1. MSQH Hospital Accreditation Standards 5th Edition
Ms Rebecca John
MSQH Project Manager

2. MALAYSIAN HOSPITAL ACCREDITATION STANDARDS
The MSQH Hospital Accreditation Standards provide the basis for assessment of healthcare facilities and services, and are applicable to all types of hospital both public and private, large and small, urban and rural.

3. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Organizational wide Service Standards 1
Governance, Leadership and
Direction 2
Environmental and Safety
Services 3
Facility Management and Safety 4
Nursing Services 5
Prevention and Control of Infection 6
Patient and Family Rights 7
Health Information Management System (HIMS)

4. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 8
Emergency Services 9
Clinical Services
(Generic)
Clinical Services – Non Specialist
Facility 10 9A
Cardiology Services
Clinical Services – Medical Related 11 9B
Oncology Services
Clinical Services – Surgical Related 12 9C
Obstetrics & Gynaecology Services 13 9D
Paediatric Services 14 9E 15 9F
Oncology Services
Anaesthetic Services 16

5. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 13 11
Operating Suite Services 17 14 12
Ambulatory Care
Service 18
Ambulatory Care Services 15
Critical Care Services
(Generic) :
ICU, CCU, NICU, PICU
& Haemodialysis 19
Critical Care Services:
ICU/CCU/CICU/CRW/HDU/Burns
Care Unit 16
13A
Labour Delivery
Services 20
Critical Care Services :
SCN/NICU/PICU/PHDW

6. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 21
13B
Critical Care Services :
Labour/Delivery Services 22
13C
Chronic Dialysis Treatment 17 14
Radiology/Diagnostic Imaging Services 23 18 15
Pathology Services 24 19 16
Blood Transfusion
Services 25
Blood Transfusion Services

7. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 20 17
Rehabilitation Medicine Services 26
Rehabilitation Medicine Services 21
17A
Allied Health Professional Services - Physiotherapy Services 27 22
17B
Allied Health Professional Services - Occupational Therapy Services 28 23
17C
Allied Health Professional Services - Dietetic Services 29 24
17D
Allied Health Professional Services – Speech Language Pathology Services 30
Allied Health Professional Services – Speech - Language Therapy Services 25
17E
Allied Health Professional Services – Audiology Services 31

8. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 26
17F
Allied Health Professional Services – Optometry Services 32 27
17G
Allied Health Professional Services – Health Education Services 33 28
17H
Allied Health Professional Services – Medical Social Services 34 29
17I
Allied Health Professional Services – Psychology Counselling Services 35 30
17J
Allied Health Professional Services – Clinical Psychology Services 36

9. MSQH Hospital Accreditation StandardsNo
Std
4th Edition
5th Edition
Service Standards 31 18
Pharmacy Services 37 32 19
Central Sterile Supply Services 38 33 20
Housekeeping Services 39 34 21
Linen Services 40 35 22
Food and Dietary Services 41
Food Services 36 23
Forensic Medicine Services 42
22A
Mortuary Services 43
23A 24
Standards for General Applications 44
Standards for General Application
- Generic 45
24A
Standards for Clinical Research Centre

10. Outline of Standards 5th Edition
The MSQH Hospital Accreditation Standards 5th Edition has both the standards and the assessment tool in the same document. This document is also termed the MSQH Hospital Accreditation Guide. The sections of the Guide includes the following:
i) Title of the Service Standard
ii) Preamble

11. Outline of Standards 5th Edition
iii) Service Standards
iv) Criteria for compliance
- Core Criteria*
* A number of criteria have been identified as core to the standards. They include core processes that impact patient/staff safety and compliance to regulatory requirements.
Notes/Explanation
Evidence of Compliance

12. Outline of Standards 5th Edition
vii) Facility Comments
viii) Self Rating
ix) Surveyor Findings & Comments
x) Surveyor Summary & Overall Rating

13. Outline of Standards 5th Edition
The Standards are organised into 5 Areas of Focus/Topics (except for Standard No: 6)
- Organisation and Management
- Human Resource Development and
Management
- Policies and Procedures
- Facilities and Equipment
- Safety and Performance Improvement Activities
& Special Requirements for specific standards

14. Outline of Standards – Topic: Special Requirements
Std. 2: Environmental and Safety Services
Std. 3: Facility and Biomedical Equipment Management
and Safety
Std. 7: Health Information Management System (HIMS)
Std. 9A: Cardiology Services – invasive & non invasive
cardiac laboratories
Std. 9B: Oncology Services
Std. 10: Anaesthetic Services
Std. 14: Radiology/Diagnostic Imaging Services
Std. 19: CSSS
Std. 22: Food Services

15. Outline of Standards - Topic
Standard No. 6: Patient & Family Rights; the areas of focus are:
Patient and Family rights
Informed consent
Research
Organ donation
Patient Centred Care

16. Standards & Self Assessment Tool

17. Outline of Standards
Every Service Standard is categorized by Title of Service & Preamble:
SERVICE STANDARD 1 : GOVERNANCE, LEADERSHIP AND
DIRECTION
PREAMBLE :
Each Facility shall have a body ultimately responsible for all aspects of the Facility’s operations. This is commonly called the Board of Directors/Facility Management or other similar name. For the purposes of these Standards, this group shall be called “The Governing Body”. The
Governing Body may delegate its duties and functions to the Person In Charge (PIC) of the Facility who shall be responsible for the organisation,
management and control of the Healthcare Facility and services.
For private healthcare facilities, a license or registration is required which relates to the services.

18. Outline of Standards Every Service Standard is categorized by Topic:
Topic 1.1: ORGANISATION AND MANAGEMENT
Standard 1.1.1
The Governing Body shall adopt a governing framework that constitutes
the internal legislation that will meet the particular needs and
complexities of the management of the Facility and the range of
services. These may be called Facility Operational Policies and Medical
Staff By-Laws, which include Rules and Regulations, Terms of
Reference, Policies, Resolutions or other similar terms and they shall
govern the actions of the Board and Management of the Facility. The
governing framework is essential for the governance of the Facility.

19. Outline of Standards
CRITERIA FOR COMPLIANCE:
The Governing Body shall ensure that the Vision, Mission and values statements, goals and objectives are identified, clearly documented and measurable; these reflect the Facility’s roles and aspirations in the community that it serves. These statements are monitored, reviewed and revised as required accordingly and communicated to all staff.

20. Outline of Standards EVIDENCE OF COMPLIANCE
1. Vision, Mission and values statements, goals, and objectives of
the Facility are available; endorsed and dated by the Governing
Body.
2. Evidence of planned reviews of the above statements
3. These statements are communicated to all staff (orientation
programme, minutes of meeting, etc).
4. Achievement of goals and objectives are monitored, reviewed
and revised accordingly.

21. Outline of Standards- Core Criteria
The Governing Body shall adopt a governing framework in accordance with statutory and other legal requirements.
Evidence of Compliance :
1.License to operate (Private Healthcare Facility)/Gazetement letters and supporting documents (Public Healthcare Facility)
2. Appointment of full time Person In Charge (PIC) in accordance with the Fourth Schedule in Private Healthcare Facilities and Services Act 1998 and Regulations 2006.
3. Facility Operational Policies
4. Medical Staff By-Laws

22. Outline of Standards Note:
3. Notes/Explanation Additional information to clarify the requirements/guide what information to look for. e.g.
Note:
Staff personal record may be kept in Human Resource Department as per Facility policy.

23. Malaysian Hospital Accreditation Standards – 5th Edition
MSQH Copyright

24. MSQH Hospital Accreditation Standards (GENERIC)
Interpretation of MSQH Hospital Accreditation Standards - 5th Edition

25. Organization and Management
1. Standard
The …………… Services shall be organised, directed and coordinated with other services in the Facility according to the goals and objectives of the Facility to meet the needs of the patient population being served. .

26. Organization and Management
1.1 Criteria for Compliance
Vision, Mission and values statements of the Facility are accessible. Goals and objectives that suit the scope of the ………… Services are clearly documented and measurable that indicates safety, quality and patient centred 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. .

27. Organization and Management
Evidence of Compliance
Vision, Mission and values statements of The Facility
Goals and objectives of the Services
Evidence of planned reviews of the above statements.
These statements are communicated to all staff
Achievement of goals and objectives are monitored & revised

28. Organization and Management
1.2 Criteria for Compliance (Core)
There is an organisation chart which:
provides a clear representation of the structure,
functions and reporting relationships between the PIC,
Head of the Services, Consultants, medical
practitioners and staff of the Services
accessible to all staff and clients
is revised when there is a major change in the
organisation, functions, reporting relationships & staffing
patterns

29. Organization and Management
Evidence of Compliance 1. Clearly delineated current organisation chart with line of functions and reporting relationships 2. Organisation chart is endorsed, dated and accessible 3. The organisation chart is revised when there is a major change

30. Organization and Management
1.3 Criteria for Compliance
Regular staff meetings are held between Head of Service and staff to discuss issues and matters pertaining to the operations of the ……….Services
Minutes are kept; decisions and resolutions made during meetings made accessible & communicated to all staff and implemented

31. Organization and Management
Evidence of Compliance
Minutes are accessible, disseminated & acknowledged by
the staff.
2. Attendance list of members
3. Frequency of meetings as scheduled.
4. Discussion and resolutions are implemented.

32. Organization and Management
1.4 Criteria for Compliance
The Head of the Services is involved in clinical governance and patient management.
Evidence of Compliance
1. Departmental, unit or committee meetings are chaired
by Head of Services.
2. Clinical procedures are endorsed by the Head of Services.

33. Organization and Management
1.5 Criteria for Compliance
The Head of the Service is involved in the planning, justification and management of the budget and resource utilisation of the services.
Evidence of Compliance
Minutes of Facility-wide management meetings.
Documented evidence on request for allocation of budget and
resources (staffing, equipment, etc)
Approved budget and resources.

34. Organization and Management
1.6 Criteria for Compliance
The Head of the Service is involved in the appointment and /OR assignment of the staff
Evidence of Compliance
1. Records on staff interview (if applicable)
2. Appointment/assignment letter of Head of Service
3. Job description of Head of Service
4. Duty roster
5. Records on staff deployment

35. Organization and Management
1.7 Criteria for Compliance
Appropriate statistics and records shall be maintained and used for managing the services and patient care purposes.

36. Organization and Management
Evidence of Compliance
Records are available but not limited to the following:
workload/census;
annual report;
accident/incident reports;
staffing number and staff profile;
staff training records;
data on performance improvement activities, including performance indicators

37. Organization and Management
1.8 Criteria for Compliance
Where the ………. Services provides clinical experience for students of medicine and paramedical sciences, a comprehensive documented agreement between the Facility and the educational institution shall exist detailing the responsibilities of all parties.

38. Organization and Management
Evidence of Compliance 1. Valid letter of intent (MoU) or request/posting and assigned supervisor 2. Ratio of Clinical Instructor (CI) and students commensurate with the number of students 3. Student allocation roster or programme

39. Organization and Management
1.2 Standard
Where the Facility does not have the facilities or medical ability to render optimum care to the patient, arrangements shall be made for transfer to another facility or appropriate treatment centre after performing basic resuscitation or stabilization

40. Organization and Management
1.2.1 Criteria for Compliance
When arranging for patient to be transferred to a receiving facility, there is evidence that:
communication between the facilities is established and
the transfer is mutually agreed
appropriately qualified staff accompanies the patient when clinically deemed necessary;
relevant clinical details need to be documented and communicated to the accompanying staff and the team receiving the patient;
clinical accountability and continuity of care is in place.

41. Organization and Management
Evidence of Compliance 1. Copy of referral letter is available 2. Contents in the referral letter are appropriately written; including acceptance of the patient by the referred facility and name of receiving person. 3. Ambulance transfer and in-transit records

42. Organization and Management
Where external services are used to assist in the operations of the Facility, these contracted or referral services shall meet the MSQH Standards of Accreditation
1.3 STANDARD

43. Organization and Management
1.3.1 Criteria for Compliance
There are written agreements on the appointment and provision of external services to the Facility, which include the following:
The services shall meet all patient and environmental safety standards contained in the MSQH Standards of Accreditation, regardless of where the activities occur, on-site and off-site.
There is detailed documentation on the external aspects of the services

44. Organization and Management
Evidence of Compliance
Service contracts have appropriate terms and conditions
date and duration of contract;
system for quality control of outsourced services (visit to off-site services, recognised certification);
procedures for managing shortfall in service;
Involvement in performance measurement of the relevant services provided to the Healthcare Facility.

45. 45

46. Human Resource Development & Management
2. Standard
The ………. Services shall be directed by and staffed with suitably qualified and trained personnel to achieve the goals and objectives of the services.

47. Human Resource Development & Management
2.1 Criteria for Compliance
The Head and staff of the….. Services shall be individuals qualified by education, training, experience and certification to commensurate with the requirements of the various positions.

48. Human Resource Development & Management
Evidence of Compliance:
1. Records on credentials of Head of Service and staff required to fill up the posts within the service (to match the complexity of the Facility and services)
2. Appointment/assignment letters
3. Certification, Valid professional Annual Practising Certificate (APC), National Specialist Registration (NSR).
4. Training and competency records

49. Human Resource Development & Management
2.2 Criteria for Compliance
The Authority, responsibilities of the Head of the
……………Services are clearly delineated and
documented in a letter of appointment
Evidence of Compliance
1. Appointment /assignment letter for Head of
Service
2. Description of duties and responsibilities

50. Human Resource Development & Management
2.3 Criteria for Compliance
Sufficient numbers of personnel and support staff with
appropriate qualifications are employed to enable the
services to meet the documented purposes

51. Human Resource Development & Management
Evidence of Compliance
1. Compliance with current norms - Policy of the Ministry of Heath (where applicable), PHFS Act 1998, Regulations 2006
2. Number of staff and qualification commensurate with
workload
3. Staffing pattern
4. Duty roster
5. Census and statistics

52. Human Resource Development & Management
2.4 Criteria for Compliance
Credentialing and Privileging
Clinical staff appointments, re-appointment, credentialing and privileging shall be documented. These shall meet the requirements of the relevant Acts and Regulations.
There is documented evidence of appropriate training and competency for the granting of clinical privileging. The criteria for determining privileges are specified and documented.

53. Human Resource Development & Management
Evidence of Compliance
Documented policies and procedures are established to govern the credentialing and privileging processes
Compliance with policy and criteria for credentialing and privileging
Annual Practising Certificate (APC), National Specialist Register (NSR) certificates and privileging certificates.
Availability of the list of procedures requiring credentialing and privileging.

54. Human Resource Development & Management
2.5 Criteria for Compliance
Documented evidence of privileges conferred by the Governing Body is available and accessible to relevant staff at point of care
Evidence of Compliance
Formal letter of assignment or certificate of privileging with stipulated timeline are issued and reviewed accordingly.
Updated list of staff with privileges conferred is made accessible at point of care.

55. Human Resource Development & Management
2.6 Criteria for Compliance
Clinical staff performs within the privileges conferred
Evidence of Compliance
Verification of procedures performed by individuals at point of care within the awarded privileging rights with evidence of:
a) list of procedures privileged
b) clinical notes

56. Human Resource Development & Management
2.7 Criteria for Compliance
There are written and dated job description for all categories of staff that include:
qualifications, training, experience and certification required for the position
lines of authority, accountability, functions and responsibilities
reviewed when required and when there is a major change in
duties and responsibilities, qualifications, privileges granted,
d) administrative and clinical functions

57. Human Resource Development & Management
Evidence of Compliance
1. Updated specific job description is available for each staff
2. Job description includes specialisation skills
3. Relevant privileges granted where applicable
4. The nature and scope of work of each staff is specified
5. The job description is acknowledged by the staff and
signed by the Head of Service and dated.

58. Human Resource Development & Management
2.8 Criteria for Compliance
Personnel records on training, staff development, leave and others are maintained for every staff.
Note:
Staff personal record may be kept in Human Resource Department as per Facility policy.

59. Human Resource Development & Management
Evidence of Compliance Staff personal records include: a) staff biodata; b) qualification and experience; c) evidence of current registration; d) training record; e) competency record and privileging; f) leave record; g) confidentiality agreement.

60. Human Resource Development & Management
2.9 Criteria for Compliance
There is a structured orientation programme for all newly appointed staff to the Emergency Services including medical practitioners and for those new to specific areas.

61. Human Resource Development & Management
Evidence of Compliance
1. Policy requiring all new staff to attend a structured orientation programme.
2. Records on structured orientation programme
3. Orientation module
4. List of attendance

62. Human Resource Development & Management
2.10 Criteria for Compliance
There is evidence of training needs assessment and staff development plan which provides the knowledge and skills required for staff to maintain competency in their current positions and future advancement.

63. Human Resource Development & Management
Evidence of Compliance
i. Training needs assessment is carried out and gaps
identified.
ii. A staff development plan based on training needs
assessment is available.
iii. Training schedule/calendar is in place.
iv. Training module

64. Human Resource Development & Management
2.11 Criteria for Compliance
There are continuing education activities for staff including medical practitioners to pursue professional interests and to prepare for current and future changes in practice i.

65. Human Resource Development & Management
Evidence of Compliance
1. Training calendar includes in-house/external
courses/ workshop/conferences
2. Contents of training programme
3. Training records on continuing education activities
are kept and maintained for each staff.
4. Certificate of attendance/degree/post basic training. i.

66. Human Resource Development & Management
2.12 Criteria for Compliance
Staff including medical practitioners receive written evaluation of their performance at the completion of the probationary period and annually thereafter, or as defined by the Facility.
Evidence of Compliance
1. Performance appraisal for staff including medical
practitioners is completed and acted upon appropriately
upon probationary period and as an annual exercise.

68. Policies and Procedures
3. STANDARD
There are written and dated policies and procedures for all activities of the……… Services. They shall reflect current standards of practice and serve as standard operating procedures and are consistent with the objectives of the services, relevant regulations and statutory requirements.

69. Policies and Procedures
3.1 Criteria for Compliance
There are written policies and procedures for the …………..Services which are consistent with the overall policies of the Facility, regulatory requirements and current standard practices. 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.

70. Policies and Procedures
Evidence of Compliance
Documented policies and procedures for the service.
Policies and procedures are consistent with regulatory requirements and current standard practices.
Evidence of periodic review of policies and procedures.
The policies and procedures are endorsed and dated

71. Policies and Procedures
Examples of Policies and Procedures:
Hospital operational policies & procedures
Departmental/Service specific operational policies & procedures
Cross departmental policies & procedures
Medical Staff By- Laws

72. Policies and Procedures
3.2 Criteria for Compliance
Policies and procedures are developed in collaboration with staff, medical practitioners, Management and where required with other external service providers and with reference to relevant sources involved.
Cross departmental collaboration is practised in developing relevant policies and procedures where applicable.

73. Policies and Procedures
Evidence of Compliance
1. Minutes of committee meetings on development and
revision on policies and procedures.
2. Minutes of meeting with evidence of cross reference
with other departments
3. Documented cross departmental policies

74. Policies and Procedures
3.3 Criteria for Compliance
New and revised policies and procedures are
communicated to all staff
Evidence to Compliance
1. Training and briefing on the current policies and
procedures
2. Minutes of meetings
3. Circulation list and acknowledgement

75. Policies and Procedures
3.4 Criteria for Compliance
There is evidence of compliance with policies and procedures
Evidence to Compliance
1. Results of audit on practices
2. Practices in line with established policies and procedures

76. Policies and Procedures
3.5 Criteria for Compliance
Copies of policies and procedures, relevant Acts
Regulations, By-Laws and statutory requirements
are accessible to staff
Evidence of Compliance
Copies of relevant Acts, Regulations, policies and
procedures etc are accessible on site/ designated
location for staff reference.

77. Facilities and Equipment-

78. Facilities and Equipment
4. STANDARD
The Head of the ……..Services shall ensure that adequate facilities and equipment that are safe and appropriate are available for the staff to function effectively and to meet the goals and objectives of the …………Services.

79. Facilities and Equipment
4.1 Criteria for Compliance
There are adequate and appropriate facilities and equipment with proper utilisation of space to enable staff to carry out their professional, teaching and administrative functions.

80. Facilities and Equipment
Evidence of Compliance
1. Adequate and proper utilisation of space
2. Appropriate type of equipment to match the complexity
of services
3. Adequate facilities and equipment at each patient care
area for safe care (defibrillator, emergency cart, hand
washing facilities etc)
4. Easy access and clear exit routes
5. Absence of overcrowding

81. Facilities and Equipment
4.2 Criteria for Compliance
There is documented evidence that facilities and equipment comply with relevant national & international standards and current statutory requirements

82. Facilities and Equipment
Evidence of Compliance
Testing, commissioning and calibration records (certificates or stickers)
Certificates of calibration, e.g. Standards and Industrial Research Institute of Malaysia (SIRIM), etc.

83. Facilities and Equipment
4.3 Criteria for Compliance (Core)
There is evidence that the facility has a comprehensive maintenance programme such as predictive maintenance, planned preventive maintenance and calibration activities, to ensure the facilities and equipment are in good working order.

84. Facilities and Equipment
Evidence of Compliance
Planned Preventive Maintenance records such as schedule,
sticker
Planned Replacement Programme where applicable
Complaint records
Asset inventory

85. Facilities and Equipment
4.4 Criteria for Compliance
Where specialised equipment is used, there is evidence that only staff who are trained and authorised operate such equipment.

86. Facilities and Equipment
Evidence of Compliance
User training records
Competency assessment record
Letter of authorisation
List of staff trained and authorised to operate specialised
equipment

87. Facilities and Equipment
4.5 Criteria for Compliance
Evidence of general safety of the facility
(building design, location)
4.6 Criteria for Compliance
Evidence of attention given to safety pertaining to fire, electrical supply, water, air
and medical gases

88. Facilities and Equipment
4.7 Criteria for Compliance
Presence of uninterrupted supply of amenities (electricity, water, medical gases, steam, telephone etc)
4.8 Criteria for Compliance
Presence of monitoring and alarm systems
4.9 Criteria for Compliance
Error prevention & recovery mechanisms (Contingency Plans)

89. Safety and Performance Improvement Activities
5. STANDARD
The Head of Emergency Services shall ensure the provision of high quality performance with staff involvement in the ongoing safety and performance improvement activities of the Emergency Services.
5.1 Criteria for Compliance
There are planned and systematic safety and performance improvement activities to monitor and evaluate the performance of the services.

90. Safety and Performance Improvement Activities
Evidence of Compliance
Planned performance improvement activities :
Records on performance improvement activities
Minutes of performance improvement meetings
Performance improvement studies
Mortality and morbidity audits with remedial actions
Records on innovation if available

91. Safety and Performance Improvement Activities
5.2 Criteria for Compliance
The Head of the Service assigns the responsibilities for planning, monitoring and managing safety and performance improvement activities to appropriate individual/personnel within the respective services.
Evidence of Compliance
a) Minutes of meetings
b) Letter of assignment of responsibilities
c) Job description

92. Safety and Performance Improvement Activities
5.3 Criteria for Compliance
The Head of the Service shall ensure that the staff completes incident reports which are promptly reported, investigated, discussed by the staff with learning objectives and forwarded to the PIC of the Facility.
Incidents reported have Root Cause Analysis done and action taken within the agreed time frame to prevent recurrence.

93. Safety and Performance Improvement Activities
Evidence of Compliance
1. System for incident reporting is in place, which include:
a) Training of staff
b) Policy on incident reporting
c) Methodology of incident reporting
d) Register/records of incidents

94. Safety and Performance Improvement Activities
2. Completed incident reports 3. Root Cause Analysis 4. Corrective and preventive action plans 5. Remedial measure 6. Minutes of meetings 7. Acknowledgment by Head of Service and PIC/Hospital Director 8. Feedback given to staff regarding incident reporting

95. Safety and Performance Improvement Activities
5.4 Criteria for Compliance
There is tracking and trending of specific performance indicators not limited to but at least two (2) for each service

96. Safety and Performance Improvement Activities
Evidence of Compliance
Specific performance indicators monitored
Records on tracking and trending analysis
Remedial measures taken where appropriate

97. Safety and Performance Improvement Activities
5.5 Criteria for Compliance
Feedback on results of the safety and performance
improvement activities are regularly communicated to the
staff.
Evidence of Compliance
Results on safety and performance improvement activities are
accessible to staff.
Evidence of feedback via communication on results of
performance improvement activities through continuing medical
education/meetings
Minutes of service meetings

98. Safety and Performance Improvement Activities
 5.5 Criteria for Compliance
Appropriate documentation of safety and performance improvement activities is kept and confidentiality of medical practitioners, staff and patients is preserved.
Evidence of Compliance
Documentation on performance improvement activities and
performance indicators.
Policy statement on anonymity on patients and providers
involved in performance improvement activities.

99. Safety Concerns Addressed in MSQH Hospital Accreditation Standards
IS IT SAFE TO BE TREATED IN THIS HOSPITAL?
IS IT SAFE TO BE WORKING HERE?
IS IT SAFE TO VISIT?

100. Thank
You