MSQH SURVEYING PROCESS ROLE OF SURVEYORS SURVEY ASSESSMENT

MSQH SURVEYING PROCESS; ROLE OF SURVEYORS, SURVEY ASSESSMENT, SUMMATION CONFERENCE & MCHS and VOTING PROCESS by Assoc. Prof. Dr. Kadar Marikar CHIEF Executive Officer, MSQH

ROLE OF SURVEYORS - conduct Accreditation Survey on Malaysian health care facilities and services, both public on behalf of MSQH; - provide a comprehensive Survey Report with commendations and recommendations which are consistent with the Standards to MSQH; - provide overall recommendation on the Accreditation Status (surveyors do not make the final decision on the Accreditation Status).

RESOURCES CODE OF CONDUCTS/ETHICS EVIDENCE BASED MEDICINE CUSTOMER SATISFACTION ACCREDITAT ION AWARD QUALITY OF CARE MSQH SERVICE STANDARDS ON PROVIDERS HRM ORG & MGMT STRUCTURE F&E P&P PROCESS DOCUMENTATION EVIDENCE OF PRACTICE QIA OUTPUT

HOSPITAL-WIDE SURVEY ACCREDITATION AWARD – AN IMPARTIAL PROCESS IND. SURVEYOR PRESENTATION SURVEY TEAM DELIBERATION SECRET BALLOT HOSPITAL IDENTITY EXPUNGED S 1 S 2 S 3 S 4 S 5 VOTE VOTE POST SURVEY - ON SITE SURVEY TEAM CONCENSUS EDITED SURVEY REPORT ENDORSEMENT BY CHIEF SURVEYOR FINAL SURVEY REPORT MINIMUM 3 INDEPENDENT VOTING COUNCILLOR 1 VOTE COUNCILLOR 2 COUNCILLOR 3 VOTE MSQH Accreditation Chairman Endorsed by MCHS Chairman FINAL ACCREDITATION STATUS CONFERMENT – MSQH PRESIDENT

MALAYSIAN COUNCIL ON HEALTHCARE STANDARDS: VOTING PROCESS

ORGANISATION MSQH BOARD SECRETARIAT RESOURCE CENTER DOMESTIC & RESEARCH INT. RELATIONS & DEVELOPMENT MALAYSIAN COUNCIL ON HEALTHCARE STANDARDS EDUCATION ACCREDITATION SURVEY STANDARD

CURRENTLY COUNCILLORS ARE FROM: (2) (1) (5) (2) (1) MALAYSIAN NURSES ASSOCIATION (This will further be increased as required with the increasing needs and activities of MSQH)

MALAYSIAN COUNCIL ON HEALTHCARE STANDARDS (MCHS): Undergone special training from MSQH on: • MSQH Accreditation Policies • Accreditation Standards, process and voting Criteria: • Nominated by the respective bodies • High standing/senior position in their organisation • Good understanding of the healthcare system

Voting process-Selection of Councilors • Done by MSQH Secretariat • Minimum three (3) for each Survey Report • MSQH ensures impartially • Independent voting – no contact except with MSQH • Confidential appointment for each report • Confidentiality maintained – code of conduct

ROLE OF COUNCILORS • 1. Ensures objective assessment of facility rating by surveyors. • 2. Confirming surveyor recommendations based on a thorough assessment of the final survey report of the facility. • 3. Voting on the accreditation status to be awarded to the facility. • 4. Provide comments on the basis on which the vote is arrived at. • 5. Making any additional comments on the quality of report and any other areas of concern relating to the report format/report writing. • 6. Any clarification on the final report should ne addressed to the MSQH Secretariat.

VOTING • Refer voting form in the package.

VOTING DECISION • Results tallied by MSQH Secretariat • Final Result is endorsed by MCHS Chairman • MSQH President confers the certification to the respective organization. • Public announcement is at the discretion of the hospital

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