL CENTRE
15 SARAWAK 1.HOSPITAL BINTULU
2.HOSPITAL SIBU
3.HOSPITAL KANOWIT
4.HOSPITAL SERIAN
5.HOSPITAL MIRI
6.HOSPITAL SARIKEI

MSQH 6TH EDITION :
STRATEGIES & LIST OF
INDICATORS (53 SERVICE STANDARDS)

1. ORGANISATION & MANAGEMENT
2. HUMAN RESOURCE DEVELOPMENT & MANAGEMENT
3. POLICIES & PROCEDURES
4. FACILITIES & EQUIPMENT
5. SAFETY & PERFORMANCE IMPROVEMENT ACTIVITIES
6. SPECIAL REQUIREMENTS
MSQH 6TH EDITION : FOCUS
ELEMENTS
(6 ELEMENS)

MSQH 6TH EDITION : STANDARD
25
MEDICAL ASSISTANTS
SERVICES

25
MEDICAL ASSISTANTS
SERVICES
ELEMENT 1-3 : PPP U32 (CHIEF MOHD
SAIFULLAH
AFFENDI NGO
ABDULLAH)

6TH EDITION
SERVICE STANDARD 25:
MEDICAL ASSISTANT SERVICES
MOHD. SAIFULLAH AFFANDI NGO ABDULLAH
Penolong Pegawai Perubatan
Unit Pengurusan Penolong Pegawai Perubatan
Hospital Umum Sarawak

INTRODUCTION
Medical Assistants are a group of registered professional healthcare providers
within the Malaysian healthcare system and they are governed legally by Act 180, i.e. Medical
Assistants (Registration) Act 1977. The title Medical Assistant was changed administratively
by the Public Services Department through a circular effective 2nd of July 2009. The change was
imperative to reflect the current role, functions and direction of the profession. Medical Assistants
(Assistant Medical Officers) are a group of highly trained competent professionals who
form an integral part in primary and specialised health services. The scope of services
provided encompasses the aspects of promotive, preventive, curative and rehabilitative
in health care. It includes the clinical and governance aspects of various disciplines in both medical
and public health setting.
The services of the Medical Assistant (Assistant Medical Officers) is an integral component in the
integrated services of healthcare as partners that aspires to enhance the quality of life and create a
healthy and productive Malaysian nation.

OVERVIEW
 Organisation And Management
 Human Resource Development And Management
 Policies And Procedures
 Facilities And Equipment
 Safety And Performance Improvement Activities
 Special Requirements

STANDARD 25.1 :
ORGANISATION AND MANAGEMENT
The services of Medical Assistants (Assistant Medical
Officers) shall be organised, directed and coordinated
with other services to provide professional middle level
healthcare uncompromised in terms of quality and
standards as required by the relevant authorities.

STANDARD 25.1.1.1
Vision, Mission and values statements of the Facility are
accessible. Goals and objectives that suit the scope of the
services of Medical Assistants are clearly documented
and measurable that indicates safety, quality and patient
centered care. These reflect the roles and aspirations of
the service and the needs of the community. These
statements are monitored, reviewed and revised as
required accordingly and communicated to all staff.

STANDARD 25.1.1.2
The organisational structure of the services of Medical Assistants is clearly
represented in one or more organisation charts which:
 Provides a clear representation of the structure, functions and
reporting relationships between the Person in Charge (PIC), Head of
Service (Chief Medical Assistant), Senior Medical Assistants, Medical
Assistants (numbers only), Senior Healthcare Assistants / Pembantu
Perawatan Kesihatan (PPK) and Healthcare Assistants (numbers only).
 Accessible to all staff and clients and revised when there is a major
change in any one of the organisation, functions, reporting relationships
and staffing patterns.

STANDARD 25.1.1.3
Regular staff meetings are held between the Chief Medical
Assistant and staff with sufficient regularity to discuss issues and
matters pertaining to the operations of the services of Senior
Medical Assistants and Senior Healthcare Assistants / Pembantu
Perawatan Kesihatan (PPK). Minutes are kept; decisions and
resolutions made during meetings shall be accessible,
communicated to all staff of the service and implemented.

STANDARD 25.1.1.4
THE CHIEF MEDICALASSISTANT IS INVOLVED IN THE
PLANNING, JUSTIFICATION AND MANAGEMENT OF
THE BUDGET AND RESOURCE UTILISATION OF THE
SERVICES.
STANDARD 25.1.1.5
The Chief Medical Assistant is involved in the assignment
of staff (i.e. assignment letter, job description, duty roster).

STANDARD 25.1.1.6
All statistics and records pertaining to the services of Medical Assistants
shall be maintained and used for managing the services and patient care
purposes:
- Workload / census (inpatients and outpatients)
- Annual report
- Incident and near misses reports
- Staffing number and staff profile
- Staff training records
- Data on performance improvement activities (performance indicator)

STANDARD 25.1.1.7
The Chief Medical Assistant heads the planning, development
and evaluation of the services of Medical Assistants and
Healthcare Assistants / Pembantu Perawatan Kesihatan (PPK).
STANDARD 25.1.1.8
There is evidence that the services of Medical Assistants are
involved in the development and implementation of new
technologies.

STANDAR 25.1.1.9
If the Facility provides clinical experience for student Medical Assistants, there
should be a comprehensive documented agreement between the Facility and the
educational institution detailing the responsibilities of all parties, which shall
include:
 time period
 liability
 review of terms of contract
 accountability for clinical practices
 Appointment of local preceptors from among the existing
staffs

STANDARD 25.2 :
HUMAN RESOURCE DEVELOPMENT AND
MANAGEMENT
The Medical Assistant Services shall be directed by
suitably qualified and experienced Chief Medical
Assistant, and adequately staffed by Medical Assistants
and Healthcare Assistants / Pembantu Perawatan
Kesihatan (PPK) to achieve the goals and objectives of
the services.

STANDAR 25.2.1.1
All Medical Assistants shall be individuals qualified in terms of
education, training, experience, certification and registration under the
Medical Assistants (Registration) Act 1977 to commensurate with the
requirements of the various positions.
STANDARD 25.2.1.2
The Chief Medical Assistant is a member of the Senior Management
Team and sits on relevant committees of the Governing Body.

STANDARD 25.2.1.3
The Chief Medical Assistant shall designate suitably qualified Medical Assistants
with delegated responsibilities for delivering of services for each unit.
STANDARD 25.2.1.4
Medical Assistants staffing pattern shall reflect:
a) Patient needs and patient acuity level of care;
b) Staffing profile to comply with relevant guidelines and regulatory
requirements:
i) numbers;
ii) credentials and privileges;
iii) experience of the various categories of Medical Assistants.

STANDARD 25.2.1.5
There are written and dated specific job descriptions for all Medical Assistants that include:
a) qualifications, training, experience and certification required for the position;
b) lines of authority;
c) accountabilities, functions and responsibilities;
d) review when required and when there is a major change in any of the following:
i) nature and scope of work;
ii) duties and responsibilities;
iii) general and specific accountabilities;
iv) qualifications required and privileges granted;
v) staffing patterns;

STANDARD 25.2.1.6
The Chief Medical Assistant shall be responsible for the management,
supervision, training and performance appraisal of Healthcare Assistants
/ Pembantu Perawatan Kesihatan (PPK).
STANDARD 25.2.1.7
There is structured orientation programme for all newly appointed
Medical Assistants, Healthcare Assistant / Pembantu Perawatan
Kesihatan (PPK) and for those new to specific areas which shall include
the followings:

a) explanation of the Goals and Objectives, policies and procedures of the Facility, Medical
Assistant Services and Healthcare Assistant Services;
b) lines of authority and areas of responsibility;
c) explanation of particular duties and functions;
d) explanation of the methods of assigning specific care and the standards of practice;
e) handover communications;
f) processes for resolving practice dilemmas;
g) information about safety procedures;
h) training in basic/ advanced life support techniques;
i) methods of obtaining appropriate resource materials;
j) Annual Renewal Certificate (applicable to Medical Assistant only)
k) education on Patient and Family Rights;
l) education on MSQH standard requirements;
m) fire safety and disaster management;
n) patient safety;
o) staff appraisal procedures.

STANDARD 25.2.1.8
The Chief Medical Assistant ensures all Medical Assistants and Healthcare
Assistants/ Pembantu Perawatan Kesihatan (PPK) receive evaluation of their
performance at the completion of the probationary period and annually.
STANDARD 25.2.1.9
There is evidence of training needs assessment and staff development
plan which provide the knowledge and skills required for staff to
maintain competency in their current positions and future advancement.

STANDARD 25.2.1.10
There are continuing medical education and Continues Professional Development activities for
staff to pursue professional interests and to prepare for current and future changes in practice.
STANDARD 25.2.1.11
Personnel records on training, staff development, leave and others are maintained for every staff.
STANDARD 25.2.1.12
In a Facility where Medical Assistant education programmes are conducted, the Chief Medical
Assistant shall ensure that there are sufficient skilled clinical instructors with right credentials,
experience, certification and privileged to provide clinical guidance and supervision of students.

STANDARD 25.2.1.13
The Services of Medical Assistant shall ensure the establishment of a mechanism which includes requirements, methodology and certification
for credentialing and privileging for Medical Assistants in specialised areas for specific procedures. The mechanism taken by the Medical
Assistants shall adhere to the following:
a) the written policies and procedures documents the criteria for privileging;
b) the decisions made are objective, fair and impartial and consistent with written policies, procedures
and criteria;
c) the granting of privileges for a specified period of time;
d) the allocation of privileges in such a way that each staff functions within a specified area of
competence;
e) the granting of privileges is approved by the Credentialing and Privileging Committee and certified
by the Person in Charge (PIC)/ Governing Body.

STANDARD 25.3 :
POLICIES AND PROCEDURES
There are written and dated policies and procedures for all
services provided by Medical Assistants and Healthcare
Assistants/ Pembantu Perawatan Kesihatan (PPK). These
policies and procedures reflect current standards of services and
practice, relevant regulations, statutory requirements and the
purposes of the services.

STANDARD 25.3.1.1
There are written policies and procedures for services provided by
Medical Assistants and Healthcare Assistants / Pembantu Perawatan
Kesihatan (PPK) which are consistent with the overall policies of the
Facility, regulatory requirements and current standard practices which
include:
a) policies and procedures, applicable laws and regulations that
guide the medical care of all patients;
b) policies and procedures that guide the care of high risk
patients and high risk services.

CARE OF HIGH RISK PATIENTS & HIGH RISK
SERVICES:
Care of high risk patients and high risk services are:
i) Pre Hospital Care ix) Patients on dialysis
ii) Disaster/ Mass Casualty Management xv) Care of patients on restraints/violence
iii) Emergency patients xvi) High risk medications (Radio-iodine Oncology)
iv) Use of resuscitation services xii) Substance abuse (Methadone Clinic)
v) Administration of blood and blood products xiii) Medico legal cases
vi) Patients on life support/comatose xiv) Forensic services
vii) Patients with communicable disease xv) Community psychiatry
viii) Immune-compromised patients xvi) Public Health Emergency
** These policies and procedures are signed, authorised and dated. There is a
mechanism for and evidence of a periodic review at least once in every three years.

STANDARD 25.3.1.2
Policies and procedures are developed by a committee in collaboration with
staff, medical practitioners, nursing staff, Management and where required
with other external service providers and with reference to relevant sources
involved. Cross departmental collaboration is practiced in developing
relevant policies and procedures where applicable.
STANDARD 25.3.1.3
Current policies and procedures are communicated to all staff of the
Medical Assistant Services.

STANDARD 25.3.1.4
There is evidence of compliance with policies and procedures.
- verify with observation on practices
- audit on practices
STANDARD 25.3.1.5
Copies of policies and procedures, protocols, guidelines, relevant Acts,
Regulations, By-Laws and statutory requirements are accessible to staff
of Medical Assistant Services.

STANDARD 25.3.1.6
The Chief Medical Assistant is responsible for the organisation, documentation
and implementation of policies and procedures for the Medical Assistant
Services.
STANDARD 25.3.1.7
The Medical Assistants participate in planning, decision making and
formulation of polices of the Facility.

STANDARD 25.3.1.8
Medical Assistants practice is in accordance with nationally
accepted standards based on current evidences:
a) initial assessment of patients and immediate intervention
deemed necessary where relevant (i.e. triaging of patients
for emergency services, pre-hospital care and dialysis
patients);
b) administering treatment and performing procedures as
ordered by the medical practitioners;

c) reviewing and reporting changes in the progress of the
patient where relevant;
d) completing the planned management with proper
documentation;
e) planning follow up that reflects continuity of care where
required;
f) patient education which shall be documented (e.g.
Outpatient Clinic, Orthopedics, Dermatology and Eye
Clinics; Hemodialysis and Asthma patients).

THINGS TO DO
1) Organisation Chart
2) Workload / Annual Report
3) ARC Report
4) Staffing Number Report / Manpower Planning (ABM)
5) Staff Qualification – Post Basic, Credentialing & Privileging, e-Latihan, Training & Competency Report
(Quarterly)
6) Staff Training Report – BLS, ALS, PALS, BTS, ATLS, Fire Safety
7) Performance Improvement Activities / KPI / HPIA
8) Clinical Audit Report

25
MEDICAL ASSISTANTS
SERVICES
ELEMENT 4-6 : PPP U32 (CHIEF RIGEN
GEORGE)

NO CORE ELEMENT
1. THERE ARE EDEQUATE AND APPROPRIATE FACILITIES AND
EQUIPMENT FOR PROVIDING SAFE AND EFFICIENT MEDICAL
ASSISTANT’S SERVICES ACCORDING TO STANDARDS SET BY THE
RELEVENT AUTHORITIES AND REGULARITY REQUIREMENTS :
i) ADEQUATE AND PROPER SPACE (TRAINIG/TUTORIAL
AREA/ROOM)
ii) ADEQUATE FACILITIES & EQUIPMENT (AVAILABILITY/STOCKS
INVENTORY/PLAN PREVENTIVE MAINTENANCE(PPM)
iii) CONSUMABLE OR NON CONSUMABLE – e.g DEFIBRILLATOR,
EMERGENCY CART, PPE, HAND WASHING
MSQH 6 EDITION : STANDARD
25
MEDICAL ASSISTANTS
SERVICES

2 – CORE ELEMENT (25.5.1.3 – INCIDENT REPORTING,
25.5.1.4 – KPI/HPIA)
1. THE CHIEF MEDICAL ASSISTANT SHALL ENSURE THE
PROVISION OF QUALITY PERFORMANCE AND SAFETY
OF PATIENTS WITH THE STAFF INVOLVEMENT IN
CONTINUOUS SAFETY AND PERFORMANCE
IMPROVEMENT ACTIVITIES OF THE MEDICAL
ASSISTANT SERVICES.
25
MEDICAL ASSISTANTS
SERVICES

7 CORE ELEMENT : ALL ( WAJIB LULUS!!! )
1. ROLE IN ENVIROMENTAL & SAFETY SERVICES
2. ROLE AS FIRE SAFETY OFFICER
3. ROLE IN EXTERNAL/INTERNAL DISASTER MANEGEMENT
4. ROLE IN CLINICAL SUPERVISION
5. ROLE IN SPECIFIC CLINICAL SERVICES (ETD/PRE-HOSPITAL CARE,
HAEMODIALISIS, PSYCHIATRIC, ANAESTESIA/INTENSIVE CARE,
ORTHOPEDIC, OPTHALMOLOGY, OTORINOLARINGOLOGY,
NEUROPHYSIOLOGY, CARDIOTHORASIC SURGERY,
NEUROSURGICAL, ENDOSCOPY
25
MEDICAL ASSISTANTS
SERVICES

1. JABATAN KECEMASAN & TRAUMA : ASTMA CARE (PEFR),
TRIAGE CARE
2. JABATAN ORTHOPEDIK : POP CARE
3. JABATAN NEFROLOGI/HDU : HD TREATMENT VIA
PERMANENT VASCULAR ACCESS ( PRE HD, INTRA HD,
POST HD )
4. HDU & ETD : KAWALAN INFEKSI (HAND HYGIENE /
ENVIROMENTAL)
( PLEASE SENT A COPY OF AUDIT REPORT TO THE PPP
MEDICAL ASSISTANTS
SERVICES :
PERFORMANCE INDICATORS / CLINICAL
AUDIT

MSQH 6TH EDITION :
RATING SCALE SYSTEM
RATING RATIONALE
4
Excellent achievement
i(a) Rating of criteria in service standard:
80% to 100% of evidence of compliance to the criteria have
been achieved
i(b) For rating of overall performance of service
standard; an achievement of 80% to 100% of the
maximum score of the applicable criteria shall be rated as 4.
Example:
The total score of criteria (numerator) divided by
maximum score of applicable criteria (denominator).
210 (total score) x 100 = 91%
232 (4 x 58 applicable criteria)

RATING RATIONALE
3 Good achievement
ii(a) Rating of criteria in service standard:
been achieved.
ii(b) For rating of overall performance of ser vice
standard; an achievement of 60% to 79% of the maximum
score of the applicable criteria shall be rated as 3.
Example:
The total score of criteria (numerator) divided by maximum
score of applicable criteria (denominator).
165 (total score) x 100 = 71%
MSQH 6TH EDITION :
RATING SCALE SYSTEM

RATING RATIONALE
2 Fair achievement
iii(a) Rating of criteria in service standard:
been achieved.
For rating of 2, risk assessment needs to be performed.
iii(b) For rating of overall performance of service
standard; an achievement of 4 0 % to 59 % o f th e
maximum score of the applicable criteria shall be rated as
2.
Example:
120 (total score) x 100 = 52%
MSQH 6TH EDITION :
RATING SCALE SYSTEM

RATING RATIONALE
1 Poor achievement
iv(a) Rating of criteria in service standard:
0% to 39% of evidence of compliance to the criteria
have been achieved.
For rating of 1, risk assessment needs to be performed.
iv(b) For rating of overall performance of service
standard; an achievement of 0% to 39% of the
maximum score of the applicable criteria shall be rated
as 1.
Example:
85 (total score) x 100 = 37%
MSQH 6TH EDITION :
RATING SCALE SYSTEM

BENGKEL MSQH PPP SGH 2023.pptx

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