WHAT IS HOSPITAL ACCREDITATION PROGRAMME?
The MSQH Hospital Accreditation Program (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), a not-for-profit and non- governmental society formed subsequent to a tripartite Memorandum of Understanding between the Malaysian Ministry of Health (MOH), Malaysian Medical Association (MMA) and Association of Private Hospitals, Malaysia (APHM).
The MSQH Hospital Accreditation Program (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), a not-for-profit and non- governmental society formed subsequent to a tripartite Memorandum of Understanding between the Malaysian Ministry of Health (MOH), Malaysian Medical Association (MMA) and Association of Private Hospitals, Malaysia (APHM).
The Hospital Accreditation Program of MSQH provides an effective means whereby health care facilities can assess their level of performance against applicable national standards, which have been developed by expert healthcare professionals and are accepted for nationwide application in Malaysia.
The MSQH 6th Edition Hospital Accreditation Standards provide a benchmark against which healthcare organisations can regularly assess their organizational/facility’s performance and continuously improve in an ongoing and reiterative basis.
The hospital accreditation survey visits organized by MSQH, made upon the request of a healthcare facility, provide opportunities for external peer review, mutual learning and education, validation of current performance assessment, and sharing of best practices in the healthcare industry.
The emphasis and focus of the Hospital Accreditation Program is on continuous improvement, and the promotion and propagation of patient safety and quality culture in the healthcare facility or organization.
The MSQH Hospital Accreditation Standards have been reviewed and updated. The 6th Edition Standards have been approved for implementation in January 2022. These standards have considered the current
requirements of the Private Health Care Facilities & Services Act 1998 and its corresponding Regulations 2006, Medical Device Act 2012 and other related current regulatory requirements. These updated Standards have additional focus on requirements of WHO Patient Safety Initiatives, Malaysian Patient Safety Goals, requirements of ISQua Principles for standards Development 3rd edition and the current Infectious disease Act 2019. The 6th edition standards also focuses on risk assessment andmeasurement and tracking and trending Key Performance Indicators of all services delivered.
Accreditation
a self-assessment and external peer review process used by healthcare organisations to accurately assess their level of performance in relation to established standards and to implement ways to continuously improve the healthcare system.
HOSPITAL ACCREDITATION STANDARDS
Performance measurement requires a reference standard. Therefore to measure the safety and quality of patient care, standards are required against which healthcare facilities can be compared.
The development of the MSQH Hospital Accreditation Standards is an evolutionary process, the standards are periodically reviewed and updated in light of advances in healthcare and currently accepted practices as well as regulatory requirements.
MSQH standards are developed and edited in cooperation with professionals from public and private healthcare providers and consumers.
Malaysian Hospital Accreditation Standards are grouped into six (6) major areas of concern. These areas of concern are:
Organisation & Management
Organisation & Management
Human Resource Development and Management
Human Resource Development and Management
Policies and Procedures
Policies and Procedures
Facilities and Equipment
Facilities and Equipment
Safety and Performance Improvement Activities
Safety and Performance Improvement Activities
Special Requirements
Special Requirements
Special requirements of these standards are the safety aspects that are not compromised. An organization that does not meet the safety requirements of the standards will not be accredited although it has met the rest of the standards. These standards provide the basis for organisational assessment of the delivery of safety and quality patient care and services, and the utilisation of available resources.
These standards are applicable to all types of hospitals - public and private, large and small, urban and rural. Today, many people are concerned about finding the best ways to meet their healthcare needs. When you use a facility accredited by the MSQH, you know it meets our rigorous standards.
Hospital Accreditation
The MSQH may accredit any healthcare facility or service as defined by the Private Healthcare Facilities and Services Act 1998, which defines healthcare facility as any premises in which one or more member of the public receive healthcare services. Similar healthcare services in the public sector are also eligible to be surveyed and accredited.
The MSQH may accredit any healthcare facility or service as defined by the Private Healthcare Facilities and Services Act 1998, which defines healthcare facility as any premises in which one or more member of the public receive healthcare services. Similar healthcare services in the public sector are also eligible to be surveyed and accredited.
- Medical and surgical, dental, nursing, midwifery, allied health, pharmacy, and ambulance services and any other healthcare related services provided by single or group of healthcare professionals;
- Accommodation for patient care more than 24-hour the purpose of any of the above services;
- Any service for the screening, diagnosis, or treatment of persons suffering from any disease, injury or disability of mind or body;
- Any service for preventive or promotive health care purposes;
- Any service provided by any healthcare para-professional;
- Any service for curing or alleviating any abnormal condition of the human body by the application of any kind of medical technology.
- Standalone ambulatory centres
- Be a member of MSQH
- Be a healthcare facility in operation for a minimum of 12 months, either in the public or private sector; any new services to be included in the survey shall be in operation for a minimum of at least 6 months before the survey date
- Be a provider of services for which the MSQH have applicable Accreditation Standards [MSQH will not survey the Traditional and Complimentary Medicine (TCM) Services.
- Have a current and valid "license" as required by the Ministry of Health and any other relevant regulating body.
- Ensure the availability of all services necessary to fulfil the organisation's mission and objectives. (These services may be provided on site, or may be provided off-site by partnerships with acceptable community or regional resources)
- Complete and return a "Survey Application Form" to MSQH. The application must be signed by the Person-In-Charge (PIC) of the Hospital or an equivalent person with overall authority and responsibility for the healthcare facility
Survey Application
Training Requirements
Healthcare facilities applying for first-time accreditation must attend mandatory training and education conducted by MSQH trainers.
An official request letter must be submitted to MSQH for the training.
Successful applicants will be notified in writing about the processes they must undergo, including training and self-assessment before the survey.
Training Requirements
Healthcare facilities applying for first-time accreditation must attend mandatory training and education conducted by MSQH trainers.
An official request letter must be submitted to MSQH for the training.
Successful applicants will be notified in writing about the processes they must undergo, including training and self-assessment before the survey.
Application Process
Apply online for the Hospital Accreditation Survey.
The completed application must reach MSQH at least six (6) months before the intended survey date for logistical planning.
Private Healthcare Facilities must attach a valid hospital license from the Ministry of Health. Only services listed in the license will be surveyed.
Applications are valid for 12 months from the submission date.
Survey dates will be arranged through mutual consultation, and MSQH will assign a survey team appropriate to the facility’s complexity, with facility agreement.
Application Process
Apply online for the Hospital Accreditation Survey.
The completed application must reach MSQH at least six (6) months before the intended survey date for logistical planning.
Private Healthcare Facilities must attach a valid hospital license from the Ministry of Health. Only services listed in the license will be surveyed.
Applications are valid for 12 months from the submission date.
Survey dates will be arranged through mutual consultation, and MSQH will assign a survey team appropriate to the facility’s complexity, with facility agreement.
Eligibility and Preparation
The minimum time frame required for any Healthcare Facility to be eligible for the survey is six months post-training to allow time for the facility to make adequate preparation. The facility is required to send a request letter for training.
MSQH will inform facilities about the costs related to preparation and the survey itself.
Eligibility and Preparation
The minimum time frame required for any Healthcare Facility to be eligible for the survey is six months post-training to allow time for the facility to make adequate preparation. The facility is required to send a request letter for training.
MSQH will inform facilities about the costs related to preparation and the survey itself.
For Currently Accredited Facilities
MSQH will send the renewal application form six (6) months before the current accreditation expires.
Facilities in their second or subsequent surveys are expected to demonstrate improved quality of care and services.
The survey date will be confirmed in writing by MSQH.
For Currently Accredited Facilities
MSQH will send the renewal application form six (6) months before the current accreditation expires.
Facilities in their second or subsequent surveys are expected to demonstrate improved quality of care and services.
The survey date will be confirmed in writing by MSQH.
msqh@msqh.com.my
msqh@msqh.com.my
+60 3 2681 2232
+60 3 2681 2232
Benefit of Hospital Accreditation Programme
- tested performance standards that focus on quality and safety in patient care,
- assurance that your service meets or exceeds the quality health standards available in Malaysia and is recognised internationally,
- strengthening community trust in being certified is evidence to patients and community that your organisation is committed to providing Safe and Quality Healthcare Service,
- greater client satisfaction,
- trust in your staff's ability to respond appropriately to patient needs and to protect their rights,
- security in the knowledge that quality systems are in place to identify and remedy health problems.
- comprehensive and structured analysis of performance,
- a broad based improvement in delivery of services,
- reduced re-work and rectifications, since things are done right the first time and every time,
- establishes organisational credibility, builds up staff and stakeholders’ confidence towards the hospital,
- better outcomes of care,
- reduced risk and medical defence costs,
- confidence that you focus on safety, quality care and service excellence,
- enhanced public trust, image and competitive edge.
- a valuable learning experience through self-assessment, reflection, and challenge to tradition,
- empowerment to improve the processes and change current practices in delivery of care,
- enhanced teamwork, staff satisfaction, staff morale and confidence in the services that they deliver,
- provision with the right tools and new techniques and technology for safe and quality services in a low risk environment,
- being part of a client-focused team to achieve service excellence,
- equipping with a rigorous approach to continuous improvement,
- sharing knowledge through a nationwide network of quality health providers,
- esteem and endorsement by peers and the public for a conscious and active effort in maintaining high professional standards.
- confidence that your organisation is client focused,
- assurance that your organisation operates according to industry standards and meets international safety standards and requirements,
- success and sustainability of business through safer quality outcomes,
- confidence that risk is minimised and managed to create better shareholder value.
Accreditation Status Hospital Accreditation Survey
Four Year Accreditation
- A Four-Year Accreditation is awarded to those facilities, which in the opinion of MSQH, substantially comply with the MSQH healthcare standards. It should be noted that the healthcare facilities must achieve substantial compliance in all Core Standards and other Safety Standards, to achieve Four-Year Accreditation.
Delayed Accreditation
- A one-year Accreditation is awarded to those facilities which have met the requirements of most of the standards but have some safety issues which need to be addressed. A facility awarded a one-year accreditation is offered the opportunity to undergo Focus Survey within the next twelve (12) months
Non-Accreditation
- Non Accreditation will be awarded to a facility in which the surveyors have observed and reported that a significant number of standards are not complied with. Facilities that are not accredited are encouraged to implement the recommendations made in the Survey Report and to re-apply for survey. It is recommended that a minimum of twelve (12) months should elapse, to allow time for remedial actions and rectification works, before the next survey is undertaken.