ACCREDITATION STATUS DECISION  

 

  • At the accreditation survey, the surveyors identify and commend on areas of excellence as well as highlight any opportunities for improvement, using currently accepted standards as the benchmark. The observations of the surveyors, together with individual recommendations on the accreditation status by each member of the survey team are collated by the Chief Surveyor, who will forward this composite result with a final Hospital Survey Report to MSQH.
  • The final accreditation status decision is made based on a review of the Hospital Survey Report and recommendations of the survey team by a panel of three (3) Councillors, selected from the members of the Malaysian Council of Healthcare Standards (MCHS), a body chaired by the Director Medical Development Malaysia. 
  • Three categories of Accreditation awards may be awarded, depending on the level of compliance to standards attained by the healthcare facility which is undergoing the accreditation survey process.
  • The final award decision and the recommendations are forwarded by MSQH to the Chief Executive Officer (CEO), the owner, or the chair of the Governing Body of the surveyed facility. Release of any confidential information pertaining to the facility will be subject to written consent from the CEO, the owner or the chair of the Governing Body

 


 Four-year Accreditation 

For the award of Four-Year accreditation status, the Facility shall have to comply with the following requirements:

    • The following core service standards shall achieve overall rating of minimum 3:
      • Standard 1 - Governance, Leadership & Direction
      • Standard 2 - Environmental and Safety Services
      • Standard 3 - Facility and Biomedical Equipment Management and Safety
      • Standard 4 - Nursing Services
      • Standard 5 - Prevention and Control of Infection
      • Standard 6 - Patient and Family Rights
      • Standard 7 - Health Information Management System (HIMS)
    • All clinical services standards including critical care services standards (STANDARD REFERENCE) shall achieve overall rating of at least 3.
    • Core criteria must achieve a rating of 4 or 3 for the standards to reach compliance. However, a core criterion rating of 2 may be acceptable, if the risk associated with the criterion is Moderate or Low as calculated on the risk matrix and the necessary action can be achieved within 12 months post award.
    • For other services, where there is overall rating of 2 or 1, risk assessment (by using the risk matrix) is required and the risk is categorized as Moderate or/and Low.
    • Decision for awarding accreditation status takes into consideration:
      • overall impact of the hospital services assures patient safety;
      • recommended score from the surveying team and councillors aggregated score.
      • Accreditation Status Four-Year Accreditation
        Score 20 - 30
    • Additional recommendation based on the achievement for Four-Year accreditation status for facilities receiving overall performance score of:
      • 80% to 100% will be awarded Excellent Achievement provided there are no score of 2 or 1 for any criteria in all service standards.
      • Subject to item (i), all facilities achieving 60% to 79% will be given Good Achievement.

 One-year Accreditation 

    • The above requirements , , are not met. 
    • Areas for improvement and recommendations can be rectified within 12 months period before the Focus Survey

      • Accreditation Status Four-Year Accreditation
        Score 10 - 19

 


 Non-Accreditation 

    • The above requirements , , are not met. 
    • Areas for improvement and recommendations requires more than 12 months period to rectify.
      •  
        Accreditation Status Four-Year Accreditation
        Score 1 - 9

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MSQH

B.6-1, Level 6 Menara Wisma Sejarah,

230 jalan Tun Razak, 50400 Kuala Lumpur, Malaysia

+603 2681 2232

+603 2681 3199

msqh@msqh.com.my

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